July 3, 2003
Other Illnesses
Question from Gadsden, Alabama, USA:
My 49 year old husband, diagnosed with type 2 diabetes about four and a half years ago, ago was first controlling it with diet and oral medication(s), but over the years, he has even with diet control and adhering to his regimens, and he started on premixed insulin about two years ago. Six weeks ago, he was taken to the ER with chest pains and found to have a mass on his adrenal gland consistent with a benign tumor. His liver enzymes were elevated six to seven times but were back in the normal range in about three weeks.
His blood sugar readings have been haywire since the hospital episode. His endocrinologist ordered lab work with a 24 hour urine collection (high cortisol levels) which was followed by a low dose dexamethasone test which was test was “normal”. His insulin regimen has changed several times, but nothing is effective. He is currently using four injections per day of NPH and Humalog and he is having lows in the 40s mg/dl [2.1 mmol/L] and highs in the 500s mg/dl [27.8 mmol/L] along with drops or increases of 300 mg/dl [16.7 mmol/L] or more without doing anything. We can not make a connection to anything he is doing or not doing that is affecting his readings. He does have a history of colon cancer in his early 20’s if that is of any assistance. He had 18 inches of transcending and descending colon removed.
The doctor does not see a need to follow up on the adrenal mass further, but I feel this may be at least part of the problem. We are quite frustrated and do not know what to do at this point. Is it possible that this mass is secreting cortisol some but not all of the time? Do we need to go further? Another doctor?
Answer:
Incidentally noted adrenal masses are fairly common in the general population. When found, they need to be evaluated to determine if they are hormonally active, including the production of cortisol. This is performed by doing a 24-hour urine for free cortisol or a low dose dexamethasone suppression test. It sounds like he has had the appropriate tests.
The next step is to make sure the adrenal mass does not change in size over time. The idea would be that any mass increasing in size should be removed. Additionally, any mass larger than 6 cm should also be removed (although some argue they would remove slightly smaller masses). If these things are done, I would consider that he has had an adequate evaluation. If your husband’s sugars are not doing well and the above evaluation was done, I’m not sure you can say that this is impacting on his type 2 diabetes.
JTL
