Endocrine Abstracts

64 year old male with known hypertension presented with fatigue and mild vertigo to the emergency department. Blood pressure was 110/65 mmHg. Physical examination revealed bilateral inspratory crackles with bilateral pedal oedema. There was not any skin discolourisation or bruises. Patient history indicated a suspected lung malignancy but pathological diagnosis was yet to be concluded. Laboratury test showed that sodium level was 117 mEq/l, potassium level was 5.2 mEq/l, venouse blood gas ph was 7.37, HCO₃ level was 22 mmol/l, PaCO₂ was 44 mmHg. Spot urine sodium8 mEq/l, serum osmolarity was 271 mOsm, urine osmolarity was 425 mOsm/l. Other renal, liver, thyroid function tests and lipid levels were within normal laboratory values. He had no obvious hyponatremia sypmtoms other than fatigue and mild nausea without vomitting. Previous medical center initiated hypertonic saline for two days, yet sodium level did not improve. He was transferred with the suspicioun of inappropriate ADH syndrome. Lung imaging showed a right mid-zone opacity with bilateral basal pleural effusion. Further investigations revaled no head injury or cranial pathology, morning serum cortisol level was 26 μd/dl. Patient admitted and started on furosemid and water restriction to 1.5 L for hypervolemia. Due to two days without improvement, PET-CT imaging was requested for evaluation. A 85x60 mm heterogeneous, hypodens mass at left adrenal gland with metabolic activity (suv maks 6.93) was reported. Despite patient’s lack of metabolic acidosis, hypotension or confusion, it is suspected to be adrenal function disorder and insufficiency. Serum ACTH, cortisol, renin, aldosterone levels were sent and short synachten test was performed before corticosteroid treatment with 100 mg hydrocortizon four times daily started. Second cortisol level was 11 μd/dL and latter Synachten test was consisted with primary adrenal insufficiency. Patients’ sodium level was improved after two days of steroid treatment and increased to 128 mEq/l. Later on, patient was diagnosed with squamous cell lung cancer with adrenal and lymph node metastasis. This case was complicated with mild nonspesific symptoms with initial high basal cortisol levels and absence of hyperpigmentation. It is suggested that patients with low plasma sodium should be carefully evaluated for laboratory errors, differantial diagnosis; and adrenal functions should not be overlooked.