Excessive Secretion Research Articles

Hyperemesis gravidarum is a cytokine storm?

Aim. To study the systemic response of proinflammatory cytokines in women suffering from VP. The main group consisted of 47 women with VP, which was divided into 3 subgroups according to severity: the 1st – included 16 patients with mild VP, the 2nd – 15 with moderate severity, and the 3rd – 16 women with severe VP. The control group consisted of 10 pregnant women with a physiological course without signs of toxicosis. Interleukins (IL-1β, IL-6, TNFα) were determined in the blood serum of pregnant women by solid-phase ELISA using Cytokine test kits (St. Petersburg, Russia). With increasing severity of toxicosis, there is a significant increase in IL-1β in severe VP – 1.9 times higher than the same value of the norm (p 0.05), 2 times higher than in mild vomiting (p 0.05), and in 1.7 times – with moderate VP (p 0.05). The study of the level of IL-6 revealed a directly proportional increase in the indicator with increasing severity of toxicosis in relation to the control indicator: with mild vomiting – 1.9 times (p 0.05), with moderate vomiting – 2.6 times (p 0.001), and in severe VP – 2.9 times (p 0.0001). A significant decrease in the level of TNFα was observed with increasing severity of toxicosis in relation to the control indicator: with mild vomiting – by 1.5 times (p 0.05), with moderate vomiting – by 1.9 times (p 0.05), and with severe VP – 2.1 times (p 0.05). Excessive secretion of proinflammatory cytokines IL-1β and IL-6 (2 and 3 times, respectively), exceeding the norm, with a sharp suppression of TNFα production (2 times) can be considered as predictors of a “cytokine storm”, clinically occurring with multiple organ failure up to death if the pregnancy is not terminated in a timely manner.

Manganese nanoparticles catalyzed the formation of mesoporous helical nitrogen-doped carbon nanotubes enabled aldosterone biosensing

Primary aldosteronism (PA) is the foremost form of secondary hypertension that affects 5–20 % of healthy humans via the excessive secretion of aldosterone (ALD), which increases the level of potassium excretion and thus produces various critical combined diseases. Thus, determining trace-level ALD content in human blood or urine samples is a crucial factor in diagnosing a life-threatening disease called PA. Herein, nanosized manganese particles encapsulated within the tunable helical-shaped N-doped mesoporous carbon nanotubes (Mnx@H-NCNTs) are synthesized by a simple and facile ball-milling method at different reaction times (1, 6, 12, and 18 h). The influence of ball-milling process time on the final morphology of the as-synthesized Mnx@H-NCNTs nanostructures is systematically investigated. In order to fabricate an ALD biosensor electrode, the immobilization of Anti-ALD antibodies (Anti-ALD) on the surface of the Mn@H-NCNTs-12H electrode (Anti-ALD/Mn@H-NCNTs-12H) is achieved via the interactions of combined interactions of hydrogen bonds, Van der Waals’ force, negatively charged carboxylic acid functionalities of antibodies and positively charged metal centers, and π-π stacking interaction between nucleosides of Anti-ALD and mesoporous H-NCNTs. In addition, BSA was used as a blocking additive for covering non-specific adsorption sites of Anti-ALD/Mnx@H-NCNTs (BSA/Anti-ALD/Mn@H-NCNTs-12H) nanostructured electrodes. The BSA/Anti-ALD/Mn@H-NCNTs-12H can be used as an effective signal amplifying probe for ALD detection through a noticeable reduction in the amperometric i-t current response over a linear range from 1 to 2500 pM, with a LOD of 0.72 pM (S/N = 3). The practical applicability of BSA/Anti-ALD/Mn@H-NCNTs-12H is further demonstrated by the detection of ALD from 1 to 20 nM in human blood or urine samples with a recovery ranging from 90.5 to 97.0 %, indicating its potential use in clinical analysis.

6564 A Case of Severe Hypercalcemia in Carney's Complex

Abstract Disclosure: J. Chippior: None. M. Rayan: None. L. Wright: None. L.S. Kirschner: Grant Recipient; Self; Medpace, Sparrow, Corcept Therapeutics, Corcept, Spruce, CinCor, Crinetics, Adrenas. S.W. Ing: Grant Recipient; Self; Alexion Pharmaceuticals, Inc., Amgen Inc, Radius Health, Inc, Takeda, Ultragenyx, Amolyt, Bridge Bio. Carney complex is a rare syndrome with fewer than 750 reported cases, characterized by lentigniosis, myxomas, and the occurrence of both endocrine and non-endocrine tumors. An inactivating mutation PRKAR1A, which encodes for the type 1A regulatory subunit of Protein kinase A, is responsible for over 70% of familial cases and 37% of sporadic cases. A 31-year-old female with a history of Carney complex, Cushing syndrome due to primary pigmented nodular adrenocortical disease (PPNAD), facial lentigines, spinal Schwannomas, and recent ischemic stroke secondary to embolization of a cardiac atrial myxoma, was transferred to our medical center for hyperemesis and severe hypercalcemia. Albumin-corrected serum calcium measured 15.4 mg/dL (8.6-10.5 mg/dL), ionized calcium 7.8 mg/dL (4.6-5.3 mg/dL) associated with suppressed PTH, normal PTH-related protein, and elevated bone turnover markers, C-telopeptide 4,273 pg/ml (150-635) and Procollagen Type 1 N-terminal Propeptide 222 mcg/L (19-83). Evaluation for etiology of hypercalcemia revealed elevated 1,25 dihydroxy vitamin D at 107.0 pg/ml (20-79) and elevated interleukin-6 at 11 pg/ml (<6.4). IL-6 is expressed by cardiac myxomas. Serum angiotensin-converting enzyme level was 50 U/L (16-85) and infectious workup was negative for potential granulomatous causes of elevated calcitriol (including testing for tuberculosis, histoplasma, blastomyces, bartonella, and coccidioides). CT angiogram of the abdomen and pelvis (completed in preparation of atrial myxoma resection) revealed ground-glass opacities in bilateral posterior lung fields and multiple pulmonary nodules, with the largest measuring 8 mm. After treatment with aggressive intravenous fluid resuscitation, intramuscular calcitonin, and intravenous zoledronic acid, corrected calcium normalized to 9.4 mg/dL at discharge. Urinary cortisol was 6.2 mcg per 24-hr (3.5-45), for which she started hydrocortisone 20 mg daily to treat suspected adrenal insufficiency as excess cortisol secretion in PPNAD may be episodic. Thus remission of hypercortisolism may have unmasked an underlying hypercalcemia, and adrenal insufficiency itself may have contributed to this finding. She had excision of left atrial myxoma and has continued to exhibit normal calcium levels on steroid replacement therapy. Repeat chest CT to further characterize these pulmonary findings is planned. This case illustrates a unique constellation of endocrine features associated with severe hypercalcemia in Carney complex. Presentation: 6/1/2024

