adrenocortical carcinoma ( acc ) is a rare malignant tumour of the adrenal cortex with an approximate incidence of 1 to 2 cases per million adults annually [ 1 , 2 ] . most of these tumours are functional , presenting clinically with cushing 's syndrome and/or signs of virilization . it is extremely rare for an adrenocortical tumour to present as an adrenal medullary tumour viz . , a pheochromocytoma , thus posing a diagnostic and therapeutic challenge . here , we report the case of an acc mimicking a pheochromocytoma clinically , biochemically and radiologically . a 45-year - old female presented with complaints of vague abdominal pain for 3 years . she was diagnosed with hypertension and put on anti - hypertensive medication but failed to achieve control with regular use of the prescribed medication . on examination the pulse rate was 92 bpm , regular , good volume , without delay . blood pressure ( bp ) was 170/100 mmhg , right arm , supine . a ballotable mass of 5  5 cm was palpated in the right lumbar region , firm , non - tender , non - fluctuant and non - pulsatile . ultrasound of the abdomen showed a 5  5 cm solid - cystic mass overlying the right kidney . cect abdomen confirmed the presence of a right suprarenal tumour measuring 6  5  5 cm with solid - cystic components and fluid levels suggestive of intratumoural haemorrhage . magnetic resonance imaging ( mri ) of abdomen suggested an space occupying lesion in the right adrenal gland with multiple cystic spaces of variable sizes suggestive of pheochromocytoma . fat planes to the adjacent structures were preserved with no evidence of metastases ( figs  14 ) . figure  1:cect abdomen showing an inhomogeneously dense right suprarenal mass ( transverse section ) . 
 figure  2:cect abdomen showing an inhomogeneously dense right suprarenal mass ( coronal section ) . 
 figure  3:mri abdomen showing a hyperintense right suprarenal mass ( transverse section ) . 
 figure  4:mri abdomen showing a hyperintense right suprarenal mass ( coronal section ) . 24-h urinary vanillyl mandelic acid ( vma ) was 8.8 mg ( n=1.87 mg/24 h ) . owing to limited resources and low socio - economic status of the patient , further diagnostic biochemical tests , such as fractionated plasma - free metanephrines , urinary catecholamines and metanephrines , could not be undertaken . pre - operative control of bp was achieved within 3 weeks with oral phenoxybenzamine 10 mg during the first week , increased to 10 mg 6 h during the second week and 10 mg 4 h during the third week . volume expansion was achieved with 0.9% normal saline infusion 2 l / day during the immediate pre - operative week . during elective right adrenalectomy , the bp shot up to 180/140 mmhg ( pre - operative bp was 140/90 mmhg ) . no anti - hypertensive agents were prescribed during the hospital stay or on discharge ( figs  5 and 6 ) . histopathological analysis reported a well - encapsulated cellular lesion composed of sheets , cords and trabeculae of round to oval epithelial cells with abundant eosinophilic cytoplasm and vesicular nuclei showing grade 12 pleomorphism . foci of bizarre - looking cells with frequent mitotic figures ( 12/10 hpf ) seen . acc is a rare malignant tumour of the adrenal cortex with an incidence of 1 to 2 cases per million adults annually and bimodal presentation mostly during the fourth to fifth decade of life and the first decade [ 1 , 2 ] . most of these tumours are functional , and secrete glucocorticoids and androgens excessively , causing clinical cushing 's syndrome and signs of virilization , both of which can be the initial presentation . the annual incidence is 28 cases per million and presents during the third to fourth decade of life , with 10% cases occurring in children . the clinical history of pheochromocytoma includes episodic headaches , palpitations and diaphoresis with severe uncontrolled hypertension . these spells are due to the excess secretion of catecholamines viz . , epinephrine and norepinephrine . depending on the catecholamine secreted , hypertension is either paroxysmal or persistent , rarely absent . biochemical diagnosis of acc is done by the standard 24-h urinary cortisol excretion test and the 1 mg - dexamethasone suppression test in the presence of cushing 's syndrome and by serum adrenal androgens in the presence of virilization . whereas , the diagnosis of pheochromocytoma can be supported by the measurement of catecholamine metabolites such as plasma metanephrines , 24-h urinary catecholamines or their metabolites such as vma and metanephrines . radiologically , a suprarenal mass , with a non - homogenous density on cect scans with fluid levels suggestive of intratumoral haemorrhage goes in favour of pheochromocytoma . intermediate - to - high - intensity lesions on t2 imaging of the mri go in favour of malignant carcinomas , whereas pheochromocytomas are very high - intensity tumours owing to higher water content . another significant utility of the mri is to evaluate the surrounding fat planes and exclude metastases . ultrasound has less sensitivity for detecting adrenal incidentalomas and is highly user dependant . in the present case , our patient , was in her fifth decade of life , presenting with vague symptoms such as diffuse abdominal pain with a palpable mass , episodic headache , palpitation and vertigo , with uncontrolled hypertension and postural hypotension . she had raised urinary vma level of 8.8 mg/24 h ( n = 1.87 mg/24 h ) with normal serum and 24-h urinary cortisol levels . an intra - operative boom in the bp on handling the tumour further confirmed it . this peculiar behaviour of the adrenocortical tumours is due to the neuroendocrine differentiation , known as pseudo - pheochromocytomas . such tumours show positivity for markers such as neuron - specific enolase , and synaptophysin and negativity for chromogranin . testing for calretinin and inhibin further increases the sensitivity and specificity in differentiating an adrenocortical neoplasm from pheochromocytoma . in the literature , only 14 cases have been reported so far making these tumours a rare entity , but which can still cause a diagnostic dilemma . to the best of our knowledge ,