Rare Adrenocortical Carcinoma Case Triggers Acute Psychosis and Emergency Surgery
A 33-year-old male patient presented with ACTH-independent Cushing syndrome secondary to a cortisol-secreting adrenocortical carcinoma, which rapidly progressed to an acute psychotic episode and a suicide attempt two days before scheduled open adrenalectomy, Cureus reported. While neuropsychiatric manifestations like depression and anxiety occur in up to 80% of Cushing syndrome cases, progression to acute psychosis and suicidal behavior remains exceptionally rare, affecting only about 1% of patients according to retrospective cohort data cited in the medical report. The patient’s acute presentation required emergency department admission and an expedited surgical intervention.
Initial Physical Symptoms and Laboratory Findings Preceding the Psychiatric Emergency
Before the psychiatric emergency, the patient experienced a five-month history of facial flushing, weight gain, muscle fatigue, and diaphoresis, alongside one week of emotional lability characterized by abrupt shifts between irritability, intense sadness, and social withdrawal. Initial physical evaluation at the outpatient clinic recorded a weight of 195 lb, a height of 162 cm, and a body mass index of 33.7 kg/kg/m², alongside a plethoric Cushingoid facies, facial acne, a posterior cervical buffalo hump, and diffuse red abdominal striae. Laboratory testing revealed morning serum cortisol at 583.51 nmol/L, 24-hour urinary cortisol at 416.14 µg/24 h, suppressed adrenocorticotropic hormone at 5.15 pg/mL, and low serum potassium at 3.2 mEq/L. Abdominal computed tomography subsequently revealed a right adrenal mass measuring 12.7 × 11.9 × 12.7 cm with irregular borders, leading to the diagnosis of ACTH-independent Cushing syndrome.
Emergency Psychiatric Evaluation and Accelerated Surgical Intervention
Two days prior to the planned operation, the patient suffered an acute psychotic episode at home featuring severe agitation, persecutory delusions, auditory hallucinations, and a complete loss of reality testing. Evaluated by the hospital’s psychiatry team, the acute psychosis and suicide attempt were directly linked to severe hypercortisolism. Because of the imminent risk to the patient’s safety, surgeons brought the operation forward urgently. Medical staff administered 100 mg of intravenous hydrocortisone prior to the open adrenalectomy to prevent acute adrenal insufficiency.
Histopathological Confirmation and Rapid Postoperative Recovery
Histopathological examination of the resected right adrenal gland confirmed adrenocortical carcinoma, showing a high mitotic rate of 27 mitoses per 50 high-power fields and tumor necrosis in 15% of the examined tissue, fulfilling more than three criteria on the Weiss scoring system. Following the tumor resection, the patient experienced a steady improvement in mental status, normalized potassium levels, and no further psychotic episodes or suicide relapses during follow-up.
Frequently Asked Questions About the Adrenocortical Carcinoma Case
What is the annual incidence of adrenocortical carcinoma?
Adrenocortical carcinoma is a rare and aggressive endocrine malignancy.
How common is psychosis in patients with Cushing syndrome?
While depression and anxiety affect up to 80% of Cushing syndrome patients, psychosis is considerably less frequent, appearing in roughly 7% of cases based on a retrospective cohort of 238 patients.
What specific diagnostic features confirmed the malignancy on imaging and pathology?
Abdominal computed tomography revealed a large, heterogeneous right adrenal mass measuring 12.7 × 12.7 × 11.9 cm with irregular margins, while pathology confirmed malignancy based on a high mitotic rate and meeting multiple criteria on the Weiss scoring system.
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