What are the symptoms and signs suggestive of adrenal hyperfunction or malignant disease?

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The groups of hyperfunction that can occur in a patient with adrenal inci-dentaloma include Cushing’s syndrome (including subclinical), pheochromo-cytoma, primary hyperaldosteronism and lastly adrenocortical carcinoma. Most of these conditions, have subtle, vague features that can be easily missed with a cursory examination. Every attempt must be made to elicit history and signs suggestive of these in all patients with adrenal incidentaloma.

Cushing’s syndrome

Symptoms

• Weight gain with central obesity facial rounding and plethora,

• Easy bruising, thin skin, poor wound healing, purple striae, proximal muscle weakness

• Emotional and cognitive changes (e.g. irritability, spontaneous tearfulness, depression)

• Opportunistic and fungal infections, altered reproductive function, acne, and hirsutism.

Signs

• Hypertension, osteopenia, osteoporosis

• Fasting hyperglycemia, diabetes mellitus

• Hypokalemia, hyperlipidemia, and leukocytosis.

Subclinical Cushing’s syndrome

The obvious stigmata of Cushing’s syndrome may be absent, but, these patients

may have the adverse effects of continuous, endogenous cortisol secretion,

including hypertension, obesity, diabetes mellitus, and osteoporosis.

Pheochromocytoma: Patient may be asymptomatic; episodic symptoms may

occur in spells (paroxysms).

Symptoms

• Forceful heartbeat, pallor, tremor, headache

• Diaphoresis; spells may be either spontaneous or precipitated by postural

change, anxiety, medications, maneuvers that increase intra-abdominal pressure (e.g. change in position, lifting, defecation, exercise).

Signs

• Hypertension (paroxysmal or sustained)

• Orthostatic hypotension, pallor, hypertensive retinopathy grades 1–4, tremor,

and fever.

Primary aldosteronism

Symptoms

Nocturia, polyuria, muscle cramps, and palpitations

Signs

• Hypertension, mild or severe

• Hypokalemia and mild hypernatremia.

Adrenocortical carcinoma

Symptoms

• Mass effect (e.g. abdominal pain) and symptoms

• Related to adrenal hypersecretion of cortisol (Cushing’s syndrome)

– Androgens (hirsutism, acne, amenorrhea or oligoamenorrhea, oily skin,

and increased libido)

– Estrogens (gynecomastia)

– Aldosterone (hypokalemia-related symptoms).

Signs

• Hypertension, osteopenia, osteoporosis, diabetes mellitus

• Hypokalemia, hyperlipidemia, fasting hyperglycemia

• Leukocytosis with relative lymphopenia.

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