Measurement Of Free Cortisol Research Articles

Steroid Profiling and Circadian Cortisol Secretion in Patients with Mild Autonomous Cortisol Secretion: A Cross-Sectional Study.

Mild autonomous cortisol secretion (MACS) is diagnosed based on post-dexamethasone cortisol>1.8 mcg/dL. Scarce evidence exists on steroid circadian secretion and steroid metabolome in MACS. To characterize 24-hour (h) urine steroid metabolome in patients with MACS and determine circadian differences in urine steroid profiling and cortisol concentrations in patients with MACS versus referent subjects. Cross-sectional study, 2018-2023. Referral center. Patients with MACS and age-, sex-, BMI-, and menopausal status-matched referent subjects. Urine was collected over 24h period as separate day- and night-time collections. High-resolution mass spectrometry assay was used to measure 25 steroids. A subgroup of patients and referent subjects were admitted for every 2h serum measurements of free and total cortisol. Steroids, sums, and ratios. Patients with MACS (n=72) had lower mcg/24h median androgens (2084 vs 3283, P<0.001), higher glucocorticoids (15754 vs 12936, P<0.001), and higher glucocorticoid/androgen ratio (8.7 vs 3.9, P<0.001), compared to referent subjects. Patients also had lower steroid day/night ratios compared to referent subjects, reflecting a higher relative nocturnal steroid production in MACS. In a subgroup of 12 patients with MACS and 10 referent subjects, the 24-hour area under the curves for total and free cortisol were similar. However, evening mean total (5.3 vs 4.0 mcg/dL, P=0.056) and free (0.2 vs 0.1 mcg/dL, P=0.035) cortisol was higher in patients vs referent subjects. Patients with MACS demonstrate an abnormal urine steroid metabolome, with a high glucocorticoid to androgen ratio, and a higher nocturnal steroid production.

LC-HRMS and GC-MS Profiling of Urine Free Cortisol, Cortisone, 6Β-, and 18-Hydroxycortisol for the Evaluation of Glucocorticoid and Mineralocorticoid Disorders.

Urine free cortisol measurements are routinely performed to evaluate hypercortisolism. Despite their analytical inaccuracy, immunoassay-based methods are frequently used. Advances in liquid chromatography-high-resolution mass spectrometry (LC-HRMS) facilitate the incorporation of powerful diagnostic tools into clinical laboratories. In addition to its high analytical specificity and simultaneous analysis of different metabolites, accurate mass measurement allows for untargeted compound identification, which may help to identify clinically relevant metabolites or drugs. The present study aimed to validate a simple routine LC-HRMS method to quantify cortisol, cortisone, 6β-hydroxycortisol, and 18-hydroxycortisol simultaneously in human urine. Additionally, the study also validated a GC-MS method for the same steroids, evaluated their cross-reactivity with commercial cortisol immunoassays, and quantified the 24 h urine excretion in patients under clinical suspicion or follow-up for hypercortisolism. The LC-HRMS method involved liquid-liquid extraction using dichloromethane, micro-LC for chromatographic separation and detection using the accurate masses of the steroids, and simultaneous high-resolution full scan acquisition. The method presented acceptable linearity, precision, and accuracy. Significant interference from 6β-hydroxycortisol and cortisone was demonstrated in the cortisol immunoassays, which impacted their reliability in the follow-up of patients with hypercortisolism and significant changes in these cortisol metabolites (i.e., due to drug-induced changes in CYP3A4 activity). A rapid and accurate routine LC-HRMS method was validated, which is useful for the evaluation of hypercortisolism and other disorders of glucocorticoid and mineralocorticoid metabolism.

Comparison of Direct and Extraction Immunoassay Methods With Liquid Chromatography-Tandem Mass Spectrometry Measurement of Urinary Free Cortisol for the Diagnosis of Cushing's Syndrome.

