SUN-385 A Rare Case of Ectopic ACTH Secretion by Pancreatic Adenocarcinoma

Background Ectopic ACTH secretion caused by pancreatic neuroendocrine tumor is rare, but is responsible for 15% of ectopic Cushing syndrome. Their presentation and treatment are challenging because their preoperatory diagnosis and treatment are difficult due to its divergent and heterogeneous nature. Case The patient is a 65year old male with recent diagnosis of pancreatic cancer with liver metastases opting for naturopathic treatment, history of excessive alcohol use, gout, and biliary stent placement, presented to the ED with abnormal labs. On admission he was noted to be bradycardic with heart rate in 50s, WBC slightly elevated at 12.3, potassium 1.6, bicarbonate 50, calcium 6.5, bilirubin 8.8, ALT 79, AST 63, TSH undetectable, and T3-T4 extremely low. Patient also had lower extremity edema, lethargy, and confusion. Initial presentation was concerning for myxedema coma. Ultrasound for DVT was negative.Twelve-lead EKG demonstrated a ventricular rate of 58, sinus bradycardia with second degree AV block . IV Synthroid and replacement protocol was initiated. MRI of the brain was unremarkable. Patient noted to have upper extremity contractures. 24 hour urine free cortisol was 12,000 (normal 7.2-60 pg/mL ); ACTH 719 pg/mL (normal 4.5 - 20 pmol/L); CEA 10.3 (normal