Diagnostic approach to a patient with bilateral adrenal masses: Case Report

Abstract

Case report: A 70-year-old female was admitted at our clinic with an 8-month history of epigastric abdominal pain, weight loss of 10 kg and vomiting, with normal upper gastrointestinal (GI) endoscopic evaluation and bilateral adrenal masses of 5 cm noted on abdominal computed tomography. Biochemical work up was significant for elevated ACTH (297 pg/ml), normal serum levels of basal cortisol and absent cortisol suppression on low dexamethasone test. The high ACTH to cortisol ratio along with clinical presentation of patient was indicative for an impending AI. Unfortunately, infusion ACTH-stimulation test for diagnosis of AI was not available at our institution. Because of persistent GI symptoms a control upper GI endoscopy was performed and revealed solitary gastric, 1 cm, necrotic nodular lesions which was biopsied. Presence of malignant cells was confirmed which was decisive for explorative laparotomy. Upon exploration, disseminated omental and mesenterial lesions were detected. Sadly, final diagnosis was metastatic malignant melanoma of unknown origin. Conclusion: The onset of overt AI is usually preceded by an increase in ACTH. Abnormal results of the pituitary-adrenal-axis in the presence of adrenal masses should raise suspicion for adrenal metastases and prompt comprehensive investigation for primary tumor should be performed.