Twenty-four-hour urinary free cortisol (UFC) measurement is the initial diagnostic test for Cushing's syndrome (CS). We compared UFC determination by both direct and extraction immunoassays using Abbott Architect, Siemens Atellica Solution, and Beckman DxI800 with liquid chromatography-tandem mass spectrometry (LC-MS/MS). In addition, we evaluated the value of 24-hr UFC measured by six methods for diagnosing CS. Residual 24-hr urine samples of 94 CS and 246 non-CS patients were collected. A laboratory-developed LC-MS/MS method was used as reference. UFC was measured by direct assays (D) using Abbott, Siemens, and Beckman platforms and by extraction assays (E) using Siemens and Beckman platforms. Method was compared using Passing-Bablok regression and Bland-Altman plot analyses. Cut-off values for the six assays and corresponding sensitivities and specificities were calculated by ROC analysis. Abbott-D, Beckman-E, Siemens-E, and Siemens-D showed strong correlations with LC-MS/MS (Spearman coefficient r=0.965, 0.922, 0.922, and 0.897, respectively), while Beckman-D showed weaker correlation (r=0.755). All immunoassays showed proportionally positive bias. The areas under the curve were 0.975 for Abbott-D, 0.972 for LC-MS/MS, 0.966 for Siemens-E, 0.948 for Siemens-D, 0.955 for Beckman-E, and 0.877 for Beckman-D. The cut-off values varied significantly (154.8-1,321.5 nmol/24 hrs). Assay sensitivity and specificity ranged from 76.1% to 93.2% and from 93.0% to 97.1%, respectively. Commercially available immunoassays for measuring UFC show different levels of analytical consistency compared to LC-MS/MS. Abbott-D, Siemens-E, and Beckman-E have high diagnostic accuracy for CS.

Cushing's syndrome in the elderly: data from the European Registry on Cushing's syndrome.

To evaluate whether age-related differences exist in clinical characteristics, diagnostic approach, and management strategies in patients with Cushing's syndrome (CS) included in the European Registry on Cushing's Syndrome (ERCUSYN). Cohort study. We analyzed 1791 patients with CS, of whom 1234 (69%) had pituitary-dependent CS (PIT-CS), 450 (25%) adrenal-dependent CS (ADR-CS), and 107 (6%) had an ectopic source (ECT-CS). According to the WHO criteria, 1616 patients (90.2%) were classified as younger (<65 years old) and 175 (9.8%) as older (≥65 years old). Older patients were more frequently males and had a lower Body Mass Index (BMI) and waist circumference when compared with the younger. Older patients also had a lower prevalence of skin alterations, depression, hair loss, hirsutism, and reduced libido, but a higher prevalence of muscle weakness, diabetes, hypertension, cardiovascular disease, venous thromboembolism, and bone fractures than younger patients, regardless of sex (P < .01 for all comparisons). Measurement of urinary free cortisol supported the diagnosis of CS less frequently in older patients when compared with the younger (P < .05). An extrasellar macroadenoma (macrocorticotropinoma with extrasellar extension) was more common in older PIT-CS patients than in the younger (P < .01). Older PIT-CS patients more frequently received cortisol-lowering medications and radiotherapy as a first-line treatment, whereas surgery was the preferred approach in the younger (P < .01 for all comparisons). When transsphenoidal surgery was performed, the remission rate was lower in the elderly when compared with their younger counterpart (P < .05). Older CS patients lack several typical symptoms of hypercortisolism, present with more comorbidities regardless of sex, and are more often conservatively treated.

Development and Validation of Liquid Chromatography/Stable Isotope-Dilution Tandem Mass Spectrometry Method for Measurement of Dexamethasone, Total Cortisol and Free Cortisol in Human Plasma

Background Cortisol plays a role in the regulation of metabolic homeostasis. Dexamethasone is a powerful synthetic glucocorticoid that acts as an anti-inflammatory and immunosuppressive agent. Plasma free cortisol, which has a low concentration in the blood, is the cortisol fraction that provides biological activity. It is emphasized that measurement of dexamethasone, total and free cortisol levels can directly affect the results of dexamethasone suppression test, which is routinely used to exclude endogenous hypercortisolemia in patients with adrenal adenoma, and is important in differential diagnosis.&#x0D; Purpose In this study, a precise and rapid method was developed for the measurement of dexamethasone, total and free cortisol levels in plasma samples, besides demonstrating the clinical applicability of the method with samples from adrenal adenoma patients. &#x0D; Methods Method optimization studies were performed using liquid chromatography-tandem mass spectrometry with stable isotope dilution-multiple reaction monitoring. &#x0D; Results The assay demonstrated a good linear dynamic range of 0.5–20 μg/L, 5–200 μg/L and 0.5–100 μg/L for dexamethasone, total and free cortisol, respectively. The values for intra- and inter-day precisions of analytes were ≤6.9% with the accuracies ranging from 91.6% to 113.0%.&#x0D; Conclusion Measurement of these parameters can be used reliably to diagnose diseases causing hypercortisolemia.

