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Abstract

Case Presentation: A 49-year-old woman with a history of hypertension and newly diagnosed type 2 diabetes mellitus presented with progressively worsening weakness and malaise during the previous 3 months. She also reported facial and abdominal hair growth, bilateral lower extremity edema, enlarging abdominal girth, male-pattern scalp hair loss, intermittent palpitations, and sweating. She had had no easy bruising, proximal muscle weakness, or headache. Menopause had occurred at age 40 years. On examination, the patient was slightly hypertensive. She appeared well developed and somewhat plethoric. Her coarse facial hair had been shaved. She had no moon facies, buffalo hump, supraclavicular fullness, striae, or ecchymoses. Her abdomen was distended with a 15-cm firm mass on the right side. She had severe pitting edema in both lower extremities. There was coarse hair in the midabdominal area and on the back. Laboratory tests revealed the following results (reference ranges shown parenthetically): total testosterone, 471 ng/dL (2 to 45); dehydroepiandrosterone sulfate, 276 μg/dL (35 to 256); cortisol after 1 mg overnight dexamethasone suppression, 36 μg/dL; midnight cortisol, 33 μg/dL; and cortisol at 7 am, 33 μg/ dL; adrenocorticotropic hormone, <5 pg/mL; normal urine metanephrines and catecholamines; plasma aldosterone concentration, <1 ng/dL; renin activity, 2.9 ng/mL per hour; and estradiol, 886 pg/mL. Abdominal computed tomographic scans were obtained (Fig. 1, Fig. 2). What is the diagnosis?