Presentation of a Patient with Cushing’s Syndrome: Discussion on Workup and Management of the Case

A 39 year old woman was referred for evaluation of facial puffiness, weight gain,hypertension and muscle weakness and cessation of menstrual cycle in 2009. Blood pressure was 170/110 and truncal obesity, muscle weakness, abdominal purplish stria and facial acne were prominent clinical findings. Serum and urine cortisol were high and could notbe suppressed with low and high dose dexamethasone. Pituitary MRI, abdominal CT and chest CT scans were negative. With respect to moderate hypercortisolism and negative imagings, treatment with ketoconazol, antihypertensive medications and oral hypoglycemic agents was instituted. Regular follow up was also advised.Treatment was partially effective and signs and symptoms improved gradually. Regular menstrual cycles also resumed. After 1 year facial puffiness became more prominent and hypertension and diabetes became more resistant to our medications. Her menstrual cycles which had become regular for about 6 months became irregular and amenorrhea developed finally. During this period morning cortisol was between 19 to 23 μg/dl and 24h UFC was between 47 to 110μg. Multiple measurement of serum ACTH showed values between 99 and 110 pg/ml (normal=9-52). In 2010, a pituitary MRI showed a 5 mm pituitary mass compatible with a microadenoma and the patient underwent TSS. Histopathologic evaluation showed pituitary tissue. Post-surgical serum and urine cortisol were still elevated and there was no menstrual bleeding. Evaluation of bone mineral density revealed osteoporosis of spine and femur. Treatment with bisphosphonates was started. Due to aggravation of symptoms of hypercortisolism, bilateral adrenalectomy was planned for control of hypercortisolism. The abdominal CT scan requested before surgery surprisingly showed a large oval shaped left adrenal mass measuring 66 by 48 mm with minimal enhancement after contrast injection. What can be the next step in evaluation of the patient