Large Adrenal Pseudocyst Causing Subclinical Cushing's Syndrome

Presentation Number: SAT 371
Date of Presentation: April 1st, 2017

Travis J Mason*, Joseph D Jakowski, Diane Mary Biskobing, Francesco Saverio Celi and Giao Quynhthi Phan
Virginia Commonwealth University, Richmond, VA

Abstract

Introduction: Adrenal cysts are uncommon, making up <10% of adrenal masses, and most present as nonfunctional incidentalomas or with vague abdominal pain.

Clinical Case: A 24 years-old man presented with acute onset of right abdominal pain while lying in bed. Past medical history was significant only for hepatitis A at age 15. Physical exam showed a healthy-looking male who was afebrile, with heart rate 106, BP 115/74, and BMI 27 kg/m2. He had mild bilateral gynecomastia but no other unusual signs. Initial labs showed elevated WBC 20K and normal liver function tests. Abdominal ultrasound showed a large cystic adrenal/liver mass. CT scan showed a 15cm x 11cm x 10cm well-circumscribed hypodense cystic right adrenal mass abutting the liver and kidney. The mass was relatively homogenous except for a fluid-layering effect, with the nondependent upper half measuring 18 HU and the dependent lower half measuring 28 HU, suggesting recent bleeding settling in the dependent areas. The parenchyma of the right adrenal gland appeared to be compressed by the mass and displaced anteromedially.

The patient was admitted for pain control and workup of the adrenal mass. 24-hour urine collection (2070 mL) showed elevated free cortisol, measuring 282 mcg/24 hrs (normal 0-50). Plasma and 24-hour urine metanephrines and normetanephrines were normal. Plasma aldosterone was <1.0 ng/dL, and plasma renin activity was 1.39 ng/mL/hr, with A-R ratio <1. Random ACTH was suppressed at 3.0 pg/mL (normal 7-63). DHEA-S was low at 87 mcg/dL (normal 164-530). The remaining laboratory workup was notable for low albumin 3.6 g/dL (3.7-5.2 g/dL), low total protein 6.0 g/dL (normal 6.4-8.5), anemia with Hgb 11.8 g/dL (normal 13.3-17.2), and hypocalcemia of 8.4 mg/dL (normal 8.9-10.7). Although his WBC was elevated at presentation, it decreased to normal spontaneously.

He underwent open right adrenalectomy uneventfully with perioperative stress dose hydrocortisone. Histological examination showed a benign adrenal gland associated with a hemorrhagic pseudocyst. No adrenal cortical or medullary tumor was seen on extensive pathologic sectioning. The adrenal cyst consisted of a thick fibrous wall with organized internal contents of fibrin clot and degenerating blood. There was chronic periadrenal inflammation. The normal appearing adrenal gland was intimately associated with the fibrous wall of the pseudocyst. The patient was discharged home with hydrocortisone taper and currently doing well on low dose replacement 20mg/5 mg hydrocortisone.

Conclusion: Adrenal pseudocysts are rare and can present with nonspecific abdominal pain, but hormonal excess due to adrenal cysts is rare, with pheochromocytoma the most common. Some case reports have documented spontaneous hemorrhage or infection in adrenal cysts. Based on literature review, this may be the first case of a hemorrhagic adrenal pseudocyst causing Cushing’s syndrome.

 

Nothing to Disclose: TJM, JDJ, DMB, FSC, GQP