SAT-478 Virilizing Adrenal Adenoma Co-secreting Cortisol and DHEA-S: A Case Report

Abstract Disclosure: M. Bhalla: None. C. Victores: None. C.R. Udedibor: None. D. Lovre: None. R.C. Galagan: None. Background: ACTH-independent Cushing’s syndrome due to adrenal adenoma (AA) is usually associated with a reduction in adrenal androgens due to the suppression of pituitary ACTH secretion. Cortisol and androgen co-secretion is common in adrenocortical cancers but rare in functioning adrenal adenomas. We report the case of a benign AA co-secreting cortisol and dehydroepiandrosterone sulfate (DHEA-S). Case: A 43- year-old female with a history of PCOS, secondary amenorrhea, infertility, hirsutism, rapid 30 lb weight gain and anxiety-depression was referred for evaluation of a 2 cm left adrenal nodule (10 Hounsfield units) with peripheral wall calcification. Physical exam revealed a BMI of 25 kg/m2, coarse facial hairs and acne, and truncal obesity. Screening lab tests revealed 0800 cortisol 22.2 ug/d (6.2-19.4 ug/dL), ACTH 3.8 pg/ml (7.2-63.3 pg/ml), DHEA-S 230.8 ug/dL (57.3-279.2 ug/dL), aldosterone 1.7 ng/dL(1-15ng/dL,) 24 hr urine free cortisol (UFC) 60 ug/24hrs (< 50 ug/24 hrs), estradiol 88.4 pg/ml (12.5-498 mIU/mL), LH 7.7 mIU/mL, (1-95.6 mIU/mL), FSH 5.3 mIU/mL (1.7-21.5 mIU/mL), testosterone 40 ng/dL (8-48 ng/dL). Confirmatory testing for adrenal Cushing’s syndrome demonstrated a 0800 ACTH 18.9 pg/ml, DHEA-S 359ug/dL (57.3-279.2 ug/dL), 1 mg overnight Dexamethasone suppression test (DST) cortisol 1.0 ug/dL (<1.8 ug/dL), 24-hr UFC 105 ug/24 hrs and late-night salivary cortisol (LNSC) <2 ng/mL. She was referred for a laparoscopic left adrenalectomy. On post-op day 1 her 0430 cortisol was low at 0.40 ug/dL. She was discharged home without hydrocortisone replacement after a normal cortisol response of 19 ug/dL (≥18 ug/dL) at 60 minutes following Cosyntropin stimulation. One month post adrenalectomy 0800 cortisol was 30 mg/dl (6.2-19.4 ug/dL), ACTH 49 pg/mL (7.2-63.3 pg/ml), DHEA-S 190 mcg/dL (57.3-279.2 ug/dL) and a 24-hr UFC was 27 ug/24 hrs (< 50 ug/24 hrs). She reported a steady decrease in facial hair growth and acne, weight loss of 12 lbs, resolution of her previous insomnia and fatigue and cessation of depression symptoms. Conclusions: Our patient was unique in several respects: 1. Her prior history of PCOS initially biased the interpretation of elevated DHEA-S. 2. The elevated 24-hr UFC levels and the normal 1 mg overnight DST result and LNSC levels were consistent with cyclic adrenal Cushing’s syndrome. 3. The abnormal 24-hr UFC levels, the most specific confirmatory test for Cushing’s syndrome, and the presence of a 2 cm left adrenal nodule and normal appearing right adrenal gland were sufficient evidence for a surgical left adrenalectomy referral. 4. Her low morning cortisol on post-op day one and rapid recovery documented by a Cosyntropin stimulation test further substantiated the diagnosis of cyclic adrenal Cushing's syndrome. 5. Clinical improvement and restoration of normal 24-hr UFC and DHEA-S after surgery confirmed co-secretion of cortisol and DHEA-S by the adrenal adenoma. Presentation: Saturday, July 12, 2025