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Nam Quang Tran Department of Endocrinology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
Department of Endocrinology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam

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Chien Cong Phan Department of Imaging, University Medical Center at Ho Chi Minh City, Ho Chi Minh City, Vietnam

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Thao Thi Phuong Doan Department of Histopathology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam

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Thang Viet Tran Department of Endocrinology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
Department of Endocrinology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam

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Summary

Primary adrenal insufficiency is a rare disease and can masquerade as other conditions; therefore, it is sometimes incorrectly diagnosed. Herein, we reported the case of a 39-year-old Vietnamese male with primary adrenal insufficiency due to bilateral adrenal tuberculosis. The patient presented to the emergency room with acute adrenal crisis and a 3-day history of nausea, vomiting, epigastric pain, and diarrhoea with a background of 6 months of fatigue, weight loss, and anorexia. Abdominal CT revealed bilateral adrenal masses. Biochemically, unequivocal low morning plasma cortisol (<83 nmol/L) and high plasma adrenocorticotropic hormone levels were consistent with primary adrenal insufficiency. There was no evidence of malignancy or lymphoma. As the patient was from a tuberculosis-endemic area, extra-adrenal tuberculosis was excluded during the work up. A retroperitoneal laparoscopic left adrenalectomy was performed, and tuberculous adrenalitis was confirmed by the histopathological results. The patient was started on antituberculous therapy, in addition to glucocorticoid replacement. In conclusion, even without evidence of extra-adrenal tuberculosis, a diagnosis of bilateral adrenal tuberculosis is required. A histopathological examination has a significant role along with clinical judgement and hormonal workup in establishing a definitive diagnosis of adrenal tuberculosis without evidence of active extra-adrenal involvement.

Learning points

  • Primary adrenal insufficiency can be misdiagnosed as other mimicking diseases, such as gastrointestinal illness, leading to diagnostic pitfalls.

  • Adrenal insufficiency can be confirmed with significantly low morning plasma cortisol levels of <83 nmol/L without a dynamic short cosyntropin stimulation test.

  • Tuberculous adrenalitis is an uncommon treatable condition; however, it remains an important cause of primary adrenal insufficiency, especially in developing countries. In the absence of extra-adrenal involvement, adrenal biopsy plays a key role in the diagnostic process. Alternatively, adrenalectomy for histopathological purposes should be considered if CT scan-guided fine needle aspiration is infeasible in cases of small adrenal masses.

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Le Tuan Linh Department of Radiology, Hanoi Medical University Hospital, Hanoi, Vietnam
Department of Radiology, Hanoi Medical University, Hanoi, Vietnam

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Nguyen Minh Duc Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh city, Vietnam
Department of Radiology, Childrent’s Hospital 2, Ho Chi Minh city, Vietnam

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Hoang Tu Minh Department of Radiology, Hanoi Medical University, Hanoi, Vietnam

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Nguyen Ngoc Cuong Department of Radiology, Hanoi Medical University Hospital, Hanoi, Vietnam

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Vuong Thu Ha Department of Radiology, Hanoi Medical University Hospital, Hanoi, Vietnam

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Dao-Thi Luan Department of Pathology, Hanoi Medical University Hospital, Hanoi, Vietnam

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Thieu-Thi Tra My Department of Radiology, Hanoi Medical University, Hanoi, Vietnam

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Bui Van Lenh Department of Radiology, Hanoi Medical University Hospital, Hanoi, Vietnam
Department of Radiology, Hanoi Medical University, Hanoi, Vietnam

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Summary

Primary hepatic neuroendocrine tumor (PHNET) is a rare type of neuroendocrine tumor (NET) that is also a primary hepatic tumor. Patients are present with almost no specific clinical symptoms and typically present with negative test results and atypical imaging characteristics; therefore, the differentiation of PHNET from other types of primary hepatic masses can be very difficult. In this article, we describe a case of PHNET that mimicked a liver helminth infection in a 57-year-old man. The diagnosis of PHNET in this patient was challenging, and the final diagnosis was based on imaging, histopathology features, and long-term follow-up.

Learning points

  • An uncommon type of neuroendocrine tumor (NET) is a primary hepatic neuroendocrine tumor (PHNET).

  • Primary hepatic neuroendocrine tumors are rare NET lesions found in the liver, characterized by non-specific clinical and imaging results, which can be easily confused with other liver lesions, including HCC and parasitic lesions.

  • To have a conclusive diagnosis and classification, a mixture of many medical assessment techniques, such as imaging, gastrointestinal endoscopy, nuclear medicine, anatomy, including histopathology, and immunohistochemistry, is essential.

