A 39-year-old hypertensive, non-diabetic female presented with one year history of moon facies, proximal myopathy, buffalo hump, abdominal striae, easy fatigability and hirsutism. The following laboratories were done and revealed a normal ACTH of 8.5 pg/mL [Reference range: 5-46 pg/mL] and elevated 1 mg Dexamethasone suppression test of 17.96 ug/dl [Reference range: < 1.8 ug/dL]. Whole abdominal CT scan revealed a 3.6 x 2.9 x 2.9 cm well-defined heterogeneously enhancing solid mass on her left adrenal. Patient was then diagnosed with Cushing's syndrome secondary to a cortisol-producing adrenal adenoma and was scheduled for elective laparoscopic adrenalectomy. However, a few days prior to the scheduled operation, the patient suddenly had eight episodes of hematochezia with an estimated cumulative blood loss of 800cc. It was not accompanied with abdominal pain, diarrhea, constipation, vomiting, fever, night sweats, weight loss, or cough. She was then admitted for colonoscopy. On physical examination upon admission, the patient was coherent, not in respiratory distress, with an estimated body mass index of 27 kg/m2. She had pale palpebral conjunctiva, normal blood pressure of 120/80, tachycardic at 105 beats per minute, and afebrile. Abdominal exam revealed normoactive bowel sounds, presence of violaceous striae, and no organomegaly, while rectal examination showed good sphincter tone and fresh blood per examining finger.
Colonoscopy showed a semi-circumferential white based ulcer on the terminal ileum (Fig. 1). Biopsies were taken and submitted for histopathology revealing acute on chronic inflammation with suspicious focus of granuloma with no intact ileal mucosa appreciated (Fig. 2). Tissue Gene Xpert revealed positive results for M. tuberculosis with no rifampicin resistance. Patient was then started on isoniazid, rifampicin, pyrazinamide, and ethambutol.
On the same admission, laparoscopic adrenalectomy (Fig. 3) of the left adrenal gland was performed showing adrenal cortical adenoma, consisting of a fairly pyramidal, brown to orange, doughy tissue, measuring 4.5 x 3.0 x 2.5 cm and weighing 50.0 g (Fig. 4) Microscopic sections showed features of adrenal cortical adenoma characterized by a well- encapsulated benign tumor composed of sheets of cells in an organoid pattern. The individual cells show relatively monomorphic, centrally located, round, bland nuclei and clear, vacuolated cytoplasm with well-defined borders. No features of malignancy such as atypical mitotic figures, venous invasion, or necrosis were noted (Fig. 5). The final pathologic report was adrenal adenoma.