Endocrine Abstracts

Clinical case MG was a 57-year-old female when first referred to endocrinology for investigation of adrenal incidentaloma. Relevant medical history included poorly controlled hypertension on two agents, dyslipidaemia and history of minimal trauma fracture. Baseline labs (including 24 h urine collection) were unremarkable as was clinical examination (exception hypertension). Cortisol levels on two 1 mg Dexamethasone suppression tests failed to suppress. Dedicated CT adrenal study showed bilateral adrenal hyperplasia: left gland was largest. A diagnosis of bilateral adrenal macronodular hyperplasia with subclinical Cushings’ syndrome was made. Further investigations showed high grade osteoporosis and normal results for aberrant receptors (TRH, GnRH, mixed meal and postural changes) and Short Synacthen test with 17-OH-P levels. Adrenal vein sampling was performed that confirmed diagnosis. Immediate progress included continued hypertension now needing three agents; moderate weight gain and new minimal trauma vertebral fracture. Following discussion with MG regarding diagnosis and its associated complications (metabolic syndrome and osteoporosis), the treatment options of medical management of complications and monitoring vs medical treatment vs surgery, she elected for medical management and monitoring. Follow-up CT adrenal studies showed interval increasing size in both glands, persistent osteoporosis despite bisphosphonate treatment and moderate weight gain. Hypertension and dyslipidaemia were controlled. 4 years following initial diagnosis, MG elected for surgery and successfully underwent a laproscopic posterior extra-peritoneal left adrenalectomy. Post-operatively she does not require glucocorticoid therapy and reduced dosages of hypertensive medications. She continues to be followed up by endocrinology.

Discussion: This case highlights the challenges in recognising and managing bilateral adrenal macronodular hyperplasia and its complications. The natural history of the condition, role of investigations including for CAH and receptor testing, the value of adrenal venous sampling, imaging options and medical and surgical treatment options will all be explored.