Endocrine Abstracts

Cushing’s syndrome results from an excess exposure to glucocorticoids which can result from various causes, divided into ACTH-dependent and ACTH-independent etiologies. An example of ACTH-independent causes are adrenal masses which are either benign adenomas, representing the majority of adrenal mass cases, or by malignant neoplasms. We present the case of a 52 yo woman who presented at the Emergency Department (ER) with thoracic pain and palpitations, for which several cardiac investigations where performed including a thoracic CT scan in order to exclude a pulmonary embolism (PE). The CT scan infirmed the PE, but revealed masses on both adrenal glands. The left adrenal gland showed a heterogeneous, hypodense aspect with a nodule of 1,7 cm and 106 HU. The right adrenal gland showed an homogeneous, hypodense aspect of -13 HU. Therefore the patient was transfered to the Endocrinology Department. Physical examination revealed an obese patient with central fat distribuition, lean proximal parts of the limbs, buffalo hump, hirsutism and kyphotic attitude of the spine. The patient was known with a history of arterial hypertension grade 3, uncontrolled despite treatment with 4 antihypertensive drugs and she complained of mechanical back pain. The routine blood tests were normal, except a mixted dyslipidemia. We excluded pheochromocytoma and primary hyperaldosteronism. Cortisol circadian rhythm was abnormal and basal plasma ACTH low. The cortisol secretion did not suppress after administration of 1 mg overnight of dexamethasone. Severe osteoporosis was diagnosed after DXA evaluation with a vertebral fracture at T4 level. After diagnosing Cushing’s syndrome due to primary bilateral macronodular adrenal hyperplasia we decided to perform unilateral adrenalectomy because our patient had moderately increased cortisol production, but with clinical evidence of cortisol excess and the left adrenal was larger on CT scan. Unfortunately, we were not able to screen for aberrant receptors or perform adrenal venous sampling. The particularity of this case is the fact that the patient presented at the ER complaining of nonspecific thoracic pain and the diagnosis of Cushing’s syndrome was suspected via an imaging which was not perfomed for evaluation of an adrenal disease.