scholarly journals SUN-187 A Case of Adrenal Mass with Elevated ACTH and Cortisol in a Woman with No Cushingoid Features

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Tara Rajiyah ◽  
Susan Sam
Keyword(s):  
Cushing’S Syndrome ◽  
Adrenal Mass ◽  
Correct Diagnosis ◽  
Fasting Blood Glucose ◽  
Clinical Signs ◽  
Case Series ◽  
Pituitary Surgery ◽  
Cushing's Syndrome ◽  
T Score ◽  
History Of

Abstract Background Adrenal incidentalomas can present with subclinical Cushing’s Syndrome (SCS), which is defined as elevated cortisol levels without overt clinical signs or symptoms. Inaccuracies in ACTH levels due to issues with the assay and non-classic presentation of Cushing’s Syndrome (CS) can delay appropriate diagnosis and timely intervention. Clinical Case A 50-year-old female with a history of an incidentally discovered 3.4 x 1.8 cm adrenal mass was referred for evaluation of hypercortisolism (midnight salivary cortisol 0.17 μg/dL, normal < 0.09 μg/dL) with lack of suppression of both ACTH (19 pg/mL, normal 6-50 pg/mL) and cortisol (13.1 μg/dL, normal 6.0-18.4 μg/dL) on overnight 1-mg dexamethasone suppression test (DST). Pheochromocytoma work up was negative. Her medical history was remarkable for premature ovarian failure at age 40 and osteoporosis at age 48 (Lumbar spine T-score -3.6, Femoral neck T-score -3.7, Hip T-score -2.7). She denied alcohol abuse and depression screening was negative. She reported high levels of stress and insomnia. She denied muscle weakness, acne, or change to body habitus. Fasting blood glucose was intermittently as high as 212 mg/dl but HbA1c was 5.5%. She did not have a history of hypertension or glucocorticoid use. Her BMI was 20 kg/m2 and she did not appear Cushingoid. A pitutiary MRI showed no evidence of pituitary lesions or enlargement. Discussion and Follow up A non-suppressed ACTH made an adrenal source of cortisol unlikely. The working diagnosis was pseudo-CS secondary to stress, loss of diurnal rhythm due to insomnia, or overlooked depression. She was taking supplements, including biotin, and was asked to discontinue these for two weeks. Repeat 1-mg DST revealed an elevated cortisol of 9.8 μg/dL with a once again non-suppressed ACTH of 20 pg/mL. Her dexamethasone level was 109 ng/dL (normal after 1 mg dexamethasone 180-950 ng/dL), which may suggest slightly faster metabolism. All ACTH levels were run on Immulite assays, which has recently been suggested to be unreliable (1). When repeated using the Roche Assay, ACTH was low at 1.6 pg/mL. Given suppressed ACTH in conjunction with hypercortisolemia and osteoporosis, an adrenal source of CS was confirmed. Diagnosis was further solidified by a DHEA-S level of 11.4 μg/dL (normal 35.4 - 256 ug/dL). She underwent adrenalectomy and pathology revealed adrenal cortical adenomas. Conclusion The correct diagnosis of adrenal CS in this patient was delayed due to erroneously higher ACTH result by the Immulite assay. Similar cases have been reported in the literature with the use of Immulite assays for measurement of ACTH leading to invasive diagnostic procedures and even unnecessary pituitary surgery (1). 1. Greene LW, Geer EB, Page-Wilson G, Findling JW, Raff H. Assay-Specific Spurious ACTH Results Lead to Misdiagnosis, Unnecessary Testing, and Surgical Misadventure-A Case Series. J Endocr Soc. 2019;3(4):763-72.

Incidentally discovered ACTH-dependent adrenal adenoma presenting as 'Pre-Cushing's syndrome'

1986 ◽  
Vol 111 (1) ◽  
pp. 89-92 ◽  
Author(s):  
U. Bogner ◽  
U. Eggens ◽  
J. Hensen ◽  
W. Oelkers
Keyword(s):  
Cushing’S Syndrome ◽  
Adrenal Mass ◽  
Adrenal Adenoma ◽  
Clinical Signs ◽  
Cushing's Syndrome ◽  
Cortisol Secretion ◽  
Adrenal Tumour ◽  
Urinary Cortisol

