Endocrine Abstracts

Introduction: Renal cell carcinoma (RCC) is the most common type of malignant renal tumors in adults. It is often difficult to detect it precociously since early-stage renal tumors are usually asymptomatic and non-palpable. We report a case of RCC revealed by acute adrenal insufficiency (AAI).

Case report: Mr. A.B, 46 years old, 30 pack-year smoker, with a medical history of gout treated with Allopurinol, was admitted to our department for acute adrenal insufficiency. The anamnesis revealed a significant weight loss, asthenia and melanoderma. The evolution was marked by acute abdominal pain with vomiting, leading the patient to consult our emergency department. A baseline blood sample revealed hyponatremia (127 mmol/l), hyperkalemia (6.4 mmol/l) and functional renal failure. The patient immediately received intravenous hydrocortisone hemisuccinate with hyperhydration. The diagnosis of primary AAI was confirmed by a low plasma cortisol level (99 nmol/l) in the face of high adrenocorticotropin hormone (ACTH) level (>2000 pg/ml). Adrenal computed tomography (CT) showed hypotrophic adrenal glands and a right corticomedullary renal mass (38*47*48 mm). Renal magnetic resonance imaging (MRI), performed for a better characterization of this mass, showed a right medio-renal tumor with a central necrotic zone and exophytic development, without signs of locoregional extension. A tumorectomy was performed. Anatomopathological examination revealed RCC.

Discussion: An AAI revealing a RCC has been reported in a few publications. In those cases, the adrenal insufficiency was related to bilateral adrenal metastases. However, in the present study medical imaging showed hypotrophic adrenal glands suggesting an auto-immune mecanism. Indeed, the increasing use of ultrasound, abdominal CT and more recently MRI has increased the diagnosis of renal cancers at a presymptomatic stage to nearly 70%.