E-Poster Presentation ESA-SRB-ANZBMS 2021

Introduction

Differentiation of severe PCOS with elevated androgens from a virilising tumour can be difficult.

Case Presentation

A 26-year-old woman of Indian descent presented with severe hirsutism and menstrual irregularity. She had been diagnosed with polycystic ovarian syndrome (PCOS) and a left sided adrenal adenoma. She took no regular medications and no relevant family history. On examination, she had a normal BMI, no acne, temporal hair recession, acanthosis nigricans, increased muscle bulk or clitoromegaly. Ferriman-Gallwey score was 32 indicating severe hirsutism.

Initial biochemistry showed markedly elevated androgens on serial testing (see table).

Pelvic ultrasound demonstrated polycystic ovarian morphology with a left 23mm cystic lesion that was deemed “intermediate risk” (on Ovarian-Adnexal Imaging-Reporting-Data system). CT adrenals showed a left 9.3mm adrenal adenoma (29 HU) with a normal right adrenal gland.  MRI adrenal findings were consistent with the CT.

24-hour urinary androgen metabolites were significantly elevated. Intravenous dexamethasone suppression test failed to suppress testosterone levels to normal range with only 25% reduction (see table). Ovarian tumour markers were within normal limits.

The differential diagnosis in this patient is an ovarian or adrenal virilising tumour with current investigations favouring an adrenal source.

Discussion

PCOS is common and generally associated with only mild androgen excess. Both adrenal and ovarian virilising tumours are rare. Failure to suppress androgens after administration of dexamethasone is characteristic of a virilising tumour. Additionally, DHEAS is predominantly produced by the adrenal glands and can be used as a marker of adrenal androgen secretion if the levels are elevated or do not suppress. However, differentiating between ovarian and adrenal sources can be difficult.

Conclusion

We report a case of a virilising tumour in a young woman. The abnormal imaging findings in both the left adrenal gland and left ovary have presented challenges in differentiating between these two potential sources.