Abstract. An adrenal tumour was incidentally discovered with no clinical signs of Cushing's syndrome. The endocrine evaluation revealed the unique hormonal constellation of an increased urinary cortisol excretion rate, unequivocal suppressibility of plasma and urinary cortisol by dexamethasone, but only to a residual level in the low normal range which probably reflected ACTH-independent 'autonomous' cortisol secretion. After removal of the adrenal mass, urinary cortisol secretion and dexamethasone suppressibility were normalized. In vitro, the tumour cells were as sensitive towards ACTH as 'normal' human adrenal cells, but showed a reduced cortisol production rate per cell. We suppose that the adrenal mass participated in the diurnal rhythm of ACTH-mediated cortisol secretion in vivo, which resulted in an increased cortisol secretion. During the night, when ACTH levels were low, the cortisol production decreased and the hormone levels were probably too low to suppress ACTH. We regard the hormonal findings in our patients as 'Pre-Cushing's syndrome', although the absence of clinical features of Cushing's syndrome remains unclear. We suggest that every patient with an incidentally discovered adrenal mass should have an endocrinological evaluation because the results may help to decide whether or not the adrenal tumour should be removed.

scholarly journals Cushing’s syndrome manifesting as chronic insomnia caused by adrenal cortical adenoma with incidental pituitary microadenoma: a case report

2021 ◽  
Vol 7 (1) ◽  
pp. 22-26
Author(s):  
Rizky Rakhmayanti ◽  
Tania Tedjo Minuljo ◽  
Herlina Suryawati ◽  
Alifiati Fitrikasari ◽  
Mohamad Adi Soedarso ◽  
...  
Keyword(s):  
Cushing’S Syndrome ◽  
Adrenal Mass ◽  
Clinical Signs ◽  
Cushing's Syndrome ◽  
Chronic Insomnia ◽  
Histopathological Study ◽  
High Dose ◽  
Neuropsychiatric Manifestation ◽  
Pituitary Microadenoma ◽  
Adrenal Cortical Adenoma

Background: Cushing’s syndrome is condition caused by excessive glucocorticoid with insomnia as one of its neuropsychiatric manifestation. Cushing’s syndrome may be caused by excessive adrenocorticotropin hormone (ACTH-dependent), for example from ACTH producing pituitary tumors, or by overproduction of cortisol by adrenocortical tumors. In this report, we presented a case with Cushing’s syndrome manifesting as chronic insomnia with adrenal cortical adenoma and pituitary microadenoma.Case presentation: A 30-year-old woman was consulted from the Neurologic Department to the Internal Medicine Department with the chief complaint of insomnia and worsening headache since 6 months prior to the admission. She had undergone head MRI and abdominal CT scan previously and was found to have both pituitary microadenoma and left adrenal mass. From the physical examination she had clinical signs of Cushing’s syndrome like Cushingoid face and purplish striae on her stomach. Midnight cortisol serum examination was done initially and showed high level of cortisol. High dose dexamethasone suppression test or DST (8 mg overnight) was later performed to help determine the main cause of Cushing’s syndrome. The result failed to reach 50% suppression of cortisol serum, suggestive that the Cushing’s syndrome was not ACTH-dependent from the pituitary but potentially from overproduction of cortisol by the left adrenal mass. Therefore, left adrenalectomy was performed and the histopathological study supported the diagnosis of adrenal cortical adenoma.Conclusion: Chronic insomnia is a very important symptoms of Cushing’s syndrome that should not be neglected. The patient had both microadenoma pituitary and left adrenal mass thus high dose DST test (8 mg overnight) needed to be performed to differentiate the source of Cushing’s syndrome. The result showed only little suppression therefore the pituitary microadenoma was not the source of Cushing’s syndrome and more suggestive from the adrenal etiology.

scholarly journals Favorable outcome of pheochromocytoma in a dog with atypical Cushing’s syndrome and diabetes mellitus following medical treatment: a case report

2020 ◽  
Vol 16 (1) ◽  
Author(s):  
Ga-Won Lee ◽  
Cho-Rong Yoo ◽  
Dan Lee ◽  
Hee-Myung Park
Keyword(s):  
Case Report ◽  
Cushing’S Syndrome ◽  
Adrenal Mass ◽  
Liver Enzymes ◽  
Glycosylated Hemoglobin ◽  
Vena Cava ◽  
Clinical Signs ◽  
Cushing's Syndrome ◽  
Elevated Liver Enzymes

