Introduction Hirsutism affects almost 10% of women of reproductive age. The two most common causes of hirsutism are polycystic ovary syndrome (PCOS) and idiopathic hirsutism. Virilizing adrenocortical tumors are rare, nonetheless, it is a differential diagnosis that physicians must consider. Clinical Case We present the case of a 23-year-old woman that was referred from the Dermatology Department due to the abrupt and progressive appearance of hirsutism and facial acne. Her menstrual cycles were regular. She had a BMI of 21.7 kg/m2, facial acne, and a Ferriman-Gallwey scale of 11 points. She did not have hypertension, nor alopecia, clitoris hypertrophy or any other virilizing sign. Table 1 summarizes the analytical determinations requested in the early follicular phase of the menstrual cycle. Pelvic ultrasound scan did not revealed abnormalities. Computed tomography (CT) scan of the abdomen revealed a well-delimited and solid mass of 4.9 × 3.8 cm in the right adrenal gland, with an average density of 48 UH with enhancement on the portal phase without the presence of fat, hemorrhage or calcifications suggesting malignancy more likely (Figure 1). After multidisciplinary assessment, laparoscopic right adrenalectomy was advised. Pathology revealed an adrenal cortex adenoma which showed cytoplasmic immunoreactivity of the cells against inhibin and Melan-A with a KI-67 of 1%, negative for anti-p53 without atypical mitotic figures, necrosis, venous invasion, sinusoidal invasion nor capsular invasion. The post-surgical evolution was satisfactory with an early normalization of androgens and resolution of the virilizing signs. The most common cause of hirsutism in premenopausal women is PCOS; another cause, and far from the first, is the non-classical form of congenital adrenal hyperplasia; and even more uncommon, androgen-secreting ovarian and adrenal tumours (1,2). Adrenal tumours, unlike ovarian, usually secrete DHEAS. Most tumours are carcinomas, which commonly also secrete cortisol (3). A very high DHEAS level (>7 µg/mL) is suggestive of adrenal carcinoma. Pure virilizing adrenal tumours are extremely rare (4). Independently from hormone secretion, the suspicion of malignancy depends on radiological CT characteristics of the tumour: size (>4–6 cm), density (>10 HU with slow contrast washout), homogeneity, and shape (5). Magnetic resonance may assess local invasion (6). Adrenalectomy is the treatment of choice when virilizing adrenal tumours with malignant characteristics are found (7). In the surgical piece, it is useful to determine the Ki 67 (carcinomas: >5%) (8). Somatic mutations in the TP53 gene are associated with aggressive phenotypes(9). Conclusion Malignant ovarian and adrenal pathology should be ruled out in the scenario of new-onset hirsutism. Adrenal malignancy is usually related with tumor size, type of hormones secreted, and the velocity of the tumor progression. Exceptionally, benign adrenal tumours are producers of virilizing hormones.
A 60-year old male was referred to the Endocrinology Department due to confusing results of thyroid tests during a routine medical check-up. The asymptomatic patient presented with increased free thyroxine (FT4) concentrations, and thyroid-stimulating hormone (TSH) and total thyroxine (T4) concentrations within the reference range (Table 1), with no tachycardia, distal tremor, visual impairment, or any other symptoms of thyrotoxicosis. He presented with a 10-kg weight gain over the previous few months (body mass index 27.7 kg/m 2 ), which was attributed to changes in dietary and exercise habits due to the mobility restraints related to control of COVID-19 dissemination. Physical examination revealed neither goiter nor signs of orbitopathy, and there was no personal or family history of thyroid disorders. His usual medications were hydroxyzine, zopiclone, famotidine, and clonazepam. The patient's clinical condition could not explain the high FT4 results with TSH within the reference range, which opened the possibility to consider unusual clinical situations.Initial results were confirmed in a new sample, so his endocrinologist consulted the biochemistry laboratory because of this lack of consistency with clinical presentation. Analytical records revealed similar results in 2016. Additionally, the patient provided analytical results from an outside laboratory, performed 2 months earlier using a different test method (Table 1, Lab 2),
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