Category: Adrenal Disorders

Type: e-Poster

Monitor: 6


Saturday, Apr 27
10:30 AM – 11:00 AM

Objective :

To recognize the importance of evaluating causes of secondary diabetes mellitus in uncontrolled diabetics through detailed history and physical exam.

Methods : n/a

Results :


Discussion :

A 57 year-old woman with PMH of uncontrolled type 2 diabetes mellitus (DM2) was initially admitted to the hospital for altered mental status secondary to UTI. Elevated liver enzymes at presentation prompted a RUQ US which revealed an 8cm mass concerning for an adrenal etiology for which Endocrinology was consulted. At initial encounter, the patient reported generalized fatigue and weakness but denied any changes in weight or distribution of fat, striae, easy bruising, hirsutism, headache, palpitations, and flushing. Menopause was 1 year ago. DM2 was diagnosed at least 9 years prior and treated with two oral agents and insulin aspart 70-30 mix 20 units BID with HbA1c of 12.3%. Vitals were normal and physical exam was significant for mild hirsutism, buffalo hump, and 2+ edema in the bilateral lower extremities. Labs showed T. Bil 0.6 mg/dL (N: 0.1-1.2 mg/dL), ALP 330 U/L (N: 38-126 U/L), AST 37 U/L (N:<36 U/L), ALT 133 U/L (N: <46 U/L). Midnight salivary cortisol was 0.43 µg/dL and 0.73 µg /dL (N:<0.01-0.09 µg/dL) and post-1mg dexamethasone cortisol was 17.0 µg/dL. ACTH, DHEAS, normetanephrines, metanephrines, renin, and aldosterone were all normal. CT revealed a large adrenal mass invaginating into the liver. No metastatic lesions were found. The patient underwent R adrenalectomy. The tumor was 13cm and 380g and pathology confirmed adrenal cortical carcinoma (ACC). Liver enzymes normalized after surgery and she was discharged on glargine 3 units and premeal lispro 3 units for the DM2.

ACC is a rare disease affecting 1-2 people per million per year. Sixty percent are hormone-producing and most present with Cushing’s syndrome. Our case is unique in that hypercortisolism manifested most prominently as uncontrolled DM2 (as evidenced by the rapid decline in insulin requirement post-surgery) and had only mild physical findings suggestive of Cushing’s syndrome. While not all patients with poor glycemic control warrant biochemical screening tests for Cushing’s syndrome, a detailed history and physical exam can help determine the next step.

Conclusion :

Even hormone-secreting ACCs can be asymptomatic. Although uncontrolled DM2 can be due to multiple factors, taking the extra time to conduct a thorough history and physical exam on patients with sudden or progressively worsening glycemic control for symptoms and signs of Cushing’s syndrome is extremely beneficial.


Yumiko Tsushima

Icahn School fo Medicine at Mount Sinai Beth Israel
New York, New York

Resident Physician

Esra Kalkan

Icahn School fo Medicine at Mount Sinai Beth Israel

Clinical Fellow

Mariana Rivera

Icahn School fo Medicine at Mount Sinai Beth Israel

Resident Physician

Maria Brito

Assistant Professor
Icahn School fo Medicine at Mount Sinai Beth Israel