Case: A 53-year-old Indigenous man from a remote community 300km north of Alice Springs presented in April 2024 with atrial fibrillation and hypertension on a background of heart failure with reduced ejection fraction of unclear aetiology. Previous computed tomography of his chest and upper abdomen from April and December 2023 revealed an incidental 32x 27mm left-sided adrenal neoplasm concerning for phaeochromocytoma. In retrospect, he described longstanding paroxysmal diaphoresis and light-headedness whilst receiving unopposed beta blockade. He was commenced on prazosin 1mg BD in addition to his usual bisoprolol 10mg daily with good effect. Post-discharge, fractionated urinary metanephrines and catecholamines returned positive with elevated noradrenaline 10400nmol/24hr(<750), normetadrenaline 24umol/24hr (<2.3), 3-methxoy tyramine 2.2umol/24hr(<1.3); and plasma normetanephrine 11859pmol/L(<900). He was referred to Queen Elizabeth Hospital, Adelaide, and underwent an uncomplicated laparoscopic left adrenalectomy in June 2024. A post-operative PET scan revealed no evidence of metastatic disease and repeat serum and urinary metanephrines fell into normal ranges.
Discussion: This case highlights the challenges in management of Indigenous patients from remote communities with complex comorbidities. Lack of resources and staffing can lead to delays in diagnoses, follow-up and therapeutic interventions. The patient’s closest clinic is staffed by nurses for 6 hours once a week, and a medical practitioner once a month. It took a year for his adrenal incidentaloma to be investigated and a further 3 months post-diagnosis for definitive surgical intervention. Cultural obligations were a priority for our patient and we involved him in all aspects of his care to successfully coordinate timing of transfer to a specialised centre. Beyond these acute issues, he has been referred for genetic testing and will need ongoing monitoring for disease recurrence. Undertaking these specialised investigations in a timely manner will be a future challenge, representing the obstacles in healthcare provision in geographically dispersed populations in Central Australia.