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Case records of the Massachusetts General Hospital. Case 40-2011. A 52-year-old man with weakness, infections, and enlarged adrenal glands.

Dr. Liana K. Billings (Medicine): A 52-year-old man was admitted to this hospital because of weakness and swelling in his legs. The patient had been in his usual health until 9 months earlier, when leg edema and weakness developed, associated with weight gain. His physician prescribed diuretic agents; the edema improved and the patient lost weight, but the leg weakness worsened and the patient had difficulty climbing stairs and standing up from a seated position. Laboratory tests revealed hypokalemia. The diuretics were discontinued, and potassium supplementation was started. Approximately 6 months after the onset of symptoms, erythema and swelling developed in both hands. The patient was admitted to another hospital, where a diagnosis of cellulitis and bacteremia caused by methicillin-sensitive Staphylococcus aureus was made. Nafcillin and daptomycin were administered, and he was discharged home after 9 days, with intravenous antibiotics. Malaise, fatigue, and bilateral leg and hip weakness worsened. Laboratory-test results are shown in Table 1. The patient was readmitted to the other hospital 2 weeks after discharge because of pain in the right arm. Studies revealed thrombosis of the right axillary and subclavian veins; anticoagulation treatment was administered. A complete blood count and tests of liver function, coagulation, and kidney function were normal, as were the serum levels of electrolytes other than potassium. Other test results are shown in Table 1. Magnetic resonance imaging (MRI) of the brain after the administration of gadolinium reportedly revealed nonspecific, small, scattered, nonenhancing hyperintensities of the cerebral white matter on T2-weighted images, without evidence of an intracranial ischemic event or a mass lesion in the pituitary. Results of ultrasonography of the kidneys were normal. Computed tomography (CT) of the chest after the administration of intravenous contrast material revealed a cavitary lung lesion (18 mm in diameter) in the left upper lobe, a pulmonary embolus in the right lower lobe, a nodule in the left adrenal gland (1 cm in diameter), and a slightly full right adrenal gland, without lymphadenopathy. On the 15th hospital day, a low-dose dexamethasone suppression test was performed; results are shown Case 40-2011: A 52-Year-Old Man with Weakness, Infections, and Enlarged Adrenal Glands