A 72‐year‐old man with a history of coronary artery disease, diabetes mellitus type 2, hypertension, and nonfunctional left adrenal cortical adenoma resected 1 month ago presented after a syncopal episode lasting several minutes. He felt lightheaded prior to losing consciousness. There was no seizure activity, confusion, unilateral weakness, chest pain, palpitations, or shortness of breath. He regained consciousness within several minutes. Vital signs showed orthostatic hypotension. Mucous membranes were moist. No murmur was auscultated. Abdomen was mildly tender to palpation over the left lower quadrant, where there was a well‐healing surgical scar. On labs, serum sodium was 134, potassium 4.7, bicarbonate 19, BUN 31, creatinine 1.9, hemoglobin 9.3, MCV 77.8, and WBC 9.2 with normal differential, platelets 286. Cardiac enzymes were normal; EKG was unchanged from prior. Computed tomography of the head without contrast revealed no intracranial hemorrhage or mass lesions. Computed tomography of the abdomen revealed no retroperitoneal hemorrhage. Transthoracic echocardiogram was normal. Blood and urine cultures were negative. His blood pressure remained symptomatically low despite resuscitation with several liters of normal saline. Random serum cortisol level was low. Dexamethasone was administered, and his blood pressure stabilized. Cosyntropin stimulation testing along with low ACTH, low aldosterone, and high renin confirmed the diagnosis of primary adrenal insufficiency. He was discharged on hydrocortisone.
Hospitalists often encounter syncope and hypotension in the inpatient setting. In patients with refractory hypotension, adrenal insufficiency (AI) should always be considered. Primary AI is seen with bilateral adrenalectomy. Adequate treatment must be administered perioperatively to prevent the development of an adrenal crisis. Unilateral adrenalectomy presents a more complex scenario. For this reason, preoperative dexamethasone suppression testing and 24‐hour urine free cortisol are recommended to rule out subclinical Cushing syndrome. Further evaluation with ACTH, renin, and aldosterone levels distinguish primary from secondary AI. Glucocorticoid maintenance is required with stress dosing at times of illness or surgery. In this case, the preoperative cortisol level was normal, yet the adenoma likely caused subclinical Cushing syndrome. The contralateral adrenal gland's cortisol production was suppressed through negative feedback of the hypothalamic‐pituitary‐adrenal axis.
Adrenal incidentalomas are commonly encountered on abdominal imaging. Both internists and surgeons must be aware of the indications for removal, perioperative workup, and potential sequelae of removal.
To cite this abstract:Somasekharan V, Cerreta K, Bhatnagar D. Incidental‐Oh‐My!. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 248. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/incidentalohmy/. Accessed August 23, 2019.