Abstract Background Pheochromocytoma (PCC) has poor prognosis and adrenalectomy is hard to be performed, in case of caudal vena cava invasion. The long-term administration of phenoxybenzamine in PCC has not been reported in dogs. Case presentation A 14-year-old castrated male Poodle dog presented with an abdominal mass. On physical examination, hypertension, increased lens opacity, calcinosis cutis, generalized alopecia, and systolic murmur were observed. Serum chemistry and urinalysis profiles revealed hyperglycemia, hypercholesterolemia, elevated liver enzymes, and glucosuria. Abdominal ultrasonography showed a right adrenal mass with invasion of the caudal vena cava, which was cytologically diagnosed as suspected PCC. An adrenal mass (width × height × length, 28 × 26 × 48 mm3) was found on computed tomography and diagnosed as PCC with increased plasma metanephrines and normetanephrines. An adrenocorticotropin hormone stimulation test showed elevated adrenal hormones (androstenedione, estradiol, progesterone, and 17-OH progesterone) with normal cortisol, compatible with atypical Cushing’s syndrome. The dog was managed with trilostane, phenoxybenzamine, and insulin therapy. Glycosylated hemoglobin and fructosamine levels gradually decreased, and hypertension resolved. In the 10-month follow-up period, the liver enzymes levels gradually decreased, and the clinical signs of the dog were well-controlled without deterioration. Conclusions This case report describes long-term medical management without adrenalectomy of PCC complicated with atypical Cushing’s syndrome and DM.

scholarly journals SAT-263 A Vicious Cycle of Hypercortisolism - Cyclical Cushing’s Syndrome

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Bahar Kapoor Force ◽  
Daniel Yoshor ◽  
Sherly Sebastian ◽  
Mas Takashima ◽  
Susan Leanne Samson
Keyword(s):  
Weight Gain ◽  
Cushing’S Syndrome ◽  
Clinical Signs ◽  
Case Series ◽  
Cushing's Syndrome ◽  
Cortisol Secretion ◽  
Diagnostic Challenge ◽  
Rapid Weight Gain ◽  
Free Cortisol ◽  
C 30

Abstract Background: Cyclical Cushing’s syndrome (CS) is described as periods of excess cortisol secretion interspersed with low or normal cortisol. The generally acceptable criteria for diagnosis is demonstration of 3 peaks and 2 troughs in cortisol secretion but, in practice, patterns and duration of cycles are unpredictable and can present a significant diagnostic challenge. Here, we present a case series of three patients who did not meet the published criteria but had pathological confirmation of ACTH-dependent CS. Clinical Case: Two women (A: 30 year-old, B: 40 year-old), and one man (C: 30 year-old) presented to the Pituitary Center for second/third opinions regarding CS. All patients had significant central weight gain. Patient A described cycles of rapid weight gain and loss, fluctuating facial and leg swelling, anxiety and darkening of stretch marks or scars punctuated with episodes of fatigue, lightheadedness and nausea. Patients B and C reported cyclical leg swelling, facial redness and acne. These patients had additional clinical signs of Cushingoid facies, dorsocervical and supraclavicular fat pads. Patient C had violaceous striae. Multiple tests for CS were performed: 1 mg overnight dexamethasone suppression test, two midnight salivary cortisols, and 24h urine free cortisol (UFC). All testing was normal, with a few exceptions. Patient A had an isolated midnight salivary cortisol elevated to 0.426 (<0.112 ug/dL). Patient C had two mildly elevated 24h UFC collections of 1.4 times upper limit of normal corresponding with his cycles of peripheral edema and acne. Patient B had completely negative testing. In all 3 patients, ACTH levels were not suppressed but also not elevated. Random serum DHEA-S levels were elevated in patients A and B. Patients A and C were found to have possible pituitary microadenomas on MRI with dynamic contrast. Patient B’s MRI was negative but inferior petrosal sinus sampling revealed a markedly elevated tumoral level of ACTH of >62,500 pg/mL with CRH stimulation. All 3 patients underwent endoscopic transsphenoidal resection by an expert pituitary surgeon with no post-operative complications in patients A & B, but development of partial diabetes insipidus in patient C. In patients A & C, pathology revealed corticotroph hyperplasia while patient B was found to have a corticotroph adenoma. Patients A & B persisted to have symptoms of hypercortisolism, opted to undergo bilateral adrenalectomy and pathology showed diffuse adrenocortical hyperplasia for both. Conclusion: Cyclical CS is likely underdiagnosed because of difficulty in obtaining biochemical confirmation even with strong clinical suspicion of CS. DHEA-S has a long half-life as well as minimal diurnal variation, and could be an additional clue in patients with suspected pituitary source of cyclical hypercortisolism. Ultimately, clinical concern should drive further diagnostic imaging and management.

