Vancouver IM LMR

In this noon report we review a case of subacute onset hypertension and edema in a previously healthy patient. Through a secondary hypertension workup, the patient was discovered to have ectopic Cushing’s syndrome from a pancreatic neuroendocrine tumour!

See the didactic slide deck here.

Key takeaway points:

• When to consider secondary hypertension workup:
  • Severe or resistant hypertension
  • Acute rise in BP over previously stable value
  • Age of onset < puberty
  • Age < 30 years without obesity or family history of HTN
  • Other features that may suggest specific etiology (e.g. hypokalemia and metabolic alkalosis → primary aldosteronism)
• Major etiologies of secondary hypertension:
  • Endocrine
    • Primary aldosteronism
    • Pheochromocytoma
    • Cushing’s syndrome
    • Thyroid disorders
    • Primary hyperparathyroidism
  • Renal
    • Primary kidney disease
    • Renovascular disease
  • Drug-induced
    • Steroids, OCPs, NSAIDs, stimulants, antidepressants/ atypical antipsychotics, TKIs, calcineurin inhibitors, etc
  • Other
    • Obstructive sleep apnea
    • Coarctation of aorta
• Consider Cushings if:
  • Central obesity/ weight gain, round face, hypertension, hyperglycemia, skin thinning and easy bruising, new striae, proximal muscle weakness, evidence of hyperandrogenism in women, psychiatric changes
  • Diagnosis:
    • Screening test (need 2/3 positive):
      • Midnight salivary cortisol (x 2)
      • 24h urine cortisol (x 2)
      • 1mg dexamethasone suppression
    • Determine source: ACTH
      • ACTH high: secondary i.e. pituitary or ectopic source → order MRI sella and consider pan CT scan
      • ACTH low: primary i.e. adrenal source → order CT/ MR adrenals