Mixed pheochromocytoma and adrenal cortical adenoma (corticomedullary adenoma) is extremely rare. We report a 41-yearold woman diagnosed preoperatively with Cushing syndrome of adrenal origin. Nonsuppressible serum cortisol and 24-hour urine free cortisol levels by a standard low-dose dexamethasone suppression test with a low plasma adrenocorticotropic hormone (ACTH) level suggested ACTH-independent Cushing syndrome. Magnetic resonance imaging (MRI) revealed a left adrenal mass about 4 cm in diameter, showing a slightly heterogenous signal drop in chemical shift imaging, suggesting high lipid content in the tumor. The T2-weighted image, however, had a mildly high signal, rather than the typical normal to low signal characteristic of a cortical adenoma. 131 I-6␤-iodomethyl-norcholesterol (NP-59) scintigraphy revealed early accumulation of radioactivity in the left suprarenal region, suggesting a functioning cortical tumor. The patient underwent left adrenalectomy, but the surgery caused a marked elevation of systolic blood pressure (greater than 200 mm Hg). The suspicion of pheochromocytoma was entertained. Mixed pheochromocytoma and adrenal cortical adenoma (corticomedullary adenoma) were disclosed by immunohistochemical stains and electron microscopic examination. This case is the fifth reported pathologically proven corticomedullary adenoma. We include special image findings that contain characteristics of both cortical and medullary components. Learning Objectives• Relate this patient's symptoms, physical signs, and clinical course to the coexistence of pheochromocytoma and Cushing syndrome.• Describe how the findings on MR imaging and scintigraphy helped to clarify the clinical picture. • Outline the immunohistochemical findings in this rare case of corticomedullary adenoma, and suggest possible mechanisms for its origin and clinical manifestations.

Rationale:Membranoproliferative glomerulonephritis (MPGN) can be induced by autoimmune diseases, chronic infection, chronic hepatitis, and paraproteins (including cryoglobulinemia). In addition, the mixed cryoglobulinemic MPGN is reported to be highly correlated with hepatitis C virus (HCV) infection.Patient concerns:We reported a rare case of a 61-year-old woman without a history of viral hepatitis infection; she presented with bilateral leg edema and proteinuria. Renal pathology revealed MPGN with multiple positive immunofluorescent staining. The consequent serum survey revealed positive cryoglobulin and monoclonal gammopathy of kappa type of immunoglobulin M. However, bone marrow study showed no obvious plasma cell proliferation, indicating that multiple myeloma was less likely.Diagnoses:This patient's cryoglobulinemic MPGN could be related to monoclonal gammopathy of undetermined significance.Interventions:Oral immunosuppressant.Outcomes:After steroid treatment, her renal function normalized and proteinuria kept in low level.Lessons:We demonstrated a rare cause of cryoglobulinemic MPGN without HCV infection, which led to a favorable prognosis after receiving steroid therapy. Moreover, the diagnosis of monoclonal gammopathy should be considered when facing such case and aggressive steroid therapy might be beneficial.

Hepatic arteritis is a rare complication in systemic lupus erythematosus (SLE). Information about its clinical manifestations is still very limited. Elevated serum r-glutamyl transpeptidase and alkaline phosphatase levels, but without elevated bilirubin and transaminase levels, were found in the present report to be the clinical presentation of hepatic arteritis. This clinical picture originally suggested a disease of the biliary tree. Hepatic arteritis must be included in the differential diagnosis of biliary tract disorders in SLE.

Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen that infects the skin and soft tissue. However, there are few reports of renal complications from MRSA involving immunoglobulin (Ig)A-dominated rapidly progressive glomerulonephritis (GN). Favorable renal outcomes from IgA GN are achieved by administering timely therapy. In the present study, we describe the case of a healthy young woman suffering from a cutaneous MRSA infection that initially presented with gross hematuria. Six months after eradicating the infection, severe impairment of renal function was noted because of intractable nausea and vomiting. Renal pathology revealed advanced IgA nephropathy with fibrocellular crescent formation. An aggressive treatment plan using immunosuppressants was not adopted because of her irreversible renal pathology, and she was therefore administered maintenance hemodialysis.This instructive case stresses the importance of being aware of the signs of IgA nephropathy post-MRSA infection, such as cutaneous lesions that are mostly painless and accompanied by hematuria and mild proteinuria. If the kidney cannot be salvaged, it will undergo irreversible damage with devastating consequences.

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