scholarly journals Correction to: Levoketoconazole improves clinical signs and symptoms and patient-reported outcomes in patients with Cushing’s syndrome

Pituitary ◽  
2020 ◽  
Author(s):  
Eliza B. Geer ◽  
Roberto Salvatori ◽  
Atanaska Elenkova ◽  
Maria Fleseriu ◽  
Rosario Pivonello ◽  
...  
Keyword(s):  
Cushing’S Syndrome ◽  
Patient Reported Outcomes ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Cushing's Syndrome ◽  
Original Version ◽  
Patient Reported ◽  
Author Group ◽  
Clinical Signs And Symptoms

The original version of the article unfortunately contained an error in the first name and the surname of one of the authors in the author group. The last author name was incorrectly published as ‘F. Pecori Giraldi’ and the corrected name is ‘Francesca Pecori Giraldi’ (First name: Francesca; Surname: Pecori Giraldi).

scholarly journals Long-term low-dose ketoconazole treatment in bilateral macronodular adrenal hyperplasia

2014 ◽  
Vol 2014 ◽  
Author(s):  
Sophie Comte-Perret ◽  
Anne Zanchi ◽  
Fulgencio Gomez
Keyword(s):  
Medical Therapy ◽  
Cushing’S Syndrome ◽  
Clinical Signs ◽  
Cushing's Syndrome ◽  
List Type ◽  
Adrenal Hyperplasia ◽  
Benign Condition ◽  
Steroid Secretion ◽  
Free Cortisol

Summary Medical therapy for Cushing's syndrome due to bilateral macronodular adrenal hyperplasia (BMAH) is generally administered for a limited time before surgery. Aberrant receptors antagonists show inconsistent efficacy in the long run to prevent adrenalectomy. We present a patient with BMAH, treated for 10 years with low doses of ketoconazole to control cortisol secretion. A 48-year-old woman presented with headaches and hypertension. Investigations showed the following: no clinical signs of Cushing's syndrome; enlarged lobulated adrenals; normal creatinine, potassium, and aldosterone; normal urinary aldosterone and metanephrines; elevated urinary free cortisol and steroid metabolites; and suppressed plasma renin activity and ACTH. A screening protocol for aberrant adrenal receptors failed to show any illegitimate hormone dependence. Ketoconazole caused rapid normalisation of cortisol and ACTH that persists over 10 years on treatment, while adrenals show no change in shape or size. Ketoconazole decreases cortisol in patients with Cushing's syndrome, and may prevent adrenal overgrowth. Steroid secretion in BMAH is inefficient as compared with normal adrenals or secreting tumours and can be controlled with low, well-tolerated doses of ketoconazole, as an alternative to surgery. Learning points Enlarged, macronodular adrenals are often incidentally found during the investigation of hypertension in patients harboring BMAH. Although laboratory findings include low ACTH and elevated cortisol, the majority of patients do not display cushingoid features. Bilateral adrenalectomy, followed by life-long steroid replacement, is the usual treatment of this benign condition, and alternative medical therapy is sought. Therapy based on aberrant adrenal receptors gives disappointing results, and inhibitors of steroidogenesis are not always well tolerated. However, ketoconazole at low, well-tolerated doses appeared appropriate to control adrenal steroid secretion indefinitely, while preventing adrenal overgrowth. This treatment probably constitutes the most convenient long-term alternative to surgery.

scholarly journals Secondary Diabetes Mellitus in Patients with Endogenous Cushing’s Syndrome - Clinical Characteristics at Diagnosis

