Endocrine Abstracts

A 40-year Caucasian female referred to Diabetes centre in November 2016. Her main complaints were 20 kg weight gain over the past 4 years, muscle weakness, high blood glucose readings, high blood pressure (up to 180/100 mmHg),menstrual irregularity.

Medical history

She was diagnosed with T2DM at the age of 39 year. She did not take any blood glucose lowering medication. Her blood glucose readings were: 12 mmol/l at fasting, 20 mmol/l postprandial. She was taking losartan 50 mg/day and bisoprolol 2.5 mg/day for her hypertension regularly. The patient had no family history of endocrine disorders.

Physical examination

Her BMI was 33 kg/m². Examination revealed central obesity, buffalo hump and red striae of skin located on the inner surface of the right thigh.

Laboratory findings

Her HbA1c was 9.91%

Plasma potassium level 3.47 mmol/l

Overnight dexamethasone suppression cortisol 488 nmol/l

24 h urinary free cortisol 1877.12 nmol/24 h

ACTH was less than 5 ng/ml

DHEAS 10.5 µmol/l

FSH 5.28 U/l; LH 2.99 U/l

Chromogranin A 45.8 µg/l

Aldosterone: renin ratio 0.4

Abdominal CT

Axial pre-contrast CT image of the left adrenal showed 3 masses: 30 × 35 mm (22 HU), 19 × 16 mm (16 HU), 17 × 17 mm (18 HU). At the right adrenal 2 masses were found: 16 × 18 mm (26 HU), 10 × 10 mm (−18 HU). The masses enhanced 60 s after rapid IV contrast bolus to +54 HU, +84 HU, +61 HU, +96 HU, +63 HU; after a 10-min delay, the contrast washed out of the masses to +38 HU, +49 HU, +49 HU, +43 HU, +32 HU (approximately 50%, 56%, 30%, 75%, 38% washout) respectively. The diagnosis of ACTH-independent Cushing`s syndrome, bilateral macronodular adrenal hyperplasia, steroid diabetes, secondary arterial hypertension, secondary amenorrhoea was established. Treatment was adjusted accordingly: glulisine 18 IU/day, glargine 100 IU/ml 20 IU/day. Losartan 100 mg/day, bisoprolol 2.5 mg/day, potassium supplements. After obtaining a satisfactory control of glycemia and blood pressure the patient was succesfully submitted to the left retroperitoneoscopic adrenalectomy (Saint-Petersburg’s Clinic of High medical technologies named after N. I. Pirogov). The histology showed adrenal macronodular hyperplasia. Cortisol following the surgery was 32 nmol/l. During the first 6 months, the patient required replacement therapy (hydrocortisone 15 mg/day). The operation led to a complete clinical remission (withdrawal of hypoglycemic and hypotensive medications). Follow-up of the patient (low-dose dexamethasone suppression test annually, CT scans) showed no deterioration of the condition and no growth of masses in the right adrenal gland.