Category: Adrenal Disorders
Objective : Several publications and guidelines highlight the importance of monitoring and follow up of patients with adrenal adenomas for risk of incident cardiovascular disease and worsening metabolic profile.
Methods : n/a
Results : n/a
Case Presentation: A 56-year-old woman presented in 2007 to the endocrine clinic with a 30-year-history of type 1 diabetes (T1D) with severe insulin resistance, morbid obesity, cardiovascular disease, depression, osteoporosis, steatosis, and a 3-year history of a left 2.5 cm adrenal adenoma incidentally diagnosed in a urologic examination. She noted a 100-pound weight gain since 1999 and provided the following medical history: ankle edema, multiple fractures, chest pain, chronic fatigue, musculoskeletal pain, muscle weakness, numbness/tingling, tremor, and failing vision. Biochemical testing revealed a cortisol post-DST of 2.3 µg/dL, ACTH 5 pg/mL, and UFC of 113 µg/24hr (0-50 µg). Her cortisol level, post-DST, according to the standard of care at the time, did not meet criteria (DST > 5 µg/dL) for surgical or medical treatment. Instead she was monitored, and her comorbidities managed.
Her adenoma was monitored intermittently by CT scan over a 14-year period and remained unchanged. In 2018, after progression of multiple comorbidities, hypercortisolism was suspected based on worsening of insulin resistance (requiring U-500 insulin), chronic infections, muscle weakness (requiring the use of a scooter due to frequent falls), osteomyelitis (with 2 toe amputations), congestive heart failure, and kidney disease. A repeat DST of 5.1 µg/dL and ACTH <5 pg/mL prompted the diagnosis of ACTH-independent Cushing syndrome and medical treatment with mifepristone (MIFE, Korlym®, Corcept Therapeutics) after the patient was deemed a nonsurgical candidate due to overall health. Within the first 4 months of MIFE treatment, the patient lost 38 lbs and decreased her insulin usage by 42%, achieving her intended weight-based insulin dose.
Patients with adrenal adenomas incidentally discovered should be referred to endocrinology for biochemical testing, as prolonged exposure to cortisol may have serious consequences. In addition to long-term observation, earlier intervention with the appropriate treatment may have decreased the chance of disease progression and worsening of other comorbidities. MIFE in this patient was effective for reducing insulin requirements and weight.
Midstate Endocrine Associates and Lipscomb University College of Pharmacy and Health Sciences, Tennessee