7239 Natural history of cystic pituitary lesions

Abstract Disclosure: B. Graner: None. D.Z. Erickson: None. D. Donegan: None. Introduction: Pituitary lesions are a common incidental finding on brain MRI, the majority of which are cystic. The natural history and management of cystic pituitary lesions have not been clearly established. Purpose: The purpose of this study is to determine the natural history of incidentally identified cystic pituitary lesions, risk factors for growth and the proportion of patients who develop clinically significant symptoms requiring surgical intervention. Methods: Pituitary MRI reports between 01/01/2015 and 12/31/2022 in patients aged 18 years and older were searched for using Dig Our Radiology Information System (DORIS) using the words “cyst” or “cystic.” Additional inclusion criteria included a follow-up pituitary MRI of at least one year duration, clinical evaluation by Endocrinology, and the presence of a cystic pituitary lesion. Patients with non-contrast exams, excessive pituitary hormone secretion, and surgery within 1 year of presentation were excluded. Patient demographics, imaging characteristics of the lesion and clinical outcomes were collected. All pituitary MRI exams were reviewed by a single neuroradiologist. Results: A total of 157 MRIs in 56 patients with a mean age of 48 ±15 years were included, 39 (70%) were female. The mean follow-up was 2.3 ± 1.4 years. The most common indication for MRI was headache (n= 18, 32%). There was no significant difference in mean maximum (max) diameter at last follow-up compared to baseline (7.45 ±4.23 vs 7.04 ±4.35 mm, p=0.06) or mean cyst volume (197.08 ±252.68 vs 201.43 ±326.18 mm3). Nine (16%) of the lesions increased in volume with a mean change in volume of 105 ±133.64 mm3/yr, note 11 (20%) decreased volume and 36 (64%) remained the same size. Using univariate logistic regression, the odds of cyst growth was greater the larger the max diameter (p= 0.03) or volume was at baseline (p= 0.02)/ Female sex (p=0.32), age at diagnosis (p=0.70) or whether the lesion was thought to be a Rathke cleft cyst or a cystic adenoma (p=0.80) were not associated with increased odds of growth. The risk of growth was higher (42 vs 9%, p=0.016) and the volume change per year was greater (67.2 ±134 vs -7 ±28 mm3, p=0.04) in those with a baseline max diameter of >10 mm. Surgery was performed in 4 patients (7%), 3 of which demonstrated lesion growth (baseline size 12-15 mm and growth rates of 59-341mm3/yr). Pathology revealed one Rathke cleft cyst, one cystic adenoma and fibrotic pituitary changes. The fourth surgical patient opted for resection at an outside facility without a demonstrated increase in size (Rathke cleft cyst). Conclusion: The majority of incidentally found cystic pituitary lesions do not increase after an average follow-up 2-3 years. Growth necessitating surgical intervention was only required in 5% of patients over the study period. A pituitary cyst >10 mm at diagnosis was associated with an increased risk of growth and therefore warrants closer follow-up. Presentation: 6/1/2024

6365 An Atypical Case Of Large Metastatic Pheochromocytoma With Negative Catecholamine Secretion

Abstract Disclosure: D. Caesario: None. J.K. Fernandes: None. Introduction: Pheochromocytomas (PCCs) are rare tumors arising from chromaffin cells of the adrenal medulla. Diagnosis is suggested by clinical presentations and confirmed by biochemical hypersecretion of metanephrines (MN) and catecholamines (CA). We report an atypical case of large metastatic PCC with normal MN and CA. Case Report: A 61-year-old female presented with uncontrolled HTN despite taking amlodipine, losartan, and carvedilol. No other symptoms reported. She had presented 12 years prior with an 8.7 cm left adrenal mass (AdM) that was incidentally found on CT scan, but she was lost to follow-up. Repeat imaging for her current presentation revealed enlargement of left AdM to 15 cm, centrally necrotic, with absolute washout of 63%. There was extensive local regional involvement, including possible invasion of the pancreas; abutment to left kidney, left renal vein, left hepatic lobe, and stomach; encasement and possible invasion of the splenic vein; and formation of perisplenic collateral vessels. Metastatic lesions were also seen in the liver, bones, and lungs. DOTATATE PET/CT scan showed variable uptake, not a definitive pattern for PCC or neuroendocrine tumor (NET). Labs showed normal levels of plasma fractionated MN and CA, dopamine, renin, aldosterone, cortisol, ACTH, and DHEA-S. Chromogranin A (CgA) was elevated to >8000 ng/dL. Biopsy taken from one of the liver lesions was consistent with metastatic PCC. No family history of NET. Genetic testing was offered, but was deferred. Due to the large tumor burden, she was determined to be nonsurgical and started on systemic therapy with sunitinib. Doxazosin was also added, which better controlled her BP. After 9 months of sunitinib therapy, a repeat CT scan showed overall stable metastatic lesions, but the left AdM had enlarged to 16 cm. Given the slowly worsening disease, patient was switched to temozolomide. She is still actively being treated and monitored today. Discussion: The clinical features of PCC result from excessive CA secretion. HTN is the hallmark of CA release, but the amount, type, and pattern of CA secretion is extremely variable, leading to varied clinical presentations. CgA secretion is also elevated in PCC, but is generally a non-specific marker as its level is also increased in multiple NETs and non-endocrine medical conditions. About 9% of patients with PCC may have normal biochemical workup, with this being even rarer in malignant cases. In general, the amount of CA, MN, and CgA released by the tumor is also positively correlated with the tumor size. The case above is unique in that despite the large tumor burden the patient only presented with HTN and had normal MN and CA levels. Her CgA was significantly elevated, which could correlate with the tumor size, but was interestingly the only marker elevated. It appears that CgA could be a useful adjunct in the diagnosis of PCC, especially in cases where PCC appeared to be non-secretory. Presentation: 6/3/2024

