Endocrine Abstracts

A 69 year old lady was initially seen in clinic in August 2020 for a right adrenal incidentaloma which was discovered after she had a CT abdomen for diverticulitis related symptoms. She subsequently had a dedicated CT Adrenal in January 2019 before she was seen in clinic which showed a 25 x 32 mm right adrenal adenoma labelled as lipid poor with an absolute & relative washout of 67% and 47% respectively. Her past medical history included hypertension and anxiety disorder. On clinical examination, she didn’t have any features of cortisol excess though she had a raised BMI of 31.99. An interval scan was organised which was stable. An overnight dexamethasone suppression test showed failed suppression with a Cortisol level of 175. 24 hr Urine Metanephrines was normal as was Aldosterone to Renin Ratio prior to which her Bisoprolol and Candesartan were switched to Doxazosin for 2 weeks. She then had a low dose dexamethasone suppression + CRH test. Baseline Cortisol was 379 and ACTH 10. At the end of the test, her cortisol still failed to suppress at 180 with an ACTH level of <3. Post CRH injection, repeat samples for cortisol & ACTH were taken at 15 and 30 mins. The cortisol levels came back at 184 and 171 and ACTH 3 and 4 at time 15 and 30 minutes respectively suggesting ACTH independent Cushing Disease. Her case was discussed at the Endocrine MDT and she went on to have a right laparoscopic subtotal adrenalectomy in August 2022. The delay was because she was referred to the drug alcohol liaison team for excess alcohol intake & her liver function tests improved dramatically as she cut down on her intake. The surgery was uneventful and she was started on IV hydrocortisone post op day 1 which was switched to 20/10/10 when she was more stable and eating and drinking. She was reviewed in clinic after 2 months and she was advised to wean down her hydrocortisone progressively over the next 10 weeks until she was on 10 mg OD. A histopathology report in the meantime confirmed an adrenocortical adenoma. An early morning cortisol done on 27/01/23 showed evidence of adequate cortisol production at 383 & her steroids were weaned down further until she was on 5 mg OD before discontinuing completely. She also has been booked for a DEXA scan & will be reviewed further in clinic.