Endocrine Abstracts

Background: Adrenocortical carcinomas (ACC) are rare malignant tumours with an incidence of 1 to 2 per million per year.

Case Report: A 70 year old lady was admitted with a one month history of new onset hypertension, hypergylcaemia, hirsutism and generalised weakness. On examination she was cushingoid with facial plethora, severe hirsutism, central obesity and severe proximal myopathy. A CT trunk showed a large, lobulated, inhomogeneous, solid left adrenal mass 8×5 cm in size with enlarged local and paraortal lymph nodes. Pulmonary metastases were noted.

Biochemistry revealed the following results:

serum random cortisol: 1209 nmol/L, (145–619 nmol/L)

ACTH <5-pg/mL (10–48)

total testosterone: 46 nmol/L (ND-1.49 nmol/L)

oestradiol: 507 pmol/L (ND-118 nmol/L)

progesterone: 5.15 nmol/L (ND-3.2 nmol/L)

OH prog: 21.6 ng/mL (0.13–0.6 ng/mL)

androstenedione 19.4 ng/mL (0.35–2.49 ng/mL)

DHEAS: 23.3 umol/L (0.95–11.67 umol/L)

Plasma cathecolamines, metanephrines and aldosterone renin ratio were normal (in the setting of normokalaemia).

A few days after she complained of severe abdominal pain and was diagnosed with sigmoid bowel perforation needing emergency laparotomy. Following this she developed severe hypokalaemia of 1.94 mmol/L (3.5–5 mmol/L) which was resistent to oral potassium supplements and aldosterone antagonists. She became dependent on continuous intravenous potassium replacement. Her post operative course was complicated by abdominal wound dehiscence. Wound healing was unsuccessful despite treatment with multiple antibiotic therapy. Poor mobility led to a right femoral vein thrombosis. She was deemed unfit for chemotherapy and passed away a few weeks later.

Discussion: This case highlights the rapid and aggressive nature of ACC. Our patient presented with a mixed Cushing’s and virilization syndrome. She suffered the complications of hypercortisolism as evidenced by sigmoid bowel perforation, poor wound healing and hypercoaaguability. The excess cortisol resulted in a mineralocorticoid effect causing recurrent profound hypokalaemia.