A 35-year-old farmer sustains chest injuries following an accident at the farm for which he is subjected to CT imaging of thorax and abdomen which reveals bilateral adrenal mass, measuring 4 cm × 3 cm × 4 cm, homogeneous, smooth walled, isodense with liver and well enhancing on contrast administration. He is asymptomatic prior to the accident. Examination reveals a normally built male, normal vitals, no postural drop in blood pressure. No obvious hyperpigmentation. Biochemical evaluation are all normal except a serum sodium levels of 129 mEq/L. TSH, total T4 levels are normal. At 8 am cortisol is 5 mg/dL with a corresponding ACTH of 100 pg/mL. A synacthen stimulation test with 250 mg given IV is done and 60 min cortisol of 13 mg/dL is obtained. A diagnosis of Addison’s disease is made. Chest X-ray and Mantoux test are normal. 24-hour urine collection for metanephrines is normal. A CT-guided FNAC is performed which reveals 2–4 μm oval, budding yeast forms with a probable diagnosis of histoplasmosis. ELISA for human immunodeficiency virus is negative. Patient is started on hydrocortisone 15 mg/day in two split doses. Patient is given intravenous amphotericin B for two weeks followed by oral itraconazole for one year.
What is the morbidity and mortality of subclinical Cushing syndrome?
Medicine
An increased frequency of hypertension, central obesity, impaired glucose tolerance or diabetes, hyperlipidemia and osteoporosis has been described in patients with subclinical Cushing syndrome in a number of retrospective or cross-sectional studies.
Despite the reported association between SCS and the metabolic syndrome, evidence of increased mortality in patients who have clinically inapparent adrenal adenomas and subclinical Cushing syndrome is lacking. The (scarce) available data suggest that most patients with adrenal incidentalomas remain asymptomatic throughout life. Also, long-term follow-up data in unavailable to choose surgery over medical management. The AACE/AAES Medical Guidelines for the management of adrenal incidentalomas suggest that until further evidence is available regarding the long-term benefits of adrenalectomy,surgical resection should be reserved for those with worsening of hypertension, abnormal glucose tolerance, dyslipidemia, or osteoporosis especially younger patients.
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