7454 Angiotensin AT1 Receptor Type 1 (AT1) Autoantibodies In Patients with Primary Aldosteronism

Abstract Disclosure: J.K. Waraich: None. G. Kline: None. M.Y. Choi: None. R.J. Sigal: None. C. Caughlin: None. S.J. Przybojewski: None. A. Leung: None. Background: Primary aldosteronism (PA) is a condition characterized by excessive aldosterone secretion, and accounts for at least 10% - 20% of all cases of hypertension. Determination of PA subtype (i.e., unilateral vs. bilateral aldosterone hypersecretion) is clinically important to inform targeted treatment. We hypothesized that pathogenesis of PA is immune-mediated and autoantibodies to angiotensin receptor type 1 (AT1) may determine PA subtype. Aims: The aim of this study was to examine whether AT1 autoantibodies predict PA subtype. Methods: We conducted a cross-sectional study of patients with PA who were referred for adrenal vein sampling (AVS) for subtyping. AT1 autoantibody titres were measured using an enzyme-linked immunosorbent assay. AT1 antibodies were defined as present when the titre was >17 U/mL, negative if <10 U/mL, and indeterminate if between 10-17 U/mL. AVS was used as a gold standard to determine lateralization and PA . The frequency of positive AT1 autoantibodies was determined according to PA subtype and clinical predictors of lateralization. Baseline patient characteristics were reported as means (and standard deviations) for normally distributed variables, and medians (and interquartile ranges) for non-normally distributed variables. Fisher’s exact test was performed for categorical variables and Kruskal-Wallis test for continuous variables. Results: 54 patients had successful cannulation of both adrenal veins (mean age, 52.7 years; 46.3% male; mean body mass index, 31.2 kg/m2). AT1 antibodies were detected in 14 (25.9%) of the patients, absent in 32 (59.3%), and indeterminate in 8 (14.8%). Among the 25 patients with unilateral PA, 8 (32.0%) had positive AT1 antibodies, 15 (60.0%) negative, and 2 (8.0%) indeterminate. Similarly, among the 29 patients with bilateral PA, 6 (20.7%) had positive AT1 antibodies, 17 (58.6%) negative, and 6 (20.7%) indeterminate. There was no significant association detected between AT1 antibody status and lateralization (p=0.39). There were no associations between AT1 autoantibody status and any of the clinical factors traditionally predictive of PA, including sex (p=0.94), older age (p=0.76), hypokalemia (p=0.91), higher estimated glomerular filtration rate (p=0.46), or magnitude of aldosterone-to-renin ratio elevation (p=0.58). There was also no association between AT1 titres and these factors. Conclusion: AT1 autoantibodies are common in patients with PA; over a quarter of patients who underwent AVS in our study. Although they were not predictive of PA subtype, these results may still suggest that PA is immune-mediated. Future studies comparing AT1 autoantibodies in PA to other controls are underway. Presentation: 6/1/2024

12215 A Rare Cause Of Cushing's Syndrome: Acth-producing Pheochromocytoma

Abstract Disclosure: S. Jimenez Salazar: None. C. Aguilar Londoño: None. N. Aristizabal Henao: None. N. Buitrago Gómez: None. S. Saldarriaga Betancur: None. D.L. Beltran: None. J.L. Torres: None. Background: Cushing's syndrome is a severe endocrine disorder caused by chronic, autonomous, and excessive cortisol secretion. Among all causes, ectopic ACTH production continues to be one of the most challenging diagnoses. Rarely, pheochromocytomas secrete hormones other than catecholamines, including ACTH and CRH. The secretion of these hormones can alter the clinical presentation and make the diagnosis more difficult. Clinical Case: A previously 60-year-old woman with hypertension and no other relevant medical history presented with unintentional weight loss of 16 kg and constipation. Physical examination revealed a moon face, supra-labial and chin facial hair. Laboratory studies demonstrated hypokalemia (potassium 3.02 mEq/L, n: 3.5-5 mEq/L) and newly diagnosed diabetes (HbA1c 8.69%, n <5.7% and fasting glucose 282 mg/dL, n: 70-100 mg/dL), both difficult to control. Considering the clinical and biochemical findings, hypercortisolism was evaluated by measuring 24-hour urinary free cortisol (1853 mcg/24h, n: 4-176 mcg/24h), nocturnal serum cortisol (40.9 mcg/h, n:<7.5 mcg/h), and 1 mg dexamethasone suppression test (43.1 mcg/h, n:<1.8 mcg/h), confirming cortisol excess. ACTH was measured (95 pmol/mL, n: 4.7-48.5 pg/mL) suggesting ACTH-dependent cause, leading to a dynamic test with high doses of dexamethasone (8mg) with suppression greater than 50% and normal pituitary MRI, both compatible with an extrahypophyseal cause. Peripheral imaging evaluation was conducted with cervical-thoracic CT scan and abdominal MRI confirming the presence of a complex adrenal mass. Among adrenal hyperfunction studies, primary hyperaldosteronism was ruled out (Aldosterone 9.8 ng/dL, n: 1-32 ng/dL and Plasma Renin Concentration 1.1 ng/dL, n: 0.16-2.3 ng/dL), and pheochromocytoma was confirmed (Normetanephrines 2725.4 mcg/24h, n: 0-600 mcg/24h and Metanephrines 1550 mcg/24h, n: 0-350 mcg/24h). Considering the described adrenal lesion with biochemical behavior, the possibility of ectopic ACTH production from pheochromocytoma was studied. Therefore, ketoconazole 200mg every 8 hours was initiated for hypercortisolism control and adrenergic blockade protocol as pre-surgical preparation for adrenalectomy. Potassium levels (4.48 mEq/L, n: 3.5-5 mEq/L) and glucose levels (93 mg/dL, n: 70-100 mg/dL) normalized after the procedure. Pathology and immunohistochemistry confirmed the diagnosis of an ACTH-producing pheochromocytoma. Conclusion: Pheochromocytoma is a rare cause of ectopic ACTH secretion where pre-surgical management of catecholamine excess and hypercortisolism is crucial, and adrenalectomy is often curative. Reference: (1) Elliott PF, Berhane T, Ragnarsson O, Falhammar H. Ectopic ACTH- and/or CRH-Producing Pheochromocytomas. J Clin Endocrinol Metab 2021;106:598-608. Presentation: 6/1/2024

