Endocrine Abstracts

Background: Mrs X had experienced severe right sided abdominal pain. Brought to hospital by ambulance from the residential home. In Accident and Emergency, she was confused and the accuracy of her history was difficult to confirm. Mrs X had a CT abdomen and pelvis with contrast. This had reported a 3.8 cm enhancing, well defined left adrenal mass, this needed to be assessed with adrenal protocol CT. Referred to Nurse-Led Adrenal Incidentaloma clinic for investigations.

Past Medical History

History of falls Newly diagnosed hypertension Current Medication: Nitrofurantoin 100 mg MR 1 BD Codeine 15 mg 1-2 up to 4 x daily as required Paracetamol Newly Commenced on Amlodipine in view of elevated BP

Seen by Nurse Practitioner in clinic:

Mrs X had attended clinic by transport, accompanied by her carer. She was broadly well in herself. Has poor mobility uses walking stick. She is not obese. BP in clinic was elevated 188/91 decreased to 154/85 after resting. In residential home, BP ranging 150/76 to 164/85.

Investigations following clinic appointment

1. Plasma renin aldosterone measurement: Aldosterone renin ratio = 463 pmol/l, Renin: 0.3 nmol/L/hr 1. Plasma metanephrines (after being in the recumbent position for 30 minutes) Plasma metadrenaline: 156 pmol/l(0-511) Plasma Normetadrenaline: 346 pmol/l(0-1180) Plasma 3-Methoxytyramine: <75 pmol/l(0-180) 1. Urine free cortisol measurement. This had demonstrated a raised 24hr urine free cortisol levels significantly elevated at 618 (1-124) 1. Overnight dexamethasone suppression test-Result was 81 nmol/l, non-suppressed level. 1. low dose dexamethasone suppression test [LDSST]- Baseline cortisol day 1: 661 nmol/l Day 2 48hr: 78 nmol/l, non-suppressed level ACTH: 12.9 ng/l(7-63) CT Adrenal with contrast-Left adrenal lesion in keeping with a benign adrenal adenoma. Adrenal MDT Mrs X case was discussed amongst our MDT and this will be investigated further at a tertiary centre. The new working diagnosis

Discussion: Interestingly, this patient does not have cushingoid features and she is not obese. It has been difficult to interpret the ACTH level given that it is not fully suppressed. One may even consider a case of ectopic ACTH. Making a diagnosis may not always be straight forward. However, given the ACTH is low, cortisol levels are not suppressed, and she has an adrenal adenoma this may be in keeping with a diagnosis of adrenal incidentaloma.