A 45-year-old male suddenly experienced left-flank abdominal pain. Echocardiography revealed akinesis of the 'takotsubo cardiomyopathy' type. He experienced a sudden haemodynamic collapse (blood pressure, 324/154 mmHg; pulse rate, 180 beats/min) during emergency cardiac catheterisation. An abdominal computed tomography (CT) revealed expansion of a soft tissue mass 64 × 33 mm in dimension in the left adrenal region, with accumulation of fluid surrounding the left pararenal space. Three days after the attack, his urinary catecholamine concentrations were slightly elevated. We suspected the patient as having a pheochromocytoma followed by acute haemorrhagic rupture, based on signatures of adrenal mass, 'takotsubo cardiomyopathy', and the hypertensive crisis. Over the next few weeks, he recovered well as an outpatient, and his blood pressure remained around 110/60 mmHg without medication. Three weeks after the attack, an abdominal CT showed shrinkage of the ruptured adrenal mass (to a diameter of 30 mm) and absorption of the retroperitoneal hematoma. On day 190 after the attack, abdominal CT did not detect any left adrenal mass. This is the first report of the case showing a complete vanishing of ruptured adrenal mass with takotsubo cardiomyopathy. Although surgical approaches for ruptured adrenal mass involve either emergency or elective surgery, the patients did not need even the elective surgery. Accumulation of the similar cases may unravel clinical factors predicting self-limiting of the ruptured adrenal mass to avoid unnecessary risky surgery.

We report a 72-year-old patient who presented with an ulcerated palatal mass, weight loss and adrenal insufficiency. Repeated biopsies from the mass revealed actinomycosis with no features of malignancy, while computed tomography scanning revealed a left maxillary sinus mass with invasive features and bilateral large adrenal masses. Blood and urine investigations showed adrenal insufficiency. The patient was treated as actinomycosis with adrenal involvement and was given intravenous penicillin and intravenous hydrocortisone. However, his condition did not improve and new signs appeared, that of left facial swelling and lymphadenopathy. A repeat biopsy of the palatal and adrenal masses revealed B-cell lymphoma. This case highlights the possibility that actinomycosis and lymphoma may share similar clinical presentations and may coexist. Either may mask and/or mimic the other, thus causing a delay in diagnosis. We describe the clinical progress and review the related literature. Interestingly, 9 out of the 12 reported cases of concomitant actinomycosis and malignancy (including this case) involve haematological malignancy. A high index of suspicion and treatment response reassessment is important in the management of either rare clinical entity.

Introduction The widespread use of corticosteroids for treatment of inflammatory conditions has resulted in the need to promptly recognize drug-induced adrenal insufficiency. This scenario was inspired by an actual case and aims to enhance critical thinking. Our case is unique as we use a case-based format with written tests to track progress. Methods A pre-assessment was conducted to measure baseline knowledge with residents and medical students. A standardized patient played a 70-year-old female with sarcoidosis who was in the emergency department with weakness and fatigue. The learners obtained her history whereby they discovered that she had recently stopped taking prednisone. They identified adrenal insufficiency and reinstated glucocorticoid therapy. The scenario lasted 10 minutes after which there were a debriefing session and post-debriefing assessment. All were completed in under one hour. Results Our pre-scenario assessment revealed that all learners had less knowledge of adrenal insufficiency than thyroid disease with average scores of 66.63% and 91.25%, respectively. The average score of the adrenal insufficiency test increased from 66.63% to 87.45% on the post-debriefing assessment and the largest improvement was seen in first-year residents. Assessments measured via the Likert scale determined that all learners found the case well-devised to contribute to their understanding of adrenal insufficiency. Discussion The largest improvement unexpectedly was seen in first-year residents which may be due to variations in repetition and retention of medical knowledge in the months prior to starting residency. This module is best suited for first-year internal medicine, family medicine, and emergency medicine residents and upper-level medical students.

Pheochromocytomas are rare adrenal neoplasms characterized by excess secretion of catecholamines. We describe the case of a 65-year-old man, known for hypertension, with no family history of hereditary pheochromocytoma syndromes. He reported a two-year history of flushing, systolic blood pressure surges to 200 mmHg, headaches, tremors, and syncope. His initial workup revealed elevated 24h urine catecholamines and metanephrines. An adrenal MRI in March 2017 showed a large 7.6 cm heterogeneous right adrenal lesion. Given orthostatic hypotension, his final preoperative dose was limited to a low dose of terazosin and metoprolol. In the operating room, shortly after intubation and Foley insertion, his blood pressure rose to 350 mmHg. Surgery was cancelled and he was admitted to the intensive care unit, where intravenous phentolamine, nitroprusside, and nicardipine were started. His systolic blood pressure would oscillate between 60 mmHg and 350 mmHg at 2-3 minutes' intervals. After 3 days, he was weaned off intravenous medications. His oral medications were uptitrated to high doses of phenoxybenzamine, metoprolol, and nifedipine. Three weeks later, he underwent successful open right adrenalectomy. This case outlines the importance of preoperative preparation of pheochromocytomas and raises the question if phenoxybenzamine is the alpha-blocker of choice for larger tumours with significant hormonal secretion.

A 43-year-old man with Hashimoto's thyroiditis and previous thromboembolic events treated with warfarin for 6 months, presented with right flank pain accompanied with vomiting, dizziness, and altered mental status 2 weeks after discontinuation of warfarin. His clinical examination findings were unremarkable. Routine blood work showed lymphopenia, thrombocytopenia, and hypoosmolar hyponatremia. Random serum cortisol level was low (14 nmol/L). Computed tomography scan of the abdomen revealed bilateral bulky heterogeneous suprarenal gland surrounded by fat stranding representing adrenal hemorrhage. He was treated for acute adrenal crisis and subsequently started on hydrocortisone and fludrocortisone, with significant clinical improvement. His diagnosis was secondary antiphospholipid syndrome (APS) to systemic lupus erythematosus (SLE). Bilateral adrenal thrombosis lead to hemorrhage in the adrenals as a paradoxical effect after warfarin cessation and primarily caused by APS. Bilateral adrenal bleeding should lead to the suspicion of thrombophilic disorders, such as APS, with cautious anticoagulation as the treatment of choice.

Brugada syndrome (BrS) is an inherited channelopathy disease, caused by genetic changes in transmembrane ion channels. It has an increased risk of sudden cardiac death (SCD) in the absence of a structural heart disease. We report a case in which the presenting electrocardiogram (EKG) exhibited a type 1 Brugada-like pattern during an adrenal crisis with transformation into a type 2 Brugada-like pattern as the crisis improved.