Most children with adrenal tumors have signs of androgen excess,3,11 including acne, deepening of voice, muscular appearance, pubic hair, rapid statural growth, and enlarged penis or clitoris. The differential diagnoses in a virilized boy are quite limited and include late-onset congenital adrenal hyperplasia, Leydig cell tumor of the testis, and true isosexual precocity. Virilization associated with features of hypercortisolism or feminization occurs twice as frequently as "pure" virilization.12 Virilizing tumors tend to be small (≈50 g). Endogenous Cushing syndrome in children younger than age 10 years is usually due to an adrenal tumor,13 whereas in older children, hyperplasia may exceed tumors in frequency.14 Cushing syndrome without virilization is rarely observed. The classic features of Cushing syndrome include obesity, muscle wasting, plethora, round facies, striae, short stature, and hypertension. Linear growth may be normal in children with associated virilization. Truncal obesity may be observed in older children, but infants tend to demonstrate generalized obesity. Primary aldosteronism is rare in children and is usually due to adrenocortical hyperplasia, but few cases are reported in the literature in which primary aldosteronism is due to an adrenocortical tumor.15,16 Pure feminizing tumors are rarely encountered in children. Only 7 cases of feminizing adenomas in males have been recorded.17 About 5% of childhood adrenocortical tumors produce no clinical evidence of endocrine dysfunction. This does not mean that they are incapable of steroidogenesis but only that they do not produce an excess of active hormones. Because these tumors do not produce symptoms, they are extremely large at the time of diagnosis and have poor prognosis.