Endocrine Abstracts

Section 1: Case history: A 66-year-old man, with a history of hypertension controlled on 3 anti-hypertensives and diet-controlled Type 2 Diabetes, presented to a community-based musculoskeletal clinic to have an intra-articular Triamcinolone injection for a frozen shoulder. 30 min after the injection, he developed dyspnoea, widespread urticaria and facial angioedema. He was initially treated for suspected anaphylaxis with adrenaline, antihistamine and Hydrocortisone at the GP surgery and repeated by paramedics before presenting to Yeovil District Hospital casualty. In view of refractory hypotension not resolving with IV fluids and I/M adrenaline, he was admitted to ICU for a noradrenaline infusion, with regular hydrocortisone and antihistamine. Blood pressure remained stable overnight, but he became pyrexial with moderate hyperlactataemia. Sixteen hours later, he became extremely agitated, with a paroxysmal surge in systolic blood pressure to 300 mm Hg and a sudden rise of lactate to 15.0 mmol/l, requiring intubation and ventilation.

Section 2: Investigations: Mast cell tryptase samples were send off during the first 24 h. Abdominal CT undertaken to assess for sepsis, revealed a large left sided adrenal mass measuring 4.6 by 4.8 cm with central necrosis. Noradrenaline was discontinued, blood pressure normalised quickly and he was soon extubated. He had further investigations >48 h after discontinuing the nor-adrenaline infusion, including plasma metanephrines. He was discharged on Doxazocin and Bisoprolol. Allergy clinic assessment and endocrine follow-up were arranged.

Section 3: Results and treatment: Mast cell tryptase levels were 9.6 μg/l at presentation to casualty, 10.9 μg/l at 4 h and 1.6 μg/l at 24 h (NR 2–14), consistent with a clinically relevant dynamic rise. Skin testing confirmed a positive response to Triamcinolone. Plasma normetanephrine 1134 pmol/l (NR 0–1180); plasma metanephrine 4839 pmol/l (0-510). MIBG scan: confirmed solitary left adrenal uptake. Further history revealed intermittent episodes of warmth, palpitations and sweating, for the preceding 10 years. He was fully blocked with phenoxybenzamine and Propranolol. The suspected phaeochromocytoma was surgically removed and confirmed on histology. Post-operative plasma normetanephrine 525 pmol/l; metanephrines <100 pmol/l.

Section 4: Conclusions and points for discussion: Our patient presented acutely with synchronous anaphylaxis and phaeochromocytoma crisis following intra-articular steroid injection. Although each of these has been well described as separate adverse events following glucocorticoids, we are not aware of a synchronous presentation and this was challenging to diagnose. It is possible that the Triamcinolone precipitated both events, or the anaphylaxis precipitated the phaeochromocytoma crisis.