Endocrine Abstracts

We present a 62-year-old woman admitted after a fall that caused a severe head injury. During her hospitalization, she exhibited persistent leukocytosis despite negative inflammatory markers and cultures. Notably, she experienced episodes of delirium, which required intervention. Her medical history included palpitations, a normal sinus rhythm on ECG, treated ductal breast cancer, and tachycardia managed with beta-blockers. Her systolic blood pressure peaked at 249 mmHg, and she suffered a syncopal episode that led to shallow subgaleal hemorrhage observed on CT imaging. Given the unusual presentation and abnormal biochemistry, including hypokalemia and leukocytosis, we investigated potential endocrine causes rather than attributing her symptoms to sepsis. Laboratory tests revealed significantly elevated plasma metanephrine levels of 5686 pmol/l (normal: 51-358) and normetanephrine levels of 1959 pmol/l (normal: 137-1047). Urinary tests confirmed increased metadrenaline (25.3 µmol/24h; normal: 0-1.4) and normetadrenaline (5.03 µmol/24h; normal: 0-3). Cortisol levels were also elevated at 3300 nmol/l (normal: 140-700), with partial suppression after an overnight dexamethasone test (79 nmol/l; normal: <50) and unsuppressed ACTH at 22 pmol/l (normal 1.3-16.7). A diagnosis of pheochromocytoma, possibly with ectopic corticotropin-releasing hormone secretion, was made, and the patient was started on doxazosin. A CT scan revealed a 48mm left adrenal mass, suggesting characteristics of an adenoma rather than pheochromocytoma. Subsequent MRI and MIBG scans indicated a reduction in the mass size to 3.7 cm. The patient underwent laparoscopic left adrenalectomy, with histopathological findings confirming pheochromocytoma with central infarction. Following surgery, she experienced significant symptom relief, and her catecholamine, cortisol, and white blood cell counts normalized. This case highlights the need to recognize classic symptoms of pheochromocytoma, even when imaging results are inconclusive. This case underscores the importance of recognizing pheochromocytoma’s classic symptoms, even in the presence of conflicting imaging results, highlighting the complexities involved in managing such cases.