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BACKGROUND
This 76-year-old woman was admitted to the hospital
because she had collapsed and lost consciousness. She
had been feeling unwell for 2 weeks and was admitted 1
week previously with similar symptoms but discharged
herself 3 days later.
Her past history included diabetes mellitus type 2 of 10
years' duration. On this occasion, she complained of
nausea and vomiting. On direct questioning, she reported
having postural dizziness.
On examination, she was listless. She appeared to be
tanned, with increased pigmentation of the palmar
creases. Her BP was 90/50 mm Hg supine and 70/40 mm Hg
standing. Her pulse was 70 beats per minute, and her
oxygen saturation was 99% on pulse oximetry on room air.
The patient's ECG findings were normal, and her sodium
and potassium levels were 124 mEq/L and 4.6 mEq/L,
respectively. The rest of her biochemical and physical
findings were normal.
Palpation of the patient's breasts revealed atrophy but
no masses. Her random cortisol level was 121 mcg/dL (43
mcg/dL on her previous admission). A short cosyntropin
test showed a baseline cortisol level of 88 mcg/dL and a
30-minute level of 99 mcg/dL. The patient's
adrenocorticotropic hormone (ACTH) level was 513 pg/mL,
and tests for adrenocortical autoantibodies were
negative. Tumor markers were all negative apart from
cancer antigen (CA)–125, which was 1452 kU/L (reference
range, 0-34 kU/L) and CA 19-9, which was 3919 U/mL
(reference range, 0-35 U/mL).
Mammograms and a pelvic sonogram were normal. The
patient's initial chest radiograph was normal apart from
apical pleural thickening.
Treatment with hydrocortisone and later fludrocortisone
was started, and her symptoms improved. However, during
the next few days, the patient complained of increasing
shortness of breath. A repeat chest radiograph (A)
showed blunting of the costophrenic angles due to
pleural effusion, but no other abnormality. The pleural
effusion was tapped where a transudate was found, and no
malignant cells were seen on microscopy. CT scans showed
bilateral cystic adrenal masses (B) but no lung or
mediastinal lesions (C, D). Needle biopsy of the right
adrenal gland was unsuccessful.
What is the diagnosis? |
Hint
Bilateral adrenal masses causing adrenal failure |
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Author: |
Ali Nawaz Khan, MBBS, FRCP,
FRCS, FRCR, Lecturer, Department of Diagnostic Radiology, Faculty of
Medicine, University of Manchester, and Basil Issa, MBChB, FRCP,
Consulting Staff, North Manchester Heath Care NHS Trust |
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eMedicine Editor: |
Sat Sharma, MD, Associate
Professor, University of Manitoba, Department of
Medicine, Division of Pulmonary Medicine |
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