Endocrine Abstracts

Arterial hypertension (AH) may be the initial clinical presentation of various endocrine disorders. An accurate diagnosis provides an opportunity to achieve a cure of AH in some cases. Female patient, born in 1971, was referred to endocrinologist in 2018, at the age of 47 y, presented with AH and adrenal adenoma. Since the age of 35 y (2006), after the third delivery she had been suffering from AH with paroxysmal BP surges up to 180/120 mmHg, accompanied by panic, anxiety, sweating, tremor, palpitations, urge to urinate or defecate. Repeated urine catecholamines and metanephrines tests as well as adrenal US images were unremarkable. She had been followed by cardiologists with diagnose of hypertensive disease (paroxysmal hypertension). Despite regular taking 2–3 antihypertensive medications the paroxysmal attacks repeated occasionally. In 2017 the left-sided 17 × 14 mm adrenal mass (adenoma?) was found on CT and in 2018 she was referred to endocrinologist. Careful examination revealed moderate central body fat redistribution, normal BMI, rounded face and facial redness (though patient denied any significant changes in her appearance). No striae, easy bruising, hirsutism or thinning of the skin were found. Laboratory tests demonstrated normal 24-h urine metanephrines, 24-h urine free cortisol, plasma electrolytes, glucose, TSH, prolactin, renin and aldosterone, but increased ACTH level of 68-71-99 (normal < 46) pg/ml, increased late-night salivary cortisol- 17,1 (normal < 9.4) nmol/l and no suppression of plasma cortisolafter 1 mg overnight dexamethasone test. At the same time 4 × 4 × 2 mm microadenoma on pituitary MRI and osteopenia had been detected. The diagnosis of ACTH-dependent endogenous hypercortisolism (Cushing’s disease) was established. Retrospective analysis of patient’s medical history had revealed that in 2008 ACTH elevation up to 81.8 (normal ≤ 63.3) pg/ml was detected, but the subsequent retesting had shown ACTH at the upper level of normal range. In 2012 and 2014 no microadenoma was clearly identified at the pituitary MRI. In 2019 the transsphenoidal resection of microadenoma was performed and Cushing’s disease was histologically confirmed. After surgery BP and ACTH levels had returned to normal, and the paroxysmal attacks have not been recurred up to date. The non-typical features of this case comprise long duration of undiagnosed endogenous hypercortisolism with only manifestation of paroxysmal AH, inconsistent laboratory results, slow progression of rather modest signs of Cushingoid appearance, formation of unilateral adrenal mass. All these characteristics, more closely resembling the clinical picture of pheochromocytoma, could be misleading for cardiologists and resulted in the delayed correct diagnosis.