Atypical clinical presentation of oncocytic adrenocortical carcinoma with decompensated metabolic syndrome and psychotic outbreak.

Adrenal incidentalomas, mostly adrenal adenomas, affect 3%-10% of the global population. Adrenocortical carcinoma (ACC) is rare, with an incidence of 0.7-2 cases per million. Adrenocortical oncocytic neoplasms (ACONs) account for about 10% of ACC cases, often discovered incidentally, with 17-34% being functionally active.We report a case of a woman in her 60s with treatment-resistant hypertension, diabetes and psychotic delirium. Imaging revealed a 6 cm left adrenal mass with marginally elevated metanephrines. Laparoscopic adrenalectomy was performed. Histology confirmed ACON. Positive margins necessitated adjuvant chemotherapy and radiotherapy. Postoperatively, psychiatric symptoms and hypertension resolved, indicating the tumour's secretory nature.This case highlights the diverse ACONs hormonal secretions, leading to complex clinical presentations, including metabolic and psychiatric symptoms. ACONs secretory nature may not be reflected in standard hormonal panels.ACONs challenging diagnosis and management emphasise the need for a multidisciplinary approach and further research.