6570 Treatment of Cushing’s With Levoketoconazole: A Case Series

Abstract Disclosure: N. Chamorro-Pareja: None. M. Haines: None. L.E. Dichtel: Consulting Fee; Self; Lumos Pharma. Research Investigator; Self; Recordati, NovoNordisk, Perspectum Ltd, Lumos Pharma, Pfizer, Inc.. Stock Owner; Self; Marea Therapeutics. Other; Self; Third Rock Ventures. B.M. Biller: Consulting Fee; Self; Xeris Pharmaceuticals, Recordati Rare Diseases, Sparrow, Lundbeck. Background: Endogenous Cushing’s syndrome (CS) is a rare condition of excess cortisol secretion; the most common cause is a pituitary corticotroph tumor (Cushing’s disease [CD]). Medical treatment for CD is primarily used to control hypercortisolism in patients with persistent or recurrent disease after transsphenoidal surgery (TSS). Levoketoconazole (LKCZ), a steroidogenesis inhibitor, was FDA approved in January 2022 for CS treatment. This reports 3 cases of patients who were treated with LKCZ for recurrent CS. Clinical Cases: Case 1: 44-year-old (yo) male (M) with a history of CD with urinary free cortisol (UFC) >26x upper limit of normal (ULN) who was treated preoperatively with ketoconazole (KCZ) 1000 mg/day with UFC improved to 6x ULN. KCZ was discontinued at TSS, and he achieved remission post-operatively. He was lost to follow-up and re-presented after several years with worsening hypertension, muscle weakness, edema, and anxiety with UFC 28x ULN and a recurrent pituitary lesion on MRI. He declined repeat TSS and underwent radiation therapy (RT) and medical treatment. LKCZ was initiated at 150 mg twice daily (BID) and increased to 300 mg BID. At LKCZ 300 mg BID, he had a low UFC and mild nausea but an adequate serum morning cortisol (10.4 ug/dL, ref:6-18.4 ug/dL); LKCZ was reduced to 150 mg BID with resolution of symptoms (sxs) and normal UFC. Case 2: 56 yo M with a history of CD (UFC >3x ULN) who underwent 2 TSSs and RT over 10 years prior with eventual remission, but later recurred. Sxs included brain fog and mood disturbances. He achieved control with pasireotide but discontinued due to abnormal liver function tests. He was then treated with KCZ 400 mg/day but remained hypercortisolemic (LNSC 1.1x ULN) and was interested in trying a new medication, so was switched to LKCZ 150 mg BID with significant improvement of sxs and normalization of LNSC. Case 3: 54 yo F with presumed cyclic CD (negative whole-body and octreotide scans) with UFC 1.7x ULN and LNSC 3x ULN. TSS was performed with negative pathology; she had persistent hypercortisolemia and sxs including insomnia, fatigue, and mood disturbances. She was intolerant to and/or uncontrolled on 4 medications, including KCZ at 1000 mg/day that was discontinued due to a rash. She was started on LKCZ 150 mg BID and achieved normal LNSC and UFC after about 1 month. The drug was discontinued due to the development of a rash similar to that with KCZ. Conclusion: LKCZ is a new option for the treatment of CS in patients whose disease persists after TSS. These 3 patients had improvement of sxs and normalization of cortisol levels while on LKCZ, although one patient discontinued LKCZ due to a rash that was previously experienced with KCZ. The other two patients are being carefully monitored for liver function test elevation, QTc abnormalities and adrenal insufficiency with no issues to date. To our knowledge, this is the first case series of CS patients treated clinically with LKCZ. Presentation: 6/1/2024

6997 Atypical Presentation of Hereditary Paraganglioma

Abstract Disclosure: O. Abdulhussein: None. R.R. Correa: None. M.D. Lundholm: None. J. Ferri-Guerra: None. G. Madrigol: None. Introduction: Paraganglioma (PGL) is a rare neuroendocrine, highly vascular tumor arising from sympathetic or parasympathetic ganglia chromaffin cells. Some PGL functional while others biochemically silent. Given the possible lack of classic symptoms or convincing catecholamine elevation. They are closely related to pheochromocytomas.• However, the distinction between pheochromocytoma and paraganglioma is essential because of the implication for associated neoplasm and syndromes; paraganglioma is more metastatic. Case: 32-year-old otherwise healthy female presented to primary care clinic for 1 year of dry cough. She was a non-smoker. She denied voice changes, palpitations, hypertension, palpitations, pallor, headache, or diaphoresis, but had noticed a mass growing in her right neck for a year. On exam her blood pressure 107/73 and there was a mobile, round mass felt at the right mandible. CT neck at the time showed reactive lymphadenopathy. She referred to pulmonology and ENT, spirometry and flexible laryngoscopy were unremarkable. For persistent mass 1year later, an MRI of the neck showed a 2.8x2.3x3.8 cm right carotid mass, likely PGL. Biochemical testing revealed elevations in plasma normetanephrine (NM) (269 pg/mL, 18-101 pg/mL) and 24-hour urinary NM (848 ug/24hr, 88-444 ug/24hr) with mild elevation in 24-hour urinary metanephrine (982 ug/24 hr, 140-785 ug/24 hr) and normal plasma metanephrine. The mass was intensely avid on DOTATATE scan without other lesions. Genetic testing uncovered SDHB mutation. She was started on preoperative alpha-blockade with successful resection. She had pathology confirmation of PGL and was set up for annual SDHB surveillance testing. Discussion: A minority of patients with PCC or PGL present with classical “5 P” catecholamine symptoms: pallor, pain, pressure, perspiration, or palpitations. One main reason is a lack of excess catecholamine secretion; 17 years of retrospective data at our center showed that 61% (N=50/82) of patients with PGL with preoperative catecholamine labs had normal levels. Additionally, mild to moderate increases to 2-3x upper limit of normal may be attributed to stress or medications, which obfuscates the distinction between secretory disease and physiologic elevation.Given the infrequency of catecholamine symptoms or secretion, PGL is frequently discovered incidentally. Indeed, 92% (N=110/119) of our PGL cases were found incidentally on imaging or pathology. Alpha-blockade is the preoperative standard of care, many patients are only diagnosed post-operatively by pathology findings. Further study is needed to determine if pre-operative alpha-blockade is needed in all PGL cases, and if so, how we can better identify these patients before they go to the operating room. For now, a high level of suspicion is needed to make a timely PGL diagnosis and facilitate genetic testing. Presentation: 6/1/2024

8281 Continuous Low-Dose Etomidate Infusion For The Management Of Severe Hypercortisolism In Metastatic Adrenocortical Carcinoma