ODP057 The Unusual Case of Hypercortisolism in a Patient with Juvenile Onset Hypophosphatasia

Abstract Juvenile onset hypophosphatasia is a rare, genetic disease that is caused by inactivating mutations in the ALPL gene which encodes tissue non-specific alkaline phosphatase (TNSALP). This leads to decreased activity of the TNSALP enzyme in target tissues and accumulation of TNSALP substrates, including inorganic pyrophosphate, an inhibitor of mineralization. This disease is characterized by low levels of alkaline phosphatase in serum and bone, osteomalacia, and periodontal disease. Patients with juvenile onset hypophosphatasia present with premature loss of primary teeth, delayed walking, and a waddling gait. These symptoms may improve spontaneously after puberty and recur later in life. Here we report the case of a 51 year old male who presented initially to endocrinology clinic with a metatarsal stress fracture with subsequent diagnosis of osteoporosis, periodontal infections, and associated myopathy and joint calcifications. The patient also had a prior history of a low alkaline phosphatase level as a child. Genetic testing showed a single variant of undetermined significance found in the ALPA gene. Of note, recent lab work for the patient showed AM cortisol 27.7 mcg/dL (reference range 4. 0-22. 0 mcg/dL) with ACTH 60 pg/mL (reference range 6 - 50 pg/mL). Prior 24 hour urine free cortisol measurements with LC/MS have demonstrated elevated values 159 mcg/24 hr and 256 mcg/24 hr (reference range 4. 0 - 50. 0 mcg/24 hr) . However, most recent testing demonstrated 24 hour urine free cortisol 3.6 mcg/24 hr, and the majority of midnight salivary cortisol tests were within normal. Pituitary MRI demonstrated no abnormalities. The patient has in the past reported findings of a dorsocervical fat pad, abdominal striae, and weight gain. There is no history of diabetes mellitus or hypertension, and the patient at this time reports stable weight without current presence of a fat pad or striae. There are no clinical features of Cushing's syndrome on exam. To our knowledge, this is the second case in the literature detailing hypercortisolism in a patient with hypophosphatasia. The etiology of the hypercortisolism is likely multifactorial, with unknown association with hypophosphatasia. Based on the clinical data it appears that the patient's chronic stress, pain, and anxiety are contributing to the hypercortisolism, and that this is not a true Cushing's or cyclical Cushing's case. Repeated midnight salivary cortisol tests have excluded the possibility of Cushing's as well. Presentation: No date and time listed

Influence of cortisol cosecretion on non-ACTH-stimulated adrenal venous sampling in primary aldosteronism: a retrospective cohort study.

Cortisol measurements are essential for the interpretation of adrenal venous samplings (AVS) in primary aldosteronism (PA). Cortisol cosecretion may influence AVS indices. We aimed to investigate whether cortisol cosecretion affects non-adrenocorticotrophic hormone (ACTH)-stimulated AVS results. Retrospective cohort study at a tertiary referral center. We analyzed 278 PA patients who underwent non-ACTH-stimulated AVS and had undergone at least a 1-mg dexamethasone suppression test (DST). Subsets underwent additional late-night salivary cortisol (LSC) and/or 24-h urinary free cortisol (UFC) measurements. Patients were studied from 2013 to 2020 with follow-up data of 6 months following adrenalectomy or mineralocorticoid antagonist therapy initiation. We analyzed AVS parameters including adrenal vein aldosterone/cortisol ratios, selectivity, lateralization (LI) and contralateral suppression indices and post-operative ACTH-stimulation. We classified outcomes according to the primary aldosteronism surgical outcome (PASO) criteria. Among the patients, 18.9% had a pathological DST result (1.9-5 µg/dL: n = 44 (15.8%); >5 µg/dL: n = 8 (2.9%)). Comparison of AVS results stratified according to the 1-mg DST (≤1.8 vs >1.8 µg/dL: P = 0.499; ≤1.8 vs 1.8 ≤ 5 vs >5 µg/dL: P = 0.811) showed no difference. Lateralized cases with post DST serum cortisol values > 5 µg/dL had lower LI (≤1.8 µg/dL: 11.11 (5.36; 26.76) vs 1.9-5 µg/dL: 11.76 (4.9; 31.88) vs >5 µg/dL: 2.58 (1.67; 3.3); P = 0.008). PASO outcome was not different according to cortisol cosecretion. Marked cortisol cosecretion has the potential to influence non-ACTH-stimulated AVS results. While this could result in falsely classified lateralized cases as bilateral, further analysis of substitutes for cortisol are required to unmask effects on clinical outcome.

