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Case Reports in Endocrinology
Volume 2012 (2012), Article ID 503290, 4 pages
http://dx.doi.org/10.1155/2012/503290
Case Report

Adrenal Incidentalomas with Supraphysiologic Response to ACTH Stimulus: A Case Report

1SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 1205, Brooklyn, NY 11203, USA
2VA Medical Center, 800 Poly Place, New York, NY 11209, USA

Received 7 August 2012; Accepted 20 September 2012

Academic Editors: I. Broom, C. Capella, and T. Konrad

Copyright © 2012 Marianna Antonopoulou and Asya Perelstein. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

We present the diagnostic approach of a patient with adrenal incidentalomas. A 72-year-old African American male had a CT scan of the abdomen showing right and left adrenal masses measuring and , respectively. The patient had negative hormonal workup. The radiologist insisted that the CT findings are consistent with adrenal hyperplasia, and therefore he underwent ACTH stimulation to rule out late-onset congenital adrenal hyperplasia (CAH). The stimulation test revealed that 17-hydroxyprogesterone and 11-deoxycortisol increased to levels high enough to confirm CAH, but cortisol had exaggerated response as well, thus making the diagnosis of CAH unlikely where metabolism is shifted to precursors. Subsequently, the patient underwent screening for Cushing's syndrome (CS) with a dexamethasone suppression test. Patient failed the suppresion test, raising the issue for subclinical CS (SCS), likely due to ACTH-independent macronodular adrenal hyperplasia. Our patient had been diagnosed with MGUS and so far there are only 3 case reports of extramedullary plasmacytoma arising from the adrenals. One was bilateral and one had functional abnormalities. Our differential diagnosis includes subclinical CS with aberrant receptors versus a functioning extramedullary plasmacytoma.