Endocrine Abstracts

A 70-year old female presented with 2-week-history of lethargy, reduced appetite, altered taste of food, weight loss, night sweats and easy bruising. Her past medical history only included PMR for which she was on low dose of prednisolone. Initial examination was unremarkable. Initial lab results showed unremarkable CRP, thrombocytopenia of 28, deranged LFTs (ALP 754 U/l, ALT 145 U/l, GGT 239 IU/l, Total Bilirubin 30 umol/l) and significantly raised Ferritin of 14837 mg/l. CT CAP showed left adrenal mass measured as 3.7 × 3 cm. CT adrenals showed indeterminate mass with suspicion of malignancy. Patient steroid dose was doubled and liver biochemistry and thrombocytopenia started to improve. Plasma metanephrines and Aldosterone/renin ratio, sex steroids came back negative. ONDST showed a cortisol of 141 nmol/l. Patient did not feature any signs of Cushing’s. A week later, patient developed right 3rd, 6th and V1(ophthalmic) nerve palsies with possible 4th nerve involvement. CT angiography, MRI COW and MRI brain were all normal. LP showed increased protein & lactate with reduced glucose. Microscopy showed some lymphocytes & monocytes but no malignant cells. No evidence of infection. Autoimmune screening including ANCA, ANA, complement levels, liver autoimmune screening, paraneoplastic antibodies and Lyme serology were all negative. Neurology advised to increase steroids and patient was commenced on IV dexamethasone 10 mg OD. Liver biochemistry continued to improve and Ferritin dropped to 1512 mg/l. Myeloma screen came back negative and bone marrow biopsy showed reactive changes. Haematology advised that lymphoma is unlikely. There was no evidence of any lymphadenopathy clinically or through imaging. Adrenal MDT decided to go for adrenal biopsy. Whilst awaiting for the procedure patient developed more severe cranial nerve palsies and repeated MRI showed probable abnormality at both Meckel’s caves/medial middle cranial fossae and possible abnormality of CN V and acoustico-facial bundles bilaterally suggesting lymphomatous, malignant or granulomatous infiltration. Adrenal CT guided biopsy showed that the mass had significantly increased in size to about 7 cm within a month since the first presentation. CT CAP was repeated and showed new abdominal lymphadenopathy and new right adrenal mass. Biopsy results came back as diffuse large B-cell lymphoma. Patient was commenced on R-CHOP but unfortunately deteriorated so fast, became aphasic, confused and then developed reduced GCS. End of life care was initiated and the patient died. From day one of presentation till death was around 45 days.