Clinical and Technical Aspects in Free Cortisol Measurement.

Accurate measurement of cortisol is critical in adrenal insufficiency as it reduces the risk associated with misdiagnosis and supports the optimization of stress dose. Comprehensive assays have been developed to determine the levels of bioactive free cortisol and their clinical and analytical efficacies have been extensively discussed because the level of total cortisol is affected by changes in the structure or circulating levels of corticoid-binding globulin and albumin, which are the main reservoirs of cortisol in the human body. Antibody-based immunoassays are routinely used in clinical laboratories; however, the lack of molecular specificity in cortisol assessment limits their applicability to characterize adrenocortical function. Improved specificity and sensitivity can be achieved by mass spectrometry coupled with chromatographic separation methods, which is a cutting-edge technology to measure individual as well as a panel of steroids in a single analytical run. The purpose of this review is to introduce recent advances in free cortisol measurement from the perspectives of clinical specimens and issues associated with prospective analytical technologies.

Diagnostic workup of Cushing's syndrome.

Cushing's syndrome (CS) is a rare but detrimental endocrine disorder. Early diagnosis and prompt treatment are essential since the duration of hypercortisolism has an adverse impact on the extent of comorbidities and overall survival. The diagnostic approach involves a stepwise process that includes (1) screening and confirming the diagnosis and (2) establishing the aetiology of CS. The tests currently used to confirm the diagnosis of CS include urinary free cortisol measurements, the dexamethasone suppression test and late- night salivary cortisol or midnight serum cortisol measurements. None of these tests are ideal; all have pitfalls and require careful interpretation. Following confirmation of CS, measurement of ACTH discriminates between ACTH-dependent and non-ACTH dependent causes of CS. Adrenal imaging provides clues for the aetiology of non-ACTH dependent forms. Differentiation between the ACTH-dependent forms that involve pituitary corticotroph adenomas and ectopic ACTH sources is more complex and include pituitary MRI imaging, the high dose dexamethasone suppression test, the CRH test, bilateral inferior petrosal sinus sampling and, when required imaging modalities to detect ectopic ACTH secreting lesions. This review, which is part of a special issue on "Update of Cushing's syndrome: 100years after Minnie G" will provide an update on our current diagnostic workup for the confirmation and differential diagnosis of CS.

