Metastatic Small-Cell Lung Cancer Presenting as Primary Adrenal Insufficiency

A 40-year-old male smoker with HIV was admitted for cough, hypotension, and abdominal pain for 5 days. Chest radiographyshowed a right lower lobe consolidation. CT of the chest, abdomen, and pelvis revealed paratracheal adenopathy, a5:8×4:5cmmass invading the right bronchus intermedius, and dense bilateral adrenal masses, measuring5:4×4:0cmon the right and4:8×2:0cmon the left. Laboratory studies showed white blood cell count of 18.5 K/mm3, sodium of 131 mmol/L, creatinineof 1.6 mg/dL, and CD4 count of 567 cells/mm3. The random morning cortisol level was 7.0μg/dL, the ACTH stimulationtest yielded inappropriate response, and a random serum ACTH was elevated at 83.4 pg/mL. MRI brain revealed nopituitary adenoma confirming primary adrenal insufficiency. The adrenal CT washout study was consistent with solid masscontent, concerning for metastasis. Bronchoscopy with endobronchial mass and paratracheal lymph node biopsy confirmedsmall-cell lung cancer (SCLC). Intravenous steroids, 100 mg hydrocortisone every 8 hours, improved his hypotension andabdominal pain. PET scan revealed metabolically active right paratracheal mass, right hilar mass, and bilateral adrenalmasses. Treatment included palliative chemotherapy consisting of carboplatin/etoposide/atezolizumab and chest radiation.We present this novel case to demonstrate SCLC’s ability to cause primary adrenal insufficiency, as well as evaluate clinicalresponse to chemotherapeutics