Pheochromocytoma, cortisol-producing adenoma and bilateral primary aldosteronism in a single patient

Adrenal incidentalomas are commonly discovered during imaging evaluations conducted for unrelated reasons. The majority are non-functional, benign tumours. We report a woman in her 40s who was found to have two right adrenal nodules, measuring 4.0 and 3.5 cm on MRI during a fertility evaluation. Biochemical testing revealed concurrent catecholamine, cortisol and aldosterone excess. She received preoperative alpha blockade, a salt-liberal diet and fluid repletion for her pheochromocytoma, as well as spironolactone for blood pressure control of her primary aldosteronism before undergoing laparoscopic right adrenalectomy. Surgical pathology was consistent with a moderately differentiated pheochromocytoma, a cortisol-producing cortical adenoma (demonstrated by CYP11B1 immunohistochemistry) and multiple aldosterone-producing micronodules (demonstrated by CYP11B2 immunohistochemistry). Postoperatively, her catecholamine and cortisol excess resolved, while there was partial improvement in her aldosterone excess, consistent with residual primary aldosteronism. In cases of multiple concurrent adrenal pathologies, comprehensive biochemical and immunohistochemical analyses are essential for establishing a definitive diagnosis.