A 33-year-old lady was referred to the endocrinology clinic with mild hyperprolactinaemia on the background of having missed a single period, with a raised testosterone of 4.1 nmol/l (02). She had no other medical problems. Her menstrual cycles normalised by the time she attended clinic. She had no galactorrhoea, visual disturbance or features of hyperandrogenism. Her BMI was normal and she was normotensive. Blood tests revealed mild hyperprolactinaemia of 709 nU/l (100500), which normalised to 243 nU/l post-cannulation, confirming stress hyperprolactinaemia. However, a raised dehydroepiandrosterone sulphate (DHEAS) of 24.5 umol/l (0.711.) was also noted. Testosterone was normal on repeat measurement (1.7 nmol/l). Oestradiol, SHBG, TFTs, FSH, LH, and 17-OHP were all normal. Repeated DHEAS throughout her menstrual cycle remained elevated (17.620.4 umol/l) and adrenal imaging was therefore undertaken. CT adrenals revealed a 2.1 cm lesion in the right adrenal gland with concerning features (pre-contrast HU44). An overnight dexamethasone suppression test demonstrated a suppressed cortisol (<28 nmol/l), but an unsuppressed DHEAS (20.4 umol/l). Plasma metanephrines and a pelvic ultrasound were normal. 24-h urine steroid profile showed elevation in two androgen metabolites: aetiocholanolone-5 β 1930 ug/24 h (2701390) and androstenetriol 740 ug/24 h (100250), but overall the results were not typical of a biochemically active adrenocortical carcinoma. MDT recommended surgery based on the concerning radiological features. She underwent a right retroperitoneoscopic adrenalectomy. Her DHEAS normalised (10 umol/l) by day 1 post-op. Histology demonstrated a Weiss criteria score of 2 with no clear capsular invasion suggesting an adrenal neoplasm of uncertain malignant potential.
Discussion: Pure DHEAS-secreting tumours are very rare and typically present with hirsutism and virilisation in >90% of patients. However, here we present an androgen-secreting tumour in the absence of clinical symptoms or signs of hyperandrogenism, but with a previous one-off raised testosterone level. Thus, this case demonstrates that the absence of androgenic symptoms cannot exclude the presence of these DHEAS-secreting tumours.