Endocrine Abstracts

A retired 73 year old teacher, who had 2 sons and lived independently alone and stayed active playing tennis 3 times per week. She is an ex-smoker and drinks alcohol occasionally. Past medical history: right breast cancer T1N0 post wide local excision/radiotherapy in remission, type 2 diabetes on Linagliptin. Large cell neuroendocrine tumour of the lung with liver metastasis, on palliative chemotherapy with Octreotide injections. Admitted with generalised body weakness started after chemotherapy. Her symptoms were progressive, with fatigue, muscle weakness and frequent falls. O/E: spontaneous skin bruising, Facial hair growth and infra orbital puffiness. Raised BP with no previous hypertension and uncontrolled blood glucose necessitating insulin. Neurological examination showed generalised muscle wasting with lower limbs weakness proximal more than distal. She had no sensory or cerebellar signs. She needed a walking stick and the assistance of 1 to mobilise and had low mood. Examination otherwise unremarkable.

Work up:

• HB 132g/dl, WBC 10.7 x 109/l, PLT 264 109/l,

• CA 2.25 mg/dl, ALBUMIN 26g/dl, CRP 10, BILIRUBIN 50 mg/dl, ALT 68u/l, ALP 631u/l,

• K 3mmol/l, NA 142mmol/l, HCO3-32mmol/l, CK 68units/l,

• CORTISOL 1388, TSH 1.5, VITAMIN D <20, HBA1C 71

Neurologist investigations:

• MRI Brain- no abnormality

• MRI whole spine: no metastatic spinal cord compression. acute osteoporotic fractures T4 and L1

• Nerve conduction study: no sensory or motor polyneuropathy or myopathy. No evidence of motor neuron disease.

• Paraneoplastic antibodies screen was negative.

Endocrinology assessment showed no typical cushingoid appearance, however the possibility needed to be ruled out. Overnight dexamethasone suppression test which failed to supress her cortisol suggesting excessive secretion, her serum cortisol was 784. Her 24hr urine cortisol was >1790nmol/d, ACTH 141pg/ml. Treatment plan: Metyrapone tds started. 1 week later a 5-point cortisol curve was done to assess treatment response, it showed serum cortisol of 1097, 889, 1073, 902 and 933. Metyrapone was increased to 1g tds a repeat 5-point cortisol curve showed serum cortisol of 575, 441,449,487 and 346. Patient readmitted with hypoglycaemia and progressive weakness, insulin stopped and is being assessed currently for possibility of concomitant neurological dysfunction in view of ongoing muscle weakness. She underwent muscle biopsy to exclude Lambert Eaton myasthenic syndrome as an additional paraneoplastic phenomenon in this case.