Endocrine Abstracts

We present a 38-year-old patient who had adrenal insufficiency following laparoscopic removal of 3.2 cm cortisol-secreting right adrenal tumour. His biopsy showed adrenocortical adenoma in keeping with Cushing’s syndrome. He had a history of hypertension with suboptimal control despite being on 3 anti-hypertensives. His early morning cortisol (by GP to investigate secondary causes) were elevated and this prompted Endocrine referral. Clinical history and examination were suggestive of Cushing”s hence we performed midnight cortisol, 24hour urinary-free cortisol and cortisol day-curve which confirmed increased cortisol production. His CT adrenals showed a 3.2 cm enhancing lesion in right adrenal gland (absolute washout of 40%). His plasma metanephrines and paired renin and aldosterone were unremarkable. The working diagnosis at this point was a functioning atypical adrenocortical adenoma vs low-grade adrenocortical carcinoma so was planned for urgent surgery. He had 6mg dexamethasone during induction pre-surgery followed by 100mg IM QDS hydrocortisone post-operatively. Once he was able to eat and drink, his IM hydrocortisone was converted to oral 20mg/10mg/10mg and down to 10mg/5mg/5mg within 3 days of surgery. Steroid education was provided pre-discharge. We felt that he was metabolising the hydrocortisone too quickly, so we incremented his hydrocortisone to 10mg/10mg/5mg/2.5mg. We noted reduced absorption and rapid metabolism of the hydrocortisone, and this coincided with him reporting extreme tiredness. We switched his hydrocortisone to prednisolone 5mg. His cortisol pre-prednisolone at 12 months was 312 nmol/l and ACTH of 71 ng/l suggesting axis recovery. The cortisol and ACTH prior to this were showing inadequate axis recovery. We reduced his prednisolone by 1 mg every 2 weeks and when he was on 2 mg, his afternoon cortisol was 252 nmol/l suggesting a full recovery. We reduced it further to 1 mg and then stopped. Postoperative cortisol insufficiency following unilateral adrenalectomy for hypercortisolism is inevitable. It is mandatory to treat patients with glucocorticoid therapy intra-and post operatively. The duration of cortisol replacement is variable, and a longer follow-up is required to look into the recovery of the contralateral adrenal gland.