Endocrine Abstracts

Introduction: EAS is an endocrine emergency requiring emergency diagnosis/treatment. Bronchial carcinoid is known to cause EAS and carcinoid syndrome (without liver involvement).

Clinical features: 58-year-old lady with COPD and fibromyalgia referred as 2WW pathway with abdominal pain, diarrhoea, and weight loss. Investigated with CT-CAP: inflammatory looking 7mm lung nodule left upper lobe, enlarged left hilar, aorto-pulmonary, pre-tracheal and sub-carinal nodes without any intra-abdominal lesion. Lung MDT: rescan/discuss. Diarrhoea settled and she slowly gained weight. After 3 months admitted with fatigue and oedema legs with severe hypokalemia (not on any drugs causing hypokalaemia). Potassium - normal during earlier work-up - marginally normalised with oral and intravenous supplements. Endocrine review: Aldosterone <55 pmol/l, renin 0.5 nmol/l/h. Cortisol 1673 and 2199 nmol/l. 24-h urine free cortisol 38987 nmol/24hr. ACTH 101 ng/l. Patient had proximal myopathy, easy bruisability, and a new diagnosis of hypertension and diabetes without central obesity, purplish striae, or osteoporosis. Diagnosis - ACTH dependent Cushing. MRI pituitary – normal. Ectopic ACTH secretion (EAS) considered. With history of diarrhoea, weight loss, and lung nodules, possible bronchial carcinoid with carcinoid syndrome and EAS considered. Lung MDT planned for urgent FDG-PET. While awaiting, developed covid pneumonia and succumbed.

Discussion: EAS patients often have a shorter disease course, severe hypercortisolism, and life-threatening comorbidities including thromboembolism, hyperglycemia, hypertension, hypokalemia, infection, muscle wasting, osteoporosis, and steroid psychosis. Most have resistant hypertension and one-third have diabetes. Due to pronounced catabolism, weight gain and central obesity may not be present. EAS require simultaneous treatment of steroid induced comorbidities, cortisol lowering drugs and specific etiological treatments with rapid and complete excision of ACTH-secreting tumor. If this is not feasible, pharmacological agents and bilateral adrenalectomy are advised. Covid-19 is a severe disease with high risk of progression to ARDS, high morbidity, and mortality in patients with active CS.