A 33-year-old lady was referred to the endocrinology clinic with weight gain, hirsuitism and amenorrhea. She had been diagnosed with hypertension a year ago which was difficult to control despite being on three anti-hypertensive agents Ramipril, Amlodipine and Bendroflumethazide. Past medical history included hypothyroidism secondary to radioactive-iodine therapy for Graves disease aged 22. Her GP organised an ultrasound scan querying polycystic ovaries but this revealed a large left adrenal mass.
In the endocrine clinic her history was suggestive of phaeochromocytoma with paroxysms of chest pain, palpitations and a feeling of impending doom. On examination however, she appeared cushingoid with hirsuitism, central obesity, abdominal striae and proximal myopathy. She had no history of headaches and visual fields were full on confrontation. There was no family history of clinically overt endocrine disease.
Results: Urinary free Cortisol 260 and 424 nmol/d (normal 10147), failure to suppress on both low and high dose dexamethasone tests, ACTH <5 ng/l (047), corrected calcium 2.82 mmol/l (2.12.6), PTH 18.1 pmol/l (1.57.6), 24 h urine calcium 18.4 mmol/d (2.57.5), two sets of 24-h urine catecholamines were normal.
MRI Adrenals showed an 8 cm left adrenal mass. Neck ultrasound showed a right inferior lobe parathyroid adenoma.
She underwent laparoscopic adrenalectomy followed by parathyroidectomy a few months later. Histology showed a benign adrenal cortex adenoma and a parathyroid adenoma respectively. Interestingly soon after the adrenalectomy the hypercalcaemia got worse (levels rising above 3 mmol/l) and symptomatic that required intravenous fluids and bisphosphonate treatment.
Four months post surgery she had lost 10 kg in weight and stopped her anti-hypertensive treatment. She remains on hydrocortisone replacement.
This case highlights the rare concomitant presentation of adrenal Cushings and hyperparathyroidism as well as the unusual association of Graves disease in the same patient.
It also reminds us the importance of screening for secondary causes in young hypertensive patients.