Background: We describe a 64-year-old lady with past medical history of Thalassaemia Trait and Hypertension, who was presented with Cushings syndrome.
Clinical presentation: This patient was admitted with severe bi-basal pneumonia in February 2010 and treated successfully. But unfortunately her symptoms persisted with increasing facial swelling in end of May 2010, therefore, a staging CT was arranged and found incidental 6×5 cm left adrenal mass which was initially thought to be 2 separate left adrenal and renal masses with no evidence of metastasis or other primary site. She also had weight gain, facial plethora, thinning of the skin, easy bruising, moon face and increased subcutaneous fat deposition in the nape of the neck. Her 24 h urinary free Cortisol levels were raised at 552 and 736 (normal 10147). She had an over night 2 mg Dexamethasone suppression test which showed failure to suppress cortisol at 537 and ACTH was fully suppressed at <5.0. She also had a plasma rennin activity:aldosterone, plasma metanephrine, 24 h urinary metanephrines (2 samples), DHEA, Andostenedione which were all normal. LH, FSH and oestradiol levels were post-menopausal range. She underwent radical left adrenalectomy and left nephrectomy in June 2010 with hydrcortisone cover peri-operatively. Histology showed left adenocorticol carcinoma with penetration into the capsule and adjacent fat. We have started Mitotane 1 g BD along with Hydrocortisone 10/5/5 postoperatively and referred to Neuroendocrine Oncology team. She has been continuing to complain of significant fatigue and lethargy despite of adequate hydrocortisone supplement. She is due for hydrocortisone day curve and staging CT in a few weeks time.
Conclusion: Our patient is experiencing fatigue and lethargy for a prolonged period of time without a clear reason, after radical surgery, within the therapeutic range of Mitotane (1420) and adequate hydrocortisone replacement.