Endocrine Abstracts

Introduction: Adrenal incidentaloma are becoming very frequent. Bilateral adrenocortical adenomas are a rare cause of ACTH-independent Cushing syndrome.

Clinical case: A 64-year-old hypertensive woman presented with bilateral adrenal incidentaloma detected on the evaluation as a living kidney donor candidate. She was normotensive (129/87 mmHg) on monotherapy, BMI – 24.8 kg/m², with no recent weight gain, hirsutism, striae or mood disturbances. Angio-TC scan revealed a 16×11 mm right adrenal nodular enlargement and a left 53×51 mm one, with an enhancement washout >50% at 15 min. Hormonal tests were as follow: ACTH<5 pg/ml; serum cortisol 17 μg/dl, urinary cortisol 95 μg/24 h (r.v. 20–90): DHEA-S, 17OHP, renin, urinary aldosterone and metanefrines within normal ranges. After overnight and low dose DXM suppression tests serum cortisol were 7.8 and 7.5 μg/dl respectively and diagnostic of Cushing syndrome. Nor-iodo-cholesterol scintigraphy showed an intense uptake by the left adrenal and a nodular fixation on the right. Laparoscopic left adrenalectomy was done and histopathology revealed a single 6 cm adenoma. Four months later, she is eucortisolemic.

Conclusion: A serendipitous diagnosis of Cushing syndrome due to macronodular bilateral adrenal hyperplasia was first made in this patient. Decision of unilateral adrenalectomy was based on dimension criteria and the assumption of resolution of hypercortisolism and no need for replacement therapy.

The (unexpected) histopathologic diagnosis predicts a probable relapse and the need for right adrenalectomy in near future.