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Case 208

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18-year-old male patient sought dermatological service due to acne. Physical examination showed blood pressure of 200/140 mmHg, central obesity, edema in the lower limbs, purplish stretch marks on the lower abdomen and plethoric face. He had a history of nephrolithiasis and diagnostic of left adrenalincidentaloma detected from CT. MRI was requested to further study of the injury.

Based on patient data and images available, which is the most likely diagnosis?

a) Phaeochromocytoma

25%

b) Cushing syndrome

25%

c) Primary aldosteronism

25%

d) Adrenocortical carcinoma

25%
   

Image analysis

 

 

Images 1 and 2: CT of abdomen and pelvis in the coronal and transverse cuts, non-contrasted. Presence of adrenal nodule on the left (red circles), measuring approximately 2.7 x 2.2 cm, homogeneous and well delimited, without calcifications. Nephrolithiasis ont the right (blue arrow).

 

Image 3: MRI of the upper abdomen, weighted sequence in T1. Presence of image with nodule aspect, circumscribed, measuring 2.6 x 2.1 cm, heterogeneous, isointense to muscles and slightly hypointense relative to liver. It was requested for more important information to distinguish between benign or malignant mass.

Highlights

- Adrenal incidentalomas are masses larger than 1 cm in diameter, accidentally discovered by any imaging. They are prevalent, with an incidence of at least 2% in the general population.
- Faced with adrenal incidentalomas, even with suggestive symptoms, it is very important to confirm the hyperfunction with confirmatory laboratory tests.
- Cushing syndrome represents several clinical manifestations resulting from chronic exposure to glucocorticoids.
- Fragility of the skin, large and violet stretch marks, proximal myopathy, facial plethora and "buffalo hump" are more specific signs of the syndrome.
- Suppression test with 1 mg of dexamethasone is the preferred test if incidentalomas.
- CT is the imaging modality of choice to differentiate benign and malignant masses.

References

- Young WF Jr. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med 2007; 356:601.

- Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2008; 93:1526.

- Findling JW, Raff H, Aron DC. The low-dose dexamethasone suppression test: a reevaluation in patients with Cushing's syndrome. J Clin Endocrinol Metab 2004; 89:1222.

- Guerrero MA, Schreinemakers JM, Vriens MR, et al. Clinical spectrum of pheochromocytoma. J Am Coll Surg 2009; 209:727. 

Authors

Lucas Müller Fonseca, 6th year medical student at UFMG.

E-mail: lucmufonse[arroba]gmail.com

 

Rafael Waldolato Silva, 6th year medical student at UFMG.

E-mail: rwaldolato[arroba]hotmail.com

Supervisor

Dra. Anelise Impelizieri Nogueira, médica membro do serviço de endocrinologia do HC-UFMG

E-mail: aneliseimp[arroba]gmail.com

Reviewers

Luísa Bernardino, Fernando Bottega, Raíra Cezar Barbara Queiroz, André Guimarães, Cairo Mendes and Prof. Viviane Parisotto.

Translated by

Luísa Bernardino Valério, 4th year medical student at UFMG.

E-mail: luisabernardino[at]gmail.com

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