Abstract Disclosure: A. Jamil: None. N. Mohammad: None. S. Narayana: None. Background: Adrenocortical carcinoma (ACC) is a rare endocrine malignancy of the adrenal glands with a poor prognosis that often presents with excess hormone secretion. Approximately, 45% of cases present with hypercortisolism.1 A key component of management is achieving control of hypercortisolism. Though there are multiple enteral therapies that can inhibit cortisol production, few treatment options are available for use in critically ill patients who are not surgical candidates and cannot take oral medications. Though primarily known as a short-acting intravenous anesthetic agent used for sedation, etomidate also inhibits 11-β-hydroxylase, a key enzyme involved in corticosteroid biosynthesis.2 Clinical Case: A 28-year-old woman with metastatic adrenocortical carcinoma with associated hypercortisolism was initially admitted for anemia and thrombocytopenia, with an initial cortisol on admission of 29.3 μg/dl (normal range: 2.3-19.4 ug/dl). Due to her large tumor burden with metastasis to the liver and invasion into the inferior vena cava, she was deemed a poor surgical candidate with a poor overall prognosis. Her hospital course was complicated by acute hypoxemic respiratory failure requiring intubation, and thus her enteral steroidogenesis inhibitors (mitotane, ketoconazole, and metyrapone) were discontinued as none were administrable via nasogastric tube. Consequently, her hypercortisolism worsened rapidly with a cortisol level of 351.3 μg/dl , prompting initiation of continuous low-dose etomidate infusion, which resulted in significant improvements in her cortisol levels. After eight days of etomidate treatment, her cortisol levels reached a goal value of 25.0 μg/dl. However, she then suffered an ischemic cerebrovascular event and multiorgan failure, and was subsequently transitioned to hospice care. Conclusion: Low-dose etomidate infusion is an effective therapeutic agent for hypercortisolism in patients with ACC that are unable to take oral medications.

6564 A Case Of Severe Hypercalcemia In Carney's Complex

Abstract Disclosure: J. Chippior: None. M. Rayan: None. L. Wright: None. L.S. Kirschner: Grant Recipient; Self; Medpace, Sparrow, Corcept Therapeutics, Corcept, Spruce, CinCor, Crinetics, Adrenas. S.W. Ing: Grant Recipient; Self; Alexion Pharmaceuticals, Inc., Amgen Inc, Radius Health, Inc, Takeda, Ultragenyx, Amolyt, Bridge Bio. Carney complex is a rare syndrome with fewer than 750 reported cases, characterized by lentigniosis, myxomas, and the occurrence of both endocrine and non-endocrine tumors. An inactivating mutation PRKAR1A, which encodes for the type 1A regulatory subunit of Protein kinase A, is responsible for over 70% of familial cases and 37% of sporadic cases. A 31-year-old female with a history of Carney complex, Cushing syndrome due to primary pigmented nodular adrenocortical disease (PPNAD), facial lentigines, spinal Schwannomas, and recent ischemic stroke secondary to embolization of a cardiac atrial myxoma, was transferred to our medical center for hyperemesis and severe hypercalcemia. Albumin-corrected serum calcium measured 15.4 mg/dL (8.6-10.5 mg/dL), ionized calcium 7.8 mg/dL (4.6-5.3 mg/dL) associated with suppressed PTH, normal PTH-related protein, and elevated bone turnover markers, C-telopeptide 4,273 pg/ml (150-635) and Procollagen Type 1 N-terminal Propeptide 222 mcg/L (19-83). Evaluation for etiology of hypercalcemia revealed elevated 1,25 dihydroxy vitamin D at 107.0 pg/ml (20-79) and elevated interleukin-6 at 11 pg/ml (<6.4). IL-6 is expressed by cardiac myxomas. Serum angiotensin-converting enzyme level was 50 U/L (16-85) and infectious workup was negative for potential granulomatous causes of elevated calcitriol (including testing for tuberculosis, histoplasma, blastomyces, bartonella, and coccidioides). CT angiogram of the abdomen and pelvis (completed in preparation of atrial myxoma resection) revealed ground-glass opacities in bilateral posterior lung fields and multiple pulmonary nodules, with the largest measuring 8 mm. After treatment with aggressive intravenous fluid resuscitation, intramuscular calcitonin, and intravenous zoledronic acid, corrected calcium normalized to 9.4 mg/dL at discharge. Urinary cortisol was 6.2 mcg per 24-hr (3.5-45), for which she started hydrocortisone 20 mg daily to treat suspected adrenal insufficiency as excess cortisol secretion in PPNAD may be episodic. Thus remission of hypercortisolism may have unmasked an underlying hypercalcemia, and adrenal insufficiency itself may have contributed to this finding. She had excision of left atrial myxoma and has continued to exhibit normal calcium levels on steroid replacement therapy. Repeat chest CT to further characterize these pulmonary findings is planned. This case illustrates a unique constellation of endocrine features associated with severe hypercalcemia in Carney complex. Presentation: 6/1/2024