0379 At-home Sample Collection for Identification of Alterations in HPA-axis Activity and Cortisol Area Under the Curve

Abstract Introduction Sleep problems are associated with alterations in diurnal cortisol patterns, reflective of altered hypothalamic-pituitary-axis (HPA) activity. At-home collection of dried samples for measurement of urinary free cortisol are useful for assessment of diurnal rhythms because they do not impose the stress or sleep disruption associated with inpatient studies. The purpose of this analysis was to assess urinary cortisol responses among a large real-world dataset of at-home collection kit users and the potential for utility in identifying alterations in HPA-axis activity. Methods This retrospective analysis evaluated data from 3,966 individuals who used a Sleep and Stress Test (Everlywell, Inc.) between September 2017 and July 2021. Four dried urine spot samples were collected according to habitual sleep patterns: upon waking (T1), two hours after waking (T2), prior to the evening meal (T3), and at bedtime (T4). Urinary free cortisol normalized to creatinine, indicative of HPA-axis activity was assessed (area under the curve (AUC), wake to bedtime diurnal cortisol slope (DCS), mid-morning (T2) and bedtime (T4) cortisol levels). Sample reference ranges were established from two standard deviations above and below the log-transformed mean at each time point, values were reverted to original units for reporting. Results The sample was predominantly female (n=2,832, 71%). Mean age was 42.8 (sd=12.0) years. Seventy-eight individuals had mid-morning (T2) cortisol levels that were higher than the sample reference range (7.0-170.7 ug/g Cr), and 88 individuals below. Bedtime (T4) cortisol levels were elevated in 145 individuals (reference range 1.1-25.0 ug/g Cr). Total AUC for cortisol was high in 93 and low in 81 of individuals. The slope of the diurnal cortisol response was flattened in 20.6% (n=816) of the sample. Conclusion This real-world study demonstrates that at-home dried urine sample collection can be used to characterize normal and atypical HPA-axis activity. Convenient assessment of alterations in diurnal cortisol patterns are critical in identifying and understanding the mechanisms of HPA-axis activity common in sleep disruptions/disorders. Future studies utilizing this methodology may prove useful in identifying subpopulations with altered HPA-axis activity, sleep issues, and potential relationships to cardiometabolic health. Support (If Any)

Salivary free cortisol and serum DHEA-sulfate measurements with cosyntropin stimulation improve accuracy of secondary adrenal insufficiency diagnosis in pregnancy

Salivary free cortisol and serum DHEA-sulfate measurements with cosyntropin stimulation improve accuracy of secondary adrenal insufficiency diagnosis in pregnancy

Urinary free cortisol is a reliable index of adrenal cortisol production in patients with liver cirrhosis.

The measurement of total and free cortisol has been studied as a clinical index of adrenal cortisol production in patients with liver cirrhosis. Correlations between free plasma and salivary cortisol have previously been reported in stable cirrhotic patients. Urinary free cortisol constitutes an index of adrenal cortisol production; however, it has never been used in assessing adrenal function in patients with liver cirrhosis. The aim of this observational study was to determine associations between urinary free cortisol, serum total, salivary, measured and calculated plasma free cortisol levels in cirrhotics, determining which of them can be used as an indirect index of free cortisol levels. Moreover, we investigated the potential use of 24 h urinary free cortisol as a prognostic factor for mortality. Seventy-eight outpatients with liver cirrhosis were included. Serum, salivary and urinary free cortisol were measured using the electrochemiluminenscence immunoassay. Plasma free cortisol determination was conducted using a single quadrupole mass spectrometer. The quantification of free cortisol was achieved by determining the signal response on negative ESI-MS mode. Twenty-four hour urinary free cortisol levels correlated with free cortisol determined by mass spectrometer, total cortisol and calculated free cortisol levels. Patients with low levels of urinary free cortisol presented a significantly higher mortality rate compared to those with high levels. The factors associated with death risk were determined by Cox regression. In the multivariate analysis, two models were applied; in the first model, CP score, PVT and urinary free cortisol were found to be significantly related to patients' survival, whereas in the second, MELD score, ascites and urinary free cortisol were independently related to survival. This study suggests that 24 h urinary free cortisol could be considered as a potential index of adrenal cortisol production in patients with liver cirrhosis and it potentially detects patients with a high mortality risk.

Measurement of Urinary Free Cortisol and Cortisone by LC-MS/MS.

Monitoring urinary free cortisol (UFC) excretion helps assess adrenal function and is used to screen for endogenous Cushing's syndrome caused by an adrenal or pituitary tumor. While serum cortisol levels fluctuate in response to time of day, stress, and concentrations of cortisol-binding globulin (CBG), a 24-h urine collection measures the cortisol produced over the entire day and does not suffer from as much variability as a serum measurement.We describe here a method of measurement of urinary free cortisol (UFC) and cortisone using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Urine samples, combined with stable isotope-labeled internal standards, are extracted by liquid-liquid extraction using ethyl acetate and hexane. An API 5500 mass spectrometer operated in positive atmospheric pressure chemical ionization (APCI) mode is used for detection.

Steeper basal cortisol slopes are associated with elevated risk of pathological amyloid‐beta accumulation

AbstractBackgroundThe accumulation of amyloid‐beta (