Endocrine Abstracts

Introduction: Nasopharyngeal carcinoma is a rare entity with a predominant geographic distribution in North Africa, Arctic, Southern China and Southeast Asia.

Case Presentation: 32 yrs old, single, Saudi, male, had presented to our hospital on 26.11.2022. He had 2 months history of undocumented fever, blackish oral lesions, anorexia and profound weight loss(20kgs). He had become fully dependent and bed-bound. No addictions, allergies or high risk behaviours. Systemic review and family history-unremarkable. 7 yrs back, the patient had a road traffic accident with resultant left hemiparesis and aphasia, but was independent & mobile with support, till the current illness. On further evaluation, the patient was diagnosed to have poorly differentiated and metastatic Nasopharyngeal carcinoma [Vitally stable. GCS-E4M4V1=9/15, left sided flexion contractures & weakness. He was unkempt, markedly dehdrated & cachectic, with poor dentition & oral hygiene. Had blackish, necrotic lesions with crusting, over the dorsum of tongue, uvula & hard palate. CT scan brain, neck, facial bones(infiltrative and destructive nasopharyngeal & skull base soft tissue mass, invading sellar & suprasellar areas(1.5 x 4.7 cms), with erosion of the sella turcica and clivus. Besides, involvement of both cavernous sinuses, sphenoid sinus, left internal jugular vein, posterior nasal cavity, facial bones and bilateral retropharyngeal and left (necrotic) cervical lympadenopathy, was noted). CT chest-multiple indeterminate lung nodules, largest(13mms) in right lower lobe, suggestive of metastases. CT abdomen & pelvis-absent spleen, destructive bony lesions of right sacral ala and S1 vertebral body, suspicious of metastases. Multiple biopsies from the nasopharyngeal mass-poorly differentiated, Nasopharyngeal carcinoma (Negative for EBV, p16, fungal, TB & positive for CK 5/6]. He also had Panhypopituitarism (TSH 0.834mIU/l[0.25-5], FT4 9.42pmol/l[12-22 ], S. Cortisol AM 535nmol/l[137.9-686.7], Short Synecthen test normal, ACTH 0.33pmol/l(2.2-13.2), Prolactin 703mIu/l[86-324], LH 0.30mIU/l[1.7-8.6], FSH 2.34mIU/l[1.5-2.4], S. Testosterone 0.087nmol/l[8.64-29]). The patient had developed Cranial diabetes insipidus during hospitalization(with polyuria, S.Na+156 mmol/l, Osmolality(Serum312.19mOsm/kg [250-326], Urine185mOsm/kg[50-1400]). He was also found to have right corneal perforation with bilateral exposure keratopathy. Other significant laboratory derangements-normochromic anemia(Hb 10.4g/dl), hypoalbuminemia(S.Albumin 30.5g/l), deranged coagulation & Throat C/S+ for Candida krusei & Yeast spp. He underwent emergent, right eye tectonic corneal grafting, bilateral amniotic memrane transplant and bilateral tarsorrhaphy. He was managed with Desmopressin, Low dose Thyroxine, maintenance steroids and an anti-fungal. The Tumor board consensus was to keep the patient on DNR status and for palliative care, in view of his Palliative performance scale(30%).

Conclusion: A multi-speciality team-work led to the exact diagnosis & the issues like corneal perforation, diabetes insipidus and Pan-hypopituitarism were addressed.