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Abstract: SA-PO708

Hypertension, Hypokalemia, and Psychosis: A Case Report of Ectopic ACTH Production from Pulmonary Carcinoid Tumor

Session Information

Category: Fluid, Electrolytes, and Acid-Base Disorders

  • 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

  • Sarwal, Amara, University of Utah Health, Salt Lake City, Utah, United States
  • Kakani, Siddhartha, University of Utah Health, Salt Lake City, Utah, United States
  • Abraham, Josephine, University of Utah Health, Salt Lake City, Utah, United States
Introduction

Pulmonary carcinoid tumours are a rare cause of ectopic ACTH [1]. Herein, we present a case of ectopic ACTH production presenting as acute psychosis due to a pulmonary carcinoid tumor.

Case Description

63 year old male with rheumatoid arthritis and hypertension presented to the Emergency Department with erratic behavior and altered mental status. Initial workup revealed profound hypokalemia to 1.8 mmol/L, sodium of 152 mmol/L, bicarbonate at 34 mmol/L and serum creatinine at 1.02 mg/dL. Urine toxicology was positive for marijuana. He was also found to be hypertensive at 152/101.

Patient noted excessive sweating for 1.5 years along with weight loss of 20 pounds in the last month. Contrasted imaging of the abdomen did not reveal any masses in the adrenals, although did note bilateral adrenal hyperplasia. Hyperaldosteronism was ruled out. 24 hour cortisol was 9948 ug/d with elevated ACTH of 229 pg/mL. Patient's behaviour was thought to be due to acute psychosis from the hypercortisolism, and he was started on ketoconazole with improvement in symptoms.

Contrasted imaging of the chest revealed a 1.9cm right upper lung nodule that had been stable since 2020. Unfortunately, patient developed PJP pneumonia, causing a delay in surgical resection. Patient underwent wedge resection a month later, with pathology revealing 1.4cm well differentiated carcinoid tumor with positive ACTH immunostaining.

Discussion

Metastases in pulmonary neuroendocrine tumors have been reported at <15% of cases[1]. >80% of cases of pulmonary carcinoids are curative with surgery [1]. Our patient had a nodule that had been unchanged for years prior to presentation. After ruling out any other causes for ectopic ACTH, we decided to pursue further evaluation of the lung nodule.

Figure 1. Right sided middle lobe nodule