Introduction: Simultaneous hypersecretion of both catecholamines and cortisol in one adrenal tumor is rarely seen because cortical cells, which produce cortisol, and medullary cells, which secrete catecholamines, are derived from different germ layers1. Formidable challenges ensue from a tumor with a complex behavior. We demonstrate here the clinical course and multi-modal management of the case of an adrenocortical adenoma which had neuroendocrine differentiation accounting for the excess of both catecholamine and cortisol hormones in a patient with multiple neoplasms. Clinical Case: An adrenal mass was incidentally discovered in a 61-year old female undergoing imaging as part of the metastatic work-up for an esophageal mass. The patient has insulin-requiring diabetes mellitus, hypertension and a history of breast cancer. A right adrenal gland mass, avidly enhancing, measuring 3.8 x 2.7 x 2.7 cm was found on abdominal imaging. The 24-hour urine metanephrine collections were done, and these were more than twice elevated in two instances at 2.516 mg/24 hours and 2.101 mg/24 hours (NV: 0–1 mg/24 hours). An unsuppressed cortisol level at 6.57 μg/dL (NV: ≤ 1.8 μg/dL) was obtained after the 1 mg dexamethasone suppression test. Hypercortisolism was confirmed with an elevated 24-hour urine free cortisol at 312.07 μg/24 hours (NV: 20–90 μg/24 hours). Adrenocorticotrophic hormone (ACTH) was low at 0.90 pg/ml, indicative of the presence of an adrenal form of Cushing’s. Primary aldosteronism was ruled out based on a ratio between plasma aldosterone concentration and plasma renin activity of less than 20. Pre-operative alpha blockade with terazosin was initiated. Right adrenalectomy was done. Histopathology revealed an adrenal mass of cortical origin, atypically staining positively for synaptophysin, which is indicative of neuroendocrine differentiation of the tumor. The patient had better blood pressure and glycemic control after the adrenalectomy. Clinical Lessons: An adrenocortical adenoma very seldom undergoes neuroendocrine differentiation. Pathophysiologic mechanisms include a genetic aberration in cortical cells leading to production of catecholamines2. This case underscores the importance of a comprehensive biochemical evaluation of a patient with an adrenal mass because control of hormonal hypersecretion is essential in reducing cardiovascular risks, morbidity and mortality. References: 1Duan L, Fang F, Fu W, et al. Corticomedullary mixed tumor resembling a small adrenal gland-involvement of cancer stem cells: case report. BMC Endocr Disord. 2017;17(1):9. Published 2017 Feb 13. doi:10.1186/s12902-017-0157-7.2Donatini G, Van Slycke S, Aubert S, Carnaille B. Corticomedullary mixed tumor of the adrenal gland-a clinical and pathological chameleon: case report and review of literature. Updates Surg. 2013 Jun;65(2):161–4. Epub 2012 Jan 7. PMID: 22228558.

Objective. The sources of diabetes distress, defined as hidden negative emotions from the demands of daily self-management, are unknown to Filipinos with type 2 diabetes mellitus in the outpatient department. Therefore, we aimed to 1) explore the sources of distress in the perspective of Filipinos with type 2 diabetes mellitus and 2) create a conceptual framework of diabetes distress for Filipinos with T2DM. Methods. Focus group discussions were done and audiotaped among Filipinos with type 2 diabetes (n=17). The transcript underwent content analysis to generate themes and subthemes. Relationships were determined between codes, categories, and themes elicited in the study to create a conceptual framework unique to Filipinos. Results. The content analysis revealed five themes of diabetes distress: caregiver factor, socio-economic factor, psycho-emotional factor, medication-related factor, and health care service delivery factor. The socio-economic factor was a distinct theme missing in the prevailing validated questionnaires. Therefore, an adapted conceptual framework was created, as approved by the expert panel. Conclusion. In conclusion, Filipinos with type 2 diabetes mellitus in the outpatient department have multiple sources of diabetes distress, namely, caregiver factor, socio-economic factor, psycho-emotional factor, medication-related factor, and health care service delivery factor. The socio-economic factor is a unique theme identified among Filipinos. Recognizing the sources of diabetes distress is vital to accurately screen Filipinos with type 2 diabetes mellitus and optimize management outcomes. The study findings will help develop and validate the questionnaire to screen diabetes distress unique to Filipinos.

Infective endocarditis (IE) is the infection of the endocardium or valves of the heart. Morbidity and mortality rates are high if not recognized early and left untreated. Complications such as heart failure, embolism and aneurysmal formation further increase mortality risk. We present a complicated case of IE where these complications coexisted in a single patient. A 27-year-old male diagnosed with rheumatic heart disease (RHD) presented with 3-month history of febrile episodes and 1-week history of left-sided weakness and facial asymmetry. Physical examination revealed subconjunctival hemorrhages, left-sided hemiparesis and left central facial palsy. On auscultation, he had murmurs suggestive of mitral regurgitation and stenosis, and aortic regurgitation. Two-dimensional echocardiography revealed mitral and aortic regurgitation with multiple large-sized vegetations at both valves. Further workup showed a right middle cerebral artery (MCA) infarct, right MCA mycotic aneurysms, and bilateral kidney infarcts with secondary infectious glomerulonephritis and splenic infarct. Blood cultures were negative. He was managed as culture-negative definite IE and was started on ceftriaxone and gentamycin which was later shifted to vancomycin due to lack of clinical improvement. During the course, he also developed severe abdominal pain-CT angiography of the abdomen revealed acute mesenteric ischemia of the superior mesenteric artery, which was managed conservatively. Double valve replacement was contemplated, but acute respiratory failure from hospital-acquired pneumonia posed higher surgical risks. Unfortunately, the patient eventually succumbed to brain herniation from new-onset multiple cerebral infarcts. Literature suggests rarity of multiple complications of IE occurring in a single patient. Because high mortality associated with complications can be averted by early recognition and early intervention, multiple embolisms should be suspected in a patient who already presented embolism in one organsystem.