A 28-year-old woman with prior perforated gastric ulcer and presumed “polyendocrine metabolic ovarian syndrome” (PMOS) was found to be hypertensive during pre-anaesthetic assessment for endoscopy, following 9 months of progressive facial swelling, hirsutism, deepened voice and acne. Ambulatory monitoring confirmed hypertension with systolic peaks to 170 mmHg and she presented with hypertensive urgency, visual disturbance and palpitations. Biochemistry demonstrated marked androgen excess (testosterone 6.6–9.1 nmol/L, elevated DHEAS), severe hypercortisolism (24‑hour urinary free cortisol 2382 nmol/24h, midnight salivary cortisol 36 nmol/L) and suppressed ACTH, consistent with adrenal Cushing syndrome. Renin was suppressed with relatively preserved aldosterone; plasma metanephrines were normal.

CT and MRI identified a 5.3 cm left adrenal mass with non-contrast attenuation of 47 HU and radiological concern for adrenocortical carcinoma, while PET showed mild FDG avidity without metastases. Metyrapone, spironolactone and verapamil achieved rapid biochemical and blood pressure improvement. She underwent open left adrenalectomy 24 days after presentation; histology revealed a benign adrenal oncocytoma (Lin-Weiss-Bisceglia score 0). Post-operatively, cortisol and androgen levels normalised, she commenced hydrocortisone replacement, and at six weeks her acne, hirsutism and facial swelling had markedly improved with normotension.

Adrenal oncocytomas are rare, often large and may mimic adrenocortical carcinoma radiologically; a minority are functional, with co-secretion of cortisol and androgens reported in only a small proportion of published cases. Rapid-onset virilisation with severe hypercortisolism should prompt urgent adrenal imaging, medical optimisation of hormone excess and consideration of open adrenalectomy to enable cure while permitting accurate histopathological risk stratification