12343 Cardiac Function Recovery Following Left Adrenalectomy For A Pheochromocytoma With Ectopic ACTH Syndrome

Abstract Disclosure: T.D. Williams: None. D. Lovre: None. R.C. Galagan: None. Background: Pheochromocytoma and Cushing’s Syndrome are implicated in Non-ischemic Cardiomyopathy/Heart Failure with reduced Ejection Fraction (NICM/HfrEF) due to catecholamine induced hypertension and cardiomyocyte toxicity. Subsequent hypoxia and calcium overload in cardiomyocytes results in oxidative stress and cell death. Excess cortisol secretion increases angiotensin II, causing hypertrophy. Subsequent increases in atrogin I lead to myo-fibrinolysis and fibrosis. We present a patient with NICM/HFrEF due to both catecholamine excess and ectopic ACTH syndrome from an adrenal pheochromocytoma. Following adrenalectomy, systolic cardiac function returned to normal. Clinical Case A 42-year-old female was referred to endocrinology after a hypertensive emergency concurrent with NSTEMI, NICM, and HFrEF (EF 45%). Initial work up revealed: Troponin I 0.49 ng/ml; (0 - 0.04 ng/ml), Na+ 140 mmol/L; (136 - 144 mmol/L), K+ 2.3 mmol/L; ​​(3.7 - 5.2 mmol/L), CO2 41 mmol/L; (23 - 29 mmol/L), Glucose 53 mg/dL; (64 - 100 mg/dL), Cortisol 57.2 ug/dL; (5 - 25 ug/dL), ACTH 363.7 pg/mL; (7.2 - 63.3 pg/mL). She failed both 1 mg and 8 mg overnight dexamethasone suppression tests: 0800 cortisol 48.5 ug/dL (< 1.8 ug/dL) & 56.8 ug/dL (> 50% decrease in baseline cortisol level of 57.2 ug/dL) consistent with ectopic ACTH syndrome. Elevated plasma normetanephrine 0.98 nmol/L; (0 - 0.89 nmol/L) and chromogranin A 250 ng/mL; (0 - 103 ng/mL) suggested a neuroendocrine tumor. Pituitary MRI revealed a normal pituitary gland. Abdominal MRI detected a 3.6 x 2.5 cm left adrenal nodule and PET/CT CU-64 showed increased activity (Krenning 4) consistent with a pheochromocytoma. Notwithstanding Ketoconazole (200 mg/day) for 7 months, her EF fell to a low of 15-20%. A left adrenalectomy was performed and post-op 0800 cortisol was 12.3 ug/dL (6.0 - 26.0 ug/dL). Oral hydrocortisone was initiated at 20 mg QAM/10 mg QPM for steroid withdrawal syndrome, tapered over 8 months and withdrawn when a cosyntropin stimulation test 60-min cortisol was 19.3 ug/dL; (>18.0 ug/dL). Eleven months post op, her 0800 cortisol was 8.8 ug/dL and ACTH 27.4 pg/mL. One month post-op, TTE showed EF: 15-20%, six months post-op EF: 25-30%, eight months post-op EF: 35-40% and 15 months post-op EF was normal at 50%. Her heart failure symptoms resolved, and her activity returned to normal. Conclusion This case illustrates a remarkable restoration of cardiac function following resection of a pheochromocytoma. Our patient's case is unique due to the restoration of cardiac function despite the dual impact of excessive catecholamines and cortisol. Our patient’s clinical course contributes to an evolving understanding of cardiomyopathy associated with pheochromocytoma and ectopic ACTH syndrome and highlights the potential for cardiomyopathy reversal with targeted endocrine surgical and medical interventions. Presentation: 6/1/2024

7372 Anti-Corticotropin-Releasing Hormone (CRH) Monoclonal Antibody HBM9013 For The Treatment Of Congenital Adrenal Hyperplasia (CAH) And Polycystic Ovarian Syndrome (PCOS)

Abstract Disclosure: H. Pan: None. L.L. Liu: None. Q. Lv: None. F.G. Grosveld: None. D. Drabek: None. R.V. Haperen: None. X. Wang: None. Y. He: None. Y. Wang: None. J. Huang: None. J. Lee: None. G. Zhang: None. J.J. Rong: None. H.V. Chen: None. J.A. Majzoub: Advisory Board Member; Self; Chair of SAB of Harbour BioMed Alpha Therapeutics, which owns the rights of HBM9013.. Stock Owner; Self; Equity Owner of Harbour BioMed Alpha Therapeutics, which owns the rights of HBM9013.. J.J. Zhao: None. Anti-Corticotropin-Releasing Hormone (CRH) Monoclonal Antibody HBM9013 for the Treatment of Congenital Adrenal Hyperplasia (CAH) and Polycystic Ovarian Syndrome (PCOS). Abstract Congenital Adrenal Hyperplasia (CAH) is a rare autosomal recessive genetic disease due to mutation of CYP21A2 which leads to deficiency of 21-Hydroxylase enzymatic activity. Classical CAH patients are born with life-threatening deficiency of glucocorticoid (GC) and mineralocorticoid. Due to this enzymatic block and the lack of negative feedback on the hypothalamic-pituitary-adrenal (HPA) axis by GC, the adrenal gland produces excessive amounts of androgen which result in masculinized genitalia and virilization. The current standard care is supraphysiological doses of GC, which are difficult to balance between excess GC exposure and excess androgen secretion. Too little GC does not suppress production of androgen sufficiently and too much GC leads to Cushing Syndrome (CS). Previous work found that corticotropin-releasing hormone (CRH) is absolutely required for activation of the HPA axis during loss of GC negative feedback, via adrenocorticotropic hormone (ACTH) (1), which is necessary for production of adrenal androgens (2). We report here the development of Anti-CRH humanized monoclonal antibody HBM9013 (PR302334-24) for the treatment of CAH. HBM9013 binds to CRH with high affinity and neutralizes its signaling through both CRH Receptor 1 (CRHR1) and CRH Receptor 2 (CRHR2) in vitro. HBM9013 shows in vivo activities in two preclinical models. It blocks restraint stress-induced increases in plasma ACTH and corticosterone in mouse and rat. Mouse ACTH and Corticosterone were reduced from 210 ± 63 pg/ml to 27 ± 8 pg/ml (Mean ± SD, p = 5.2*10-6; IgG1 Control Group = 6 mice; HBM9013 Group = 8 mice) and from 303 ± 28 ng/ml to 57 ± 15 ng/ml (Mean ± SD, p = 6.2*10-[1][1]; IgG1 Control Group = 6 mice; HBM9013 Group = 8 mice), respectively. It also markedly reduces the constitutive, extremely elevated plasma ACTH levels in Mrap-knockout mice from 3847 ± 240 pg/mL to 1080 ± 302 pg/mL (Mean ± SD, n = 5 independent experiments, p = 2.3*10-7). HBM9013 has excellent CMC characteristics with ∼5 g/L titer and ∼80% yield. HBM9013 also has an excellent safety profile with no-observed-adverse-effect-level (NOAEL) of 150 mg/kg in weekly dosing for five doses in both rat and cynomolgus dose-ranging-finding (DRF) toxicology studies. HBM9013 is formulated up to 150 mg/ml as a weekly to monthly subcutaneous injection for ease of administration and compliance for CAH patient. HBM9013 could be a next generation therapy for CAH, in combination with a low physiological dose of GC that would avoid CS. Since ∼50% of Polycystic Ovarian Syndrome (PCOS) androgens may be of adrenal origin, we believe that HBM9013 could also be indicated for PCOS. References(1)Muglia LJ et al. J Clin Invest. 2000. 105:1269-77.(2)Weber A et al. Clin Endocrinol. 1997. 46:431-7. Presentation: 6/1/2024