2018 ◽  
Vol 25 (1) ◽  
pp. 77-81 ◽  
Author(s):  
Cristina Căpăţînă ◽  
Ionela Baciu ◽  
Daniela Greere ◽  
Andra Caragheorgheopol ◽  
Cătălina Poiană
Keyword(s):  
Diabetes Mellitus ◽  
Arterial Hypertension ◽  
Cushing’S Syndrome ◽  
Central Obesity ◽  
Clinical Characteristics ◽  
Clinical Signs ◽  
Cushing's Syndrome ◽  
Secondary Diabetes ◽  
Secondary Diabetes Mellitus ◽  
Proximal Myopathy

Abstract Background and aims. Endogenous Cushing’s syndrome is a rare disease associated with severe morbidity and increased mortality if untreated. Diabetes mellitus is a frequent initial complaint of these patients. Our aim was to investigate the clinical characteristics at the time of diagnosis in a cohort of patients with endogenous Cushing’s syndrome (CS). Material and methods. A retrospective analysis of the presentation of 68 cases diagnosed with endogenous Cushing’s syndrome followed-up in our institution was performed. Results: There were 57 women and 11 men, aged 18-74 years (mean 45.57±14.2). 38 had Cushing’s disease (CD) while 30 had adrenal CS. The most frequent signs/symptoms leading to the initial consultation and diagnostic suspicion were central obesity (55 cases, 80.88%), purple striae (28 cases, 41.1%), secondary arterial hypertension (27 cases, 39.7%), secondary diabetes mellitus (24 cases, 35.29%), hirsutism in 23/55 women (41.81%), hypogonadism in 23 cases (33.82%), proximal myopathy in 17 cases (25%), edema (10 cases, 14.7%). 13 cases (19.11%) also had secondary osteoporosis (diagnosed by dual energy x-ray absorptiometry - DXA osteodensitometry). Among the two diagnostic groups there were several differences. Proximal myopathy, secondary hypertension and diabetes mellitus were all more frequent in cases with adrenal Cushing compared to those with CD. (p= 0.011, 0.006 and 0.024, respectively). This did not reflect more severe hypercortisolism in adrenal CS, as the hormonal values were similar in the two groups. Conclusion: If associated with certain clinical signs, some nonspecific (central obesity, edema, arterial hypertension), other more suggestive of CS (purple striae, proximal myopathy) diabetes mellitus could be the initial sign of this severe condition.

scholarly journals Extraoral Sinus Tracts of Odontogenic Origin: A Case Series

2020 ◽  
Author(s):  
Ellahe Azizlou ◽  
Mohsen AminSobhani ◽  
Sholeh Ghabraei ◽  
Mehrfam Khoshkhounejad ◽  
Abdollah Ghorbanzadeh ◽  
...  
Keyword(s):  
Correct Diagnosis ◽  
Case Series ◽  
Signs And Symptoms ◽  
Complete Recovery ◽  
Cutaneous Lesions ◽  
Odontogenic Origin ◽  
The Face ◽  
History Of ◽  
Relationship Of ◽  
Dental Infections

Extraoral sinus tracts of odontogenic origin often develop as the result of misdiagnosis of persistent dental infections due to trauma, caries, or periodontal disease. Due to these lesions' imitation from cutaneous lesions, misdiagnosis, and mismanagement, which we frequently encounter, this article aims to describe four cases with manifestations in different parts of the face and the neck. Patients were referred to an endodontist with a history of several surgical procedures and/or antibiotic therapy due to misdiagnosis. After comprehensive examinations, root canal treatment was performed. The resolution of signs and symptoms during the follow-up period confirmed the correct diagnosis. Dermatologists and other physicians should be aware of the possibility of the relationship of extraoral sinus tracts with dental infections. Precise examination and taking a comprehensive history can aid to prevent unnecessary and incorrect therapeutic and/or pharmaceutical interventions. Elimination of dental infection leads to complete recovery in such patients.

Abstract #1003811: Cushing’s Syndrome With Unilateral Adrenal Mass: A Case Report

2021 ◽  
Vol 27 (6) ◽  
pp. S16
Author(s):  
Nur Hidayat ◽  
Dicky L. Tahapary ◽  
Tri Juli Edi Tarigan ◽  
Subekti Imam
Keyword(s):  
Case Report ◽  
Cushing’S Syndrome ◽  
Adrenal Mass ◽  
Cushing's Syndrome
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