Hypercortisolism and hyperaldosteronism may be common presentations of adrenocortical carcinoma, but may be overlooked while having other related personal histories.

A 74-year-old female with a history of diabetes mellitus, hypertension and dyslipidemia came to our hospital after noticing lower limb swelling and edema after taking a long flight from America to Taiwan. At the endocrinology out-patient department, decreased urine output was also told, and bilateral lower leg pitting edema was noted on physical examination. She was then referred to a cardiologist, and a peripheral vein Doppler was done and showed results of small thrombi at bilateral GSVs, right SFV, bilateral popliteal veins, bilateral SSVs and left SFV. Canagliflozin and edoxaban was then prescribed. A few days later, she came to our emergency department as she had chest tightness and dyspnea. Blood tests showed elevated blood glucose and ketone body level with decreased potassium, carbon dioxide and bicarbonate. Diabetic ketoacidosis was suspected considering her personal and drug history. She was then admitted for treatment of DKA and DVT, and she was then discharged about a week later after her condition was stabilized. However, two days after her discharge, she came back to our emergency department complaining of general weakness, mild abdominal discomfort, constipation and poor appetite. An abdominal and pelvic contrast enhanced CT was done and revealed a huge right suprarenal tumor with direct invasion of liver parenchyma, IVC, peritoneum and retroperitoneum, extensive hepatic and pulmonary metastasis, and upper retroperitoneal and mediastinal metastatic lymphadenopathy. Liver biopsy was done later for confirmation, and the pathology report showed results of conspicuous tumor necrosis with tiny foci of poorly differentiated malignancy. Combined with immunostaining and previous images, adrenal cortical carcinoma was highly suspected. Blood tests showed metabolic alkalosis and elevated CA125, CA19-9 and cortisol levels. The patient’s condition deteriorated quickly and passed away a few days after admission.