Severe hyperandrogenism and mild autonomous cortisol secretion from a functional lipid-poor adrenal cortical adenoma

A 44-year-old woman presented with progressive hirsutism, deepening of voice, irregular menses, and left flank discomfort. Laboratory evaluation revealed markedly elevated serum testosterone and androstenedione levels, along with unsuppressed cortisol following an overnight 1 mg dexamethasone test. Notably, dehydroepiandrosterone sulfate (DHEA-S) levels remained within normal limits. Imaging identified a 4.2-cm heterogeneously enhancing left adrenal mass with a precontrast attenuation of 15 Hounsfield units, consistent with a lipid-poor lesion. 18F-fluorodeoxyglucose positron emission tomography-computed tomography demonstrated intensely avid uptake. Open adrenalectomy was performed, and final pathology confirmed a benign adrenocortical adenoma. Postoperatively, both testosterone and androstenedione levels normalized. The patient received temporary hydrocortisone replacement per our institution's protocol for treatment of presumed postoperative adrenal insufficiency, which was discontinued after biochemical recovery of endogenous cortisol production. This case highlights that not all androgen and cortisol co-secreting adrenal masses are malignant, and that preoperative normal DHEA-S levels do not exclude an underlying adrenal source of hyperandrogenism.