Primary Adrenal Insufficiency Secondary to Bilateral Adrenal Metastases from Hepatocellular Carcinoma: A Case Report

Abstract

Background_Hepatocellular carcinoma (HCC) commonly metastasizes to the lungs and bones. In contrast, adrenal metastases are relatively uncommon. They occur in approximately 8–19% of patients with advanced HCC, although clinically apparent lesions are much rarer. Primary adrenal insufficiency (AI) develops only when >90% of both adrenal cortices are destroyed, explaining its exceptional rarity. When it does occur, it can lead to a life-threatening adrenal crisis if not promptly recognized. Case presentation_We report the case of a 76-year-old man with metastatic HCC who developed bilateral adrenal metastases complicated by primary AI. The patient presented with progressive fatigue, diarrhea, hypotension, poor appetite, hyponatremia, and hyperkalemia. Hormonal evaluation revealed elevated plasma adrenocorticotropic hormone (ACTH) levels and inadequate cortisol and aldosterone responses to an ACTH stimulation test, confirming primary AI. Abdominal computed tomography revealed large bilateral adrenal masses consistent with metastatic disease. Treatment with prednisolone and fludrocortisone ameliorated clinical symptoms and stabilized the patientʼs hemodynamic status. Conclusion_Although extremely rare, primary AI secondary to bilateral adrenal metastases from HCC should be considered in patients presenting with compatible symptoms and electrolyte disturbances. Early recognition and timely steroid replacement therapy, including glucocorticoid and mineralocorticoid supplementation, are essential for clinical stabilization and may improve patient outcomes.