Abstract
Patient’s clinical presentation was remarkable for recent onset abdominal distension, pedal edema and facial puffiness. Has been consuming alcohol for the past 15 years.
History was unremarkable for weight loss or chronic cough. Hewas found to have hyperglycemia and hypertension a week before presentation and started on T. Metformin and Enalapril.
Physical exam revealed a distended abdomen with shifting dullness and there was generalised hyperpigmentation. CECT Abdomen was proceeded with since the USG Abdomen showed multiple lesions in the Liver and it showed Chronic parenchymal liver disease with a few arterial phase enhancing lesion scattered in both lobes of liver –suggestive of metastasis / multifocal hepatocellular carcinoma. Serum alfafetoprotein was normal (5.20). The patient meanwhile also had refractory hypokalemia despite
multiple corrections with intravenous Potassium Chloride and Metabolic alkalosis.
Hence in the setting of possible metastatic malignancy with hypertension, hyperglycemia, refractory hypokalemia and metabolic alkalosis a serum 8 am Cortisol was sent which came out to be 117.2 ug/dl, this was repeated – 130 ug/dl. A serum ACTH level was sent which was >1250pg/ml. Hence a diagnosis of ECTOPIC ACTH induced Cushing’s was made and the patient underwent a DOTA SCAN to find the primary and it revealed a Somatostatin receptor expressing primary tumor in left lung upper lobe with ipsilateral hilar, mediastinal lymph nodal and liver spread with extensive skeletal metastasis. The grave prognosis was explained to the patient’s care takers and they were not willing for further management. Subsequently, through telephonic conversation it was learnt that the patient passed away a few days after being discharged.
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Corresponding Author
Dr Aditya Sanjeevi
Final year resident in the Department of General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai
DOI: https://dx.doi.org/10.18535/jmscr/v8i11.67
