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This article is the authors' final version prior to publication in Urology, April 2020.

The published version is available at Copyright © Elsevier


A 33-year-old G6P3023 was found to have a 4.2 cm right adrenal incidentaloma during an admission for right pyelonephritis. Computed tomography (CT) was performed to rule out perinephric abscess in the setting of worsening leukocytosis while on antibiotics ( Fig. 1). Initial differential diagnosis from endocrinology included pheochromocytoma and primary aldosteronism. Due to the lack of typical physical exam stigmata, Cushing syndrome was initially of low concern. Of note, her past medical history included hypertension treated with amlodipine 10 mg and hydrochlorothiazide 12.5 mg. During admission, extensive endocrine laboratory workup demonstrated an elevated aldosterone:plasma renin activity, suppressed dehydroepiandrosterone (DHEA), normal 24-hour urine metanephrine and catecholamine, and hypokalemia ( Table 1). This initial biochemical workup did not provide any definitive diagnosis; however, it did convincingly rule out pheochromocytoma due to the normal catecholamine levels in the serum and urine. Eliminating this pathology was critical due to the mortality of hypertensive crisis in the perioperative period.

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