The couple could not remember exactly when the 61-year-old man started getting sick. Was it before he retired last spring? No, it was later, the man insisted. But both men agreed they knew something was seriously wrong the day the recent retiree walked up the stairs. He was carrying his new laptop when his right leg suddenly gave way. If he hadn’t had the computer, he might have caught himself. Instead, while holding up his new machine, he fell forward and slid down a few steps. He scraped his shins and forearms; blood seeped from the shallow wounds. And he was too weak to get up. “I need help,” he called to his partner upstairs. The man, who was already on his feet after hearing the crash, appeared next to him almost immediately.

He lifted his partner to his feet and half-carried him to the upstairs bathroom. “You really should call your doctor,” he muttered as he dabbed at the scrapes. He had been urging him to do this for weeks, ever since he noticed how easily his partner bruised and how strangely thin his skin looked. And there were even more changes. He was quieter. His easy smile had all but disappeared. Most worryingly, he seemed confused and forgetful; sometimes he didn’t feel like it. They had been together for over forty years; the man knew his partner well. These changes scared him.

By the time the man agreed to go to the doctor, he could barely move the leg that gave way on the stairs. His walk was an awkward shuffle, and he had to hold on to his partner as they walked from the car to the medical center in Durham, Conn. In fact, the doctor on duty that day took one look at the bruised and limp man and sent him to Yale New Haven Hospital. The patient would at least need a scan. He would probably need more.

In the emergency room, a physical examination revealed that the muscles in his right thigh were not working at all. And the skin there was numb. His blood chemistry was off; his potassium was dangerously low. An MRI of his entire spine yielded no answers. He lived in a wooded area not far from Lyme. Had he noticed a tick bite? Or rash? No bites, but a friend had pointed out a rash earlier that summer. However, it was in a place he couldn’t see and he just forgot about it. A blood test and then a spinal tap confirmed the diagnosis: he had Lyme disease. Both men felt a shiver of relief. He would need a full month of antibiotics, but once he was treated he should get better.

The Incidentaloma

But he didn’t. A month later he was still weak, still bruised and bleeding. He was tired; his thinking remained foggy. And his blood pressure was out of control. He had a history of hypertension, which was always well controlled with a single drug. Suddenly that wasn’t the case. His GP prescribed him a second drug, then a third, but his blood pressure remained higher than ever before. His doctor sent him to a cardiologist, who prescribed the patient even stronger blood pressure medications. He also ordered an ultrasound of the man’s heart to make sure it was beating normally. It was, but the aorta looked strange. A CT scan reassured him that the man’s aorta was normal, but revealed an unexpected finding: There was a mass the size of a golf ball on top of his left adrenal gland.

Coincidental findings on CT scans are so common that they have a name: incidentalomas. Up to 7 percent of abdominal imaging studies will reveal an incidentaloma on one of the adrenal glands. Most of these masses are benign and do not produce any of the hormones normally produced by the adrenal gland. Yet everything must be evaluated. The cardiologist called the patient with the news and referred him to an endocrinologist at Yale.

Due to the difficulty of making an appointment with a subspecialist and an unexpected snowstorm, it took months before the patient could see the endocrinologist. But finally, on a cold, cloudy day in April, he and his partner found themselves in an examination room at Yale New Haven Hospital. The cheerful, smiling endocrinologist walked in and introduced himself. The two men described their strange journey over the past nine months. It started, they explained, that summer with what turned out to be Lyme disease. He was treated, but never got better. In fact, he felt even worse now. He was weak – he stopped going to the gym because he could no longer do the training. The muscles on his arms and legs seemed to evaporate. He was gaining weight, but it wasn’t muscle. He had never had a belly like that before. And he was exhausted, even though he slept 10 to 12 hours a night.

The endocrinologist had already looked at the man’s CT scan, as well as the MRI from the summer before, so she knew what she was looking for. This had nothing to do with his recent Lyme infection. The adrenal glands are responsible for supplying several hormones, including the fight-or-flight hormones such as adrenaline; cortisol, the hormone that regulates metabolism; and the fluid balance hormone aldosterone. Excesses of any of these could be responsible for his high blood pressure. His easy bruising and fragile skin indicated excess cortisol. Its low potassium levels and elevated sodium levels may be caused by excess aldosterone. His rapid heart rate could be a sign of excess stress hormones. As the doctor examined him, she looked for clues to determine which hormone was being overproduced. His body was covered in bruises. His arms and legs were thin and the muscles wasted. His abdomen, on the other hand, was soft and obese. He had fat pads at the top of each shoulder and his face was swollen, red and round. This unusual set of symptoms was classic for Cushing’s syndrome, caused by an excess of the metabolic hormone cortisol.

A puzzling contradiction

However, one aspect of his illness was confusing. These adrenal gland tumors usually grow slowly and it takes years for so much physical strife to develop. But this man described symptoms that appeared suddenly and quickly worsened. And the tumor itself seemed to be growing rapidly. Although it went unnoticed at the time, a smaller version of the tumor was visible on the MRI the summer before. A cancerous tumor can grow so quickly. Was this adrenal carcinoma? These aggressive cancers are rare – with only one or two cases per million people per year – but they can be fatal.

The endocrinologist ordered a CT scan that day. If this was a cancer it should have grown in the months since his last scan. But even if it wasn’t cancer, it had to come out clearly, and quickly. She referred him to a surgeon. He had been sick with this growth long enough.

The labs confirmed what the endocrinologist suspected. The man’s cortisol level was sky high: 25 times the normal amount. The CT scan showed no growth in tumor size. That was a relief. Adrenal cancer often spreads beyond the gland itself, and once that happens, the chance of living longer than five years plummets.

He had surgery a month later. The response was immediate. The next day his blood pressure and heart rate returned to normal. His blood values, including his cortisol level, were within the normal range. The overactive tumor had taken over cortisol production; his remaining adrenal gland was now on vacation and it would take some time for him to recover. In the meantime, he should take hydrocortisone.

The mass was examined in the laboratory. The endocrinologist was surprised when he discovered that it was adrenal carcinoma after all. Both doctor and patient were relieved when a PET scan showed no signs of spread.

The rest of his recovery was slow. The bruises faded. His muscles reappeared and his stamina returned. By the end of the year he was able to start running again. He had himself scanned every few months and after four and a half years he had what was supposed to be his last scan. But that scan showed a new lesion on his spine. It was treated with radiation. The following year, just this fall, he had a hint of a new lesion. A new metastasis. He and his doctors discuss next steps.

I recently spoke with the patient. He has a good life, he told me. He feels great. When asked about the new lesion, he was thoughtful but optimistic. He will resolve these issues as they arise, he said. In the meantime, he will continue to enjoy the life he and his partner have together. He asked: What more can any of us do?

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Lisa Sanders, MD, is a contributing writer for the magazine. Her latest book is ‘Diagnosis: Solving the Most Baffling Medical Mysteries.’ If you have a solved case to share, write to her at Lisa.Sandersmdnyt@gmail.com.