Endocrine Abstracts

Section 1: Case History: A case of 51 year old female who was referred to us by GP due to increase in size of previously known adrenal adenoma that was picked up on the abdominal ultrasound requested by GP for her deranged liver function test. She had previous investigations in 2017 by endocrinologist in another hospital for a left benign adrenal incidentiloma and it was found non-functional at that stage. She had hypertension 3 years ago and was started on Ramipril by GP. She also takes Bisoprolol 1.25 mg twice a day for palpitations, which was thought to be anxiety driven and also sertraline, Lamotrigine and Lurasidone as she had hx of bipolar disorder. She has no history of hypokalaemia. She had no overt signs of Cushings’ but had high BMI and BP was 139/86. She said she put on weight during pandemic.

Section 2: Investigations: Her Ramipril was switched over to doxazosin for 2 weeks prior blood investigations. Aldosterone 818 pmol/l, renin was 3.75 Miu/ml giving a ratio of 218(reference <35). Saline suppression test with a basal aldosterone of 552 pmol/l and the result at the end of the test of 248 nmol/l (ref <150). Renin correspondingly was 4.5 and 3.15 Miu/ml. Overnight dexamethasone suppression test was 92 nmol/l 24 hours urine metanephrines were normal. Her CT scan showing a left adrenal adenoma measuring 3.8 cm in diameter slightly increased from 3.5 cm in 2015 but with low density in keeping with an adrenal adenoma. She was referred to the tertiary hospital in Belfast for consideration of adrenal vein sampling. Results were surprisingly pointing that hyperaldosteronism was from right adrenal gland which adenoma was only on left side as cortisol was very high on left side making aldosterone/cortisol ratio lower.Results of adrenal vein sampling are as under:

Section 3 Results and Treatment: MDM decision was to do 8 mg overnight dexamethasone suppression test to evaluate extent of burden of autonomous cortisol secretion. Results was 90 nmol/l. DHEAS was 0.96 UMol/l (normal range 0.96-6.95) ACTH with undetectable levels. Result confirmed clinically significant autonomous cortisol secretion so decision for left adrenalectomy was made while continuing to treat her aldosteronism medically as it appears to be coming from right adrenal.

Section 4 Conclusion: This is a Connshing (Conn’s/Cushing’s) syndrome where both hormones are being secreted from contralateral side.