7518 A Case of Delayed Diagnosis of Acromegaly Associated with Uncontrolled Diabetes

Abstract Disclosure: A. Mahmoudabadi: None. S. Patel: None. Background: Acromegaly is a rare disorder characterized by an excess secretion of growth hormone (GH) and increased circulating insulin-like growth factor 1 (IGF-1) levels, typically due to a GH-secreting pituitary adenoma. This consequently leads to complications such as acral and soft tissue overgrowth, visual disturbance, insulin resistance, and dyslipidemia. In this case, we describe a patient who presented to the endocrinology clinic for uncontrolled diabetes and was subsequently diagnosed with acromegaly. Clinical Case: This is a 47-year-old male with a history of heart failure, hypertension, and type 2 diabetes mellitus (DM) who presented to the clinic with uncontrolled DM. He had failed to achieve adequate blood sugar control despite being compliant with metformin, dapagliflozin, and insulin degludec. Physical examination revealed frontal bossing, prognathism, macroglossia, and a deep voice. On further questioning, he had noticed these changes since five years prior. Anthropometry and laboratory tests were as follows: Height, 180 cm; body weight 107.5 kg; body mass index (BMI), 33.05 kg/m2 and A1c level of 15.0%. Suspicion of acromegaly was confirmed based on biochemical and imaging findings. Fasting growth hormone (GH), at 58 mU/L (reference range 0-10), and insulin-like growth factor 1 (IGF-1), at 857 nmol/L (reference range 81-263), were markedly elevated. Pituitary magnetic resonance imaging (MRI) showed a sellar and suprasellar mass (2.6 × 2.2 × 2.2 cm) extending and compressing the optic chiasm. He eventually underwent a transsphenoidal adenomectomy with neurosurgery. Following surgery, his insulin requirements went from a total daily dose of about 100 units to an inpatient dose of 30 units by his last day of admission. Conclusion: Acromegaly is prevalent in less than 3% of patients with DM, but higher rates of DM are seen in acromegalic patients with higher IGF-1 levels and longer duration of disease. The diagnosis of acromegaly can often be delayed due to missed findings on routine physical examination. This can lead to increased morbidity, mortality, and complications such as uncontrolled DM, witnessed in our patient. Surgical management of acromegaly is the mainstay of treatment and can lead to improvement of glycemic control and insulin sensitivity. Fortunately, our patient could undergo surgery, but delayed diagnosis can prevent patients from surgery if the pituitary tumor becomes too large or unresectable. Ultimately, this case highlights the importance of a thorough physical examination and keeping a wide differential diagnosis when evaluating patients with uncontrolled DM, as failure to diagnose acromegaly at an early stage may have devastating consequences on patient outcomes. Presentation: 6/3/2024

A-056 Investigating Iodine Contrast Contamination in Cortisol and Aldosterone Samples

Abstract Background Primary aldosteronism (PA) is a condition characterized by hypertension resulting from excess secretion of aldosterone. PA caused by a unilateral aldosterone-producing adenoma can be treated with adrenalectomy but requires diagnosis by adrenal vein sampling (AVS). In this procedure, intravenous cosyntropin is administered to stimulate adrenal cortical secretion, followed by obtaining samples from the right and left adrenal veins and IVC. Laterization index is calculated by obtaining the aldosterone:cortisol ratio for each side, with a ratio cutoff ≥3 is used for confirmation. Iodinated contrast media facilitates visualization of catheter positioning during AVS and sometimes results in contamination of samples, evidenced by abnormal gel separator flotation (i.e. gel above plasma). This study had two aims: 1) to determine at what concentration contrast dye causes gel flotation and 2) discern whether contrast media interferes with our cortisol or aldosterone assays. Methods Gel flotation studies were performed by spiking pooled plasma samples with iohexol contrast media (Omnipaque 240, GE Healthcare) at concentrations ranging from 3%-10% v/v and aliquoting into fresh lithium heparin plasma separator tubes (BD, PSTs). Samples were then centrifuged and visually inspected for abnormal gel flotation. Contrast interference studies were performed using three pools of low (5 µg/dL), medium, (30 µg/dL), and high (55 µg/dL) cortisol concentrations. Sample pools were diluted with 20% contrast media or saline (control) and subsequently mixed at different ratios to create a range of dye concentrations (0.5%-18% v/v). Each mixture was assayed in triplicate for cortisol and aldosterone on a cobas e602 (Roche Diagnostics) and LIAISON XL (DiaSorin) immunoanalyzer, respectively. The total allowable error (TEa) was ±0.4 μg/dL or ±20% for cortisol and ±2 ng/dL or ±20% for aldosterone. Results Flotation of the gel separator was observed at a dye concentration of 4.5% v/v and greater. For the cortisol interference study, the bias was <5% for the three pools at all contrast media concentrations. Aldosterone was also measured in these pools, as bias could affect ratios calculated for PA. Aldosterone interference occurred at contrast dye concentrations ranging from 12%-20% v/v. An average positive bias of 34% was observed in aldosterone samples spiked with contrast media relative to the saline control. Compared to sample pool controls without added saline or dye, measurements for cortisol and aldosterone were 19%-22% and 16-25% lower in media- and saline-spiked samples (20% v/v), respectively, indicating a logical dilution effect. Conclusions Contrast dye contamination of AVS specimens can cause gel flotation in lithium heparin PSTs, preventing their analysis. The presence of contrast media at certain concentrations interfered with the DiaSorin aldosterone assay, leading to falsely elevated results. No cortisol assay interference occurred in the presence of contrast media but results were falsely decreased due to sample dilution. Samples collected during AVS may be contaminated with contrast dye causing gel flotation to occur. This is indicative of a minimum contrast media concentration of 4.5% v/v. Aldosterone:cortisol ratios may be inaccurate due to the positive aldosterone immunoassay bias with contrast media contamination. Care should be taken when reporting and interpreting AVS results with suspected contamination.

Effect of Metformin on Interleukin-6 Expression in Human Fibroblast Cell Aging Model

During skin aging, there is excessive secretion of inflammatory cytokines such as interleukin-6 (IL-6), which can make the ageing process more severe. Metformin has been known to have good anti-inflammatory activity through various pathways, one of which reduces the expression of inflammatory cytokines. This study aimed to analyze the effect of metformin treatment on IL-6 gene expression in an in vitro human fibroblast cell. Human fibroblast cells were obtained through foreskin isolation, and 72 cultured human fibroblast cells were divided into six groups based on cell passages, ranging from the third to the eighth. The expression of IL-6 was assessed in three treatments: negative control (normal cells), metformin 100 µM, and positive control (Vitamin E 50 µM). Treatment and measurement of IL-6 gene expression were carried out using qRT-PCR and calculated using the Livak-Schmittgen method. The results were then compared and analyzed using One-Way Analysis of Variance (ANOVA) and followed by post-hoc analysis. The negative control group had the lowest IL-6 gene expression compared to the metformin group and positive control group. The negative control IL-6 expression showed the highest value at passage 3 (0.166 ± 0.04) and the lowest at passage 6 (0.048 ± 0.04). Meanwhile, the expression of IL-6 positive control passage 4 (5.590 ± 3.34) showed the highest value and passage 7 (0.000 ± 0.00) showed the lowest value. In the metformin group, IL-6 gene expression was highest in passage 5 (0.836 ± 0.15) and lowest in passage 3 (0.078 ± 0.02). Based on treatment, there is a difference in IL-6 gene expression at passage 4 (p-value <0.05) and passage 5 (p-value <0.001). Metformin treatment passage 5 showed a significant difference with negative control (p-value <0.05) and with positive control (p-value <0.05). Our study concluded that the administration of metformin had no effect on IL-6 gene expression in human fibroblasts. However, metformin demonstrated anti-aging potential, as evidenced by a statistically significant difference in IL-6 expression between the negative control and positive control treatment groups.

