72 year old female presented with lower abdominal pain and was incidentally noted to have right adrenal adenoma. On further evaluation, she was noted to be experiencing excessive weight gain despite healthy lifestyle, low trauma fracture right wrist 3 yrs ago and uncontrolled hypertension despite taking 3 anti-hypertensive medications. She had no overt clinical features of Cushings such as striae, proximal myopathy, thinning of skin or easy bruising. Screening biochemistry revealed raised aldosterone:renin ratio. Subsequent saline suppression test confirmed diagnosis of primary hyperaldosteronism. In addition, endocrine testing confirmed excessive cortisol production (abnormal overnight dexamethasone suppression test, 24 h urine cortisol × 2 and a low dose dexamethasone suppression test). Following discussion in adrenal MDT, she underwent right adrenalectomy. She was started on hydrocortisone replacement postoperatively due to concerns of developing adrenal insufficiency secondary to suppression of hypothalamicpituitaryadrenal axis following removal of a tumor that secretes glucocorticoids. A well circumscribed, homogenous and bright golden yellow adrenal adenoma without evidence of malignancy was confirmed histopathologically. Six weeks post-adrenalectomy, repeat testing showed equivocal aldosterone:renin ratio. During postoperative period, she had adequate cortisol response to short synachthen test hence she was gradually weaned off hydrocortisone replacement therapy. Six months postoperatively her Aldosterone : rennin ratio and 24 h urine cortisol measurements done twice are within normal reference range. At present, her BP is controlled on single antihypertensive agent (Doxazosin 4 mg).
Conclusion: It is important to recognize co-secreting adrenal adenomas. Given that most cases are unilateral, postoperative adrenal crisis or symptomatic adrenal insufficiency can occur in patients who had undiagnosed or untreated adrenal adenomas co-secreting excess mineralocorticoids and glucocorticoids. In addition, these patients require regular monitoring as incidence of cardiovascular and metabolic disorders in Aldosterone- and cortisol-coproducing adrenal adenoma is significantly higher than that of the pure aldosterone producing adenoma.