Concurrent secretion of aldosterone and cortisol from an adrenal adenoma -value of MRI in diagnosis

A 43-year-old female with a 24-years history of hypertension presented for further investigation and management of primary hyperaldosternoism. Postura l studies were not conclusive and magnetic resonance (MR) imaging demonstra ted a 27 x 18 mm lesion of the right adrenal gland which showed no signal l oss during in and out of phase imaging, Although these appearances were con sidered to be atypical of those seen on MR in patients with aldosterone pro ducing adrenal adenomas the patient underwent an adrenalectomy with removal of a 3 x 3 x 2 cm right adrenal mass, post-operatively she became hypotens ive and a 0900 hours serum cortisol was undetectable (<50 nmol/l), consiste nt with adrenal insufficiency, Following the administration of hydrocortiso ne there was normalization of the blood pressure and subsequent adrenal sti mulation tests confirmed the presence of functioning adrenal tissue albeit with an inadequate response, Cortisol measurement from preoperative samples revealed loss of normal diurnal rhythm whereas DHEAS levels both pre and p ostoperatively were undetectable, consistent with ACTH supression resulting from autonomous cortisol secretion in addition to aldosterone. Concurrent secretion of cortisol should always be considered in Conn's adenomas partic ularly when atypical radiological features are present.