Endocrine Abstracts

Introduction: Adrenocortical carcinoma (AC) is a rare malignant endocrine tumor of the adrenal cortex. The psychiatric manifestations observed in AC are associated with a delayed diagnosis.

Case presentation: A 27-year-old women with medical history of severe psychosis resistant to antipsychotic medications, was hospitalized in our unit for Cushing’s syndrome (CS). The physical examination revealed classical signs of CS. The Laboratory results showed 24-hour urinary free cortisol values higher than 4 times the upper limit of normal, elevated midnight serum cortisol at 86 ng/ml and no suppression of cortisol during a low-dose dexamethasone suppression. The presence of a plasma ACTH level < 3 pg/ml suggests ACTH-independent CS. Adrenal CT scan showed a 35*23 mm mass located in the left adrenal gland with an absolute washout of 28%. The patient underwent unilateral adrenalectomy. Histopathological analysis revealed adrenocortical carcinoma with a Weiss score of 4. The evolution was characterized by the improvement of psychiatric symptoms, hence the discontinuation of antipsychotic medications.

Discussion: AC is a rare malignant tumor. Its incidence is approximately 1 to 2 new cases per million per year. It occurs most often in adults between 40 and 50 years of age, with a female predominance. The prognosis is poor (five-year survival rate of less than 50%). The glucocorticoid hypersecretion observed in CS is accompanied by sleep disorders, thymic manifestations, especially depression, and cognitive disorders, but psychotic states are rare. Hypercortisolemia modulates the response of the central nervous system through the activation of membrane channels, synaptic transmission of neurotransmitters (such as serotonin, glutamate and GABA), gene transcription, synaptic plasticity, neurogenesis and apoptosis. Excessive activation of the dopaminergic system is at the basis of the pathophysiology of manic symptoms, psychotic disorders and also some forms of depression.

Conclusion: Our case illustrates the importance of a good interrogation and a careful clinical examination in all patients presenting with a psychiatric illness, in order to eliminate an organic cause which can engage the vital prognosis.