As abdominal imaging becomes more widespread, adrenal incidentalomas are increasingly detected. These are typically followed without intervention by physicians. However, growing evidence suggests that even benign-appearing adrenal lesions may be active, producing subtle but meaningful symptoms without clear initial biochemical findings. To illustrate the difficulties in diagnosis and management of patients with an incidentaloma, we present the case of a 61-year-old woman with an incidentally discovered left adrenal mass.
The patient’s past medical history is significant for hypertension and major depressive disorder, as well as a 9-month history of progressive morning anxiety, hot flashes, depressed mood, palpitations, chest discomfort, tremor, decreased appetite, and 17-lb unintentional weight loss with partial regain. Over the same interval, hormone replacement therapy (HRT) was initiated. Symptoms worsened and HRT was discontinued. Medications include triamterene–hydrochlorothiazide. The mass was identified 2 months before endocrine consult during imaging for post-influenza hepatomegaly. MRI demonstrated a 3.0 cm heterogeneous lesion.
Physical exam showed fine tremor without overt Cushingoid features (no striae, dorsocervical fat pad, central adiposity, or proximal weakness). Morning cortisol was 17 μg/dL (normal 5–19 μg/dL). A 24-hour urinary free cortisol was normal (19 μg/day; normal is 8–51 μg/day), but the urine cortisol/creatinine ratio was elevated (40; normal is 12–19). A 1-mg dexamethasone suppression test showed inadequate suppression (cortisol 5.3 μg/dL; normal is <1.8 μg/dL) with suppressed ACTH <1.5 pg/mL, supporting ACTH-independent cortisol secretion. Repeat CT at 3 months showed interval growth to 3.2 cm.
The patient was started on ketoconazole while awaiting surgery and underwent uncomplicated laparoscopic adrenalectomy 6 months after discovery. Pathology confirmed a low-grade adrenocortical adenoma. Postoperatively, she received physiologic hydrocortisone (20 mg AM/10 mg PM) with taper and reported improvement in blood pressure, mood, energy, appetite, and resolution of both anxiety and palpitations.
This case demonstrates that clinically significant but nonspecific symptoms with improvement after adrenalectomy can occur even with normal initial cortisol testing. This case emphasizes individualized evaluation and that suppression testing plus phenotype may justify adrenalectomy in selected patients with incidentaloma and suspected MACE.