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Sarah Ying Tse Tan Department of Endocrinology, Singapore General Hospital, Singapore

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Swee Ping Teh Department of Renal Medicine, Singapore General Hospital, Singapore

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Manish Kaushik Department of Renal Medicine, Singapore General Hospital, Singapore

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Tze Tein Yong Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore

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Shivani Durai Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore

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Claudia Jong-Chie Tien Department of Anaesthesiology and Surgical Intensive Care, Singapore General Hospital, Singapore

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Daphne Su-Lyn Gardner Department of Endocrinology, Singapore General Hospital, Singapore

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Summary

Gestational hypertriglyceridemia-induced pancreatitis is associated with significant maternal and fetal morbidity and mortality. We report a case of gestational hypertriglyceridemia-induced pancreatitis in a primigravida at 31-weeks gestation, complicated by impending preterm labor and metabolic acidosis requiring hemodialysis. This was successfully managed with therapeutic plasma exchange (TPE), followed by i.v. insulin, low-fat diet, and omega-3. Triglyceride levels stabilized after TPE and the patient underwent an uncomplicated term delivery. In pregnancy, elevated estrogen and insulin resistance exacerbate hypertriglyceridemia. Management is challenging as risks and benefits of treatment options need to be weighed against fetal wellbeing. We discuss management options including a review of previous case reports detailing TPE use, dietary optimization, and delivery timing. This case emphasizes the importance of multidisciplinary care to optimize maternal and fetal outcomes.

Learning points

  • Gestational hypertriglyceridemia-induced pancreatitis has high morbidity.

  • A multidisciplinary team approach is a key as maternal and fetal needs must be addressed.

  • Rapid lowering of triglycerides is crucial and can be achieved successfully and safely with plasma exchange.

  • A low-fat diet while ensuring adequate nutrition in pregnancy is important.

  • Timing of delivery requires consideration of fetal maturity and risk of recurrent pancreatitis.

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Sally K Abell Department of Endocrinology and Diabetes, St Vincent's Hospital, PO Box 2900, Fitzroy, Melbourne, 3065 Victoria, Australia

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Jessie Teng Department of Endocrinology and Diabetes, St Vincent's Hospital, PO Box 2900, Fitzroy, Melbourne, 3065 Victoria, Australia

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Anthony Dowling Department of Oncology, St Vincent's Hospital, PO Box 2900, Fitzroy, Melbourne, 3065 Victoria, Australia

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Michael S Hofman Department of Medicine, University of Melbourne, Parkville, Melbourne, Victoria, Australia
Molecular Imaging, Centre for Cancer Imaging, Peter MacCallum Cancer Centre, East Melbourne, Melbourne, Victoria, Australia

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Richard J MacIsaac Department of Endocrinology and Diabetes, St Vincent's Hospital, PO Box 2900, Fitzroy, Melbourne, 3065 Victoria, Australia
Department of Medicine, University of Melbourne, Parkville, Melbourne, Victoria, Australia

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Nirupa Sachithanandan Department of Endocrinology and Diabetes, St Vincent's Hospital, PO Box 2900, Fitzroy, Melbourne, 3065 Victoria, Australia

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Summary

This paper details the case of a 77-year-old male with refractory hypoglycaemia due to inoperable metastatic pancreatic neuroendocrine tumour (pNET) co-secreting insulin and gastrin. Multiple medical therapies were trialled with limited success, and we describe the complications experienced by our patient. Somatostatin analogues can ameliorate hypoglycaemia and may have tumour-stabilising effects; however, in our case resulted in paradoxical worsening of hypoglycaemia. This rendered our patient hospital dependent for glycaemic support including continuous dextrose infusion. Although this is a reported adverse effect with initiation of therapy, we describe successful initiation of short-acting octreotide as an inpatient followed by commencement of long-acting octreotide. Hypoglycaemic collapse occurred only after dose titration of long-acting octreotide. We outline the pitfalls of somatostatin analogue therapy and the mechanisms that may contribute to worsening hypoglycaemia. This rare side effect cannot be reliably predicted, necessitating close supervision and glucose monitoring during therapy. Our patient achieved disease stabilisation and gradual resolution of hypoglycaemia with peptide receptor radionuclide therapy (PRRT), an emerging therapeutic option for metastatic neuroendocrine tumours with high efficacy and low toxicity. We present a brief but comprehensive discussion of currently available and novel therapies for insulin secreting pNETs.

Learning points

  • Hypoglycaemia due to malignant insulin secreting pNET is frequently severe and may be life-threatening despite supportive therapies.

  • Octreotide can ameliorate hypoglycaemia, and may have anti-proliferative and tumour-stabilising effects in malignant pNETs that are surgically unresectable.

  • Paradoxical worsening of hypoglycaemia may occur with octreotide initiation and dose titration, necessitating close supervision and glucose monitoring.

  • PRRT is emerging as a therapeutic option with high efficacy and low toxicity.

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