Secondary diabetes mellitus in acromegaly: Case report and literature review.

Acromegaly, predominantly resulting from a pituitary adenoma, is marked by excessive secretion of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). However, normalization of blood glucose levels posttreatment is rarely achieved. This case study aims to highlight the diagnostic challenges posed by overlapping symptoms of acromegaly and diabetes, emphasizing the importance of precise diagnosis and effective treatment strategies for optimal patient outcomes. A 22-year-old male was hospitalized for diabetic ketoacidosis and exhibited classic signs of acromegaly, such as enlarged hands and feet, and distinct facial changes. The patient's diagnosis of acromegaly, attributed to a pituitary adenoma, was confirmed through clinical observations, laboratory findings (notably raised serum GH and IGF-1 levels, and absence of GH suppression after glucose load during an OGTT), and pituitary MRI scans. The patient underwent 2 surgical tumor resections followed by gamma knife radiosurgery (GKRS). After treatment, GH, IGF-1, and blood glucose levels normalized without further need for hypoglycemic intervention. Posttreatment, the patient achieved stable GH, IGF-1, and blood glucose levels. The hyperglycemia was attributed to the GH-secreting tumor, and its resolution followed the tumor's removal. This case emphasizes the need for comprehensive assessment in patients with acromegaly to address coexisting diabetic complications. Surgical and radiotherapeutic management of acromegaly can lead to significant metabolic improvements, highlighting the importance of interdisciplinary care in managing these complex cases.

MACROSCOPIC AND MICROSCOPIC GASTROPROTECTIVE ACTIVITY OF MUCOADHESIVE GRANULE FORMULATIONS OF CLOVE LEAF ETHANOL EXTRACT

Gastric ulcers can be triggered by excessive HCl secretion, and the regenerative capacity of mucosal cells can be weakened by high alcohol levels and anti-inflammatory drugs, including NSAIDs. This study aims to evaluate the macroscopic and microscopic gastroprotective activity of clove leaf ethanol extract mucoadhesive granule formulations. The study used 25 rats divided into five groups: normal control, negative control, positive control, clove leaf ethanol extract group, and mucoadhesive granule formulation of clove leaf ethanol extract group. All groups except the normal control were administered acetylsalicylic acid. Treatments were conducted over 9 days, with surgical examination and observations performed macroscopically and microscopically on day 10. Macroscopic assessments revealed ulcer damage improvement in the positive control, extract, and mucoadhesive granule groups, all scored at 1. Microscopic assessments also indicated a significant difference between the negative control and the positive control, extract, and mucoadhesive granule groups, showing better gastric repair, scored at 0.5. Therefore, it can be concluded that the administration of the mucoadhesive granule formulation of clove leaf ethanol extract exhibits gastroprotective activity comparable to that of the clove leaf ethanol extract

DeltaRex-G, tumor targeted retrovector encoding a CCNG1 inhibitor, for CAR-T cell therapy induced cytokine release syndrome.

Cytokine release syndrome is a serious complication of chimeric antigen receptor-T cell therapy and is triggered by excessive secretion of inflammatory cytokines by chimeric T cells which could be fatal. Following an inquiry into the molecular mechanisms orchestrating cytokine release syndrome, we hypothesize that DeltaRex-G, a tumor targeted retrovector encoding a cytocidal CCNG1 inhibitor gene, may be a viable treatment option for corticosteroid-resistant cytokine release syndrome. DeltaRex-G received United States Food and Drug Administration Emergency Use Authorization to treat Covid-19-induced acute respiratory distress syndrome, which is due to hyperactivated immune cells. A brief administration of DeltaRex-G would inhibit a certain proportion of hyperactive chimeric T cells, consequently reducing cytokine release while retaining chimeric T cell efficacy.

Cushing's Syndrome: Experience of the Endocrinology Department at University Hospital Center Mohammed VI, Marrakech

Endogenous Cushing's syndrome or endogenous hypercorticism is a rare entity, due to chronic, excessive tissue exposure to glucocorticoids, resulting from excess adrenocorticotropic hormone production or excessive adrenal-autonomous secretion of glucocorticoids. The diagnosis can only be made if the clinical features and biochemical abnormalities are present. Its comorbidities and complications can easily lead to death. Our work is a retrospective descriptive study of all patients with Cushing's syndrome hospitalized in the Endocrinology and Metabolic Diseases Department of the Mohamed VI University Hospital, Marrakech, a total of 34 patients. The aim of this study was to establish the epidemiological, clinical, radiological and etiological profile of Cushing's syndrome observed in the Endocrinology Department of the CHU, and to evaluate the diagnostic modalities, associated parameters and therapeutic management, while comparing them with data in the national and international literature. Our series was characterized by a clear female predominance (4/1) and an average age of 29.2 years. Discovery followed weight gain in 53% of patients, headache in 35%, hirsutism and secondary amenorrhea in 32% and 29% respectively. The most common clinical signs were hypercorticism in 71% of cases and hyperandrogenism in 59%. Biologically, to detect hypercorticism, dexamethasone minute braking was performed in 65% of cases. ACTH dependence was found in 91% of cases, with Cushing's disease found in 53% of cases, diagnosed on MRI, with a microadenoma in 65% of cases. Among the causes of ACTH Independence, adrenocortical carcinomas were found on adrenal CT in 25% of cases, and adenomas in 31.2%. From a therapeutic point of view, surgery took first place in these cases: trans-sphenoidal adenomectomy for adrenocortical adenomas and adrenalectomy for adrenal tumors. Adrenalectomy was also indicated in two cases of ACTH-dependent hypercorticism (Cushing's disease and paraneoplastic) ......