SUN-481 Importance of Identifying Hypercortisolism in Primary Care

Abstract Disclosure: E.R. Williams: None. D.J. Selen: None. Background: Hypercortisolism is an uncommon disorder with diverse clinical features that overlap with common conditions. A spectrum of disease exists including Mild Autonomous Cortisol Secretion (MACS) and Cushing’s Syndrome. It is encountered infrequently and requires a prompt diagnostic approach to identify the underlying cause. The initial identification of hypercortisolism is often made by the PCP, making clinical awareness of the condition crucial in Primary Care. Case Presentation: A 24-year-old female presented to her PCP with weight gain, fullness of the face, acne, fatigue, and anxiety. She had no other medical problems apart from a left radial fracture from a fall six months prior. Her medications included an oral combined contraceptive (OCP). The physical examination revealed newly elevated blood pressure, facial plethora, hirsutism, and truncal obesity, suggestive of hypercortisolism. An evaluation for hypercortisolism revealed TSH 0.791uU/mL (0.350- 5.500 uU/mL). Two, 24hr urinary free cortisol levels were elevated at 87.4 ug/d and 324 ug/d (<45.0 ug/d). Late night salivary cortisol (LNSC) was elevated at 1.250 ug/dL (age 19-30: 0.012- 0.743ug/dL). Early morning ACTH level was suppressed at 2.1pg/mL (7.2-63.3pg /mL). 1mg Dexamethasone suppression test (DST) done on OCP demonstrated lack of cortisol suppression, 47.3 ug/dL (0.0- 5.0ug/dL) with Dexamethasone 577.8ng/dL (140-295 ng/dL). A computed tomography (CT) scan of the adrenals showed two left adrenal gland nodules, 2.7x 2.0cm and 1.4x 1.4 cm with absolute washout 69.8% and 81% respectively, consistent with benign adenomas. DXA showed osteoporosis (Z Scores -2.8 in right femoral neck, -2.9 in left femoral neck). She was referred to Endocrine Surgery in NYC for management by her PCP. Conclusion: This case highlights the evaluation of hypercortisolism caused by an adrenal adenoma. Cushing’s Syndrome presents with symptoms similar to obesity and metabolic syndrome, making initial identification challenging. PCPs often encounter patients first and need to have a high index of suspicion to initiate biochemical testing. Endocrinology follow-up may be difficult to arrange, so familiarity in primary care prevents delays in diagnosis. Since hypercortisolism may present subtly, it is important to recognize MACS, a distinct clinical entity characterized by elevated serum cortisol (levels (>50nmol after 1mg DST) without overt features of Cushing’s Syndrome. While Cushing’s Syndrome is widely known, MACS is more prevalent but under-recognized in primary care. For this patient, surgical treatment was beneficial given her secondary hypertension and osteoporosis were caused by hypercortisolism. Timely recognition of hypercortisolism by the PCP allows for thorough diagnostic workup and specialty care referral. This ensures appropriate risk reduction strategies and long-term follow-up of complications. Presentation: Sunday, July 13, 2025