Endocrine Abstracts

Case History: A 46 year old lady presented to A&E with a 4 day history of headache, vomiting, abdominal pain and fever. On further questioning, she admitted to having had experienced occasional episodes of palpitations, hot flushes and headaches over the past few months. She had history of appendectomy when she was young and acoustic neuroma removal few years ago. She wasn’t on any regular medications. On clinical examination, she looked visibly unwell and was hypoxic requiring 8L of oxygen to maintain SpO2 above 94%. Her BP was raised at 177/103. She had bi-basal crackles on lung auscultation, otherwise her heart sounds were normal with no murmurs, though she was tachycardic. Abdominal examination revealed generalised mild tenderness on palpation with no guarding or rigidity.

Investigations: A Full Blood Count was as follows: Hb: 166 g/l, WCC: 31.7, Neutrophil: 28.3, PLT:332. Renal Profile: Na: 144, K:3.7, Urea: 10.2, Creatinine: 174, eGFR 30, Amylase: 556, Troponin: 1433 Arterial Blood Gas: pH 7.22, Pa02 10.5, PCO2 6.97, Lactate: 5.8, HCO3 14.9 CXR was reported as “Patchy areas of opacification in bilateral lower zones” CT Head: Previous Right temporal bone craniectomy CT Thorax Abdomen Pelvis: A large left heterogeneously enhancing solid ADRENAL mass with apparent cystic components measuring 7.5 cm in diameter suspicious for a phaeochromocytoma was noted with extensive bilateral pulmonary infiltrates Plasma Metanephrine: 1730 ng/l (Normal range 0-99), Plasma Normetanephrine: >3500 ng/l (Normal range: 0-169) 24 h Urine Metanephrine: 191.18 umol (Normal range: 0-1.2)

Results & Treatment: The patient was moved to ITU where she was commenced on intravenous antibiotics, fluids and oxygen & was catheterised. Over the next 5 days, there was a marked improvement in her biochemical profile & her oxygen requirement went down. An endocrine input was sought. She was started on Phennoxybenzamine 10mg BD which was gradually increased to 60mg TDS. Following MDT Discussion, she was listed for left Sided Adrenalectomy after 2 weeks. Post surgery, she was commenced on Hydrocortisone 20/10/10mg TDS & further Endocrine follow up was organized. Histology report eventually confirmed Phaeochromocytoma PASS 3

Conclusions and points for discussion: Screening for secondary hypertension should always be considered in relatively young patients without risk factors, those with resistant hypertension, individuals with sudden deterioration in BP control, hypertensive urgency and emergency & those presenting with high probability of secondary hypertension based on strong clinical clues. Relevant investigations should then be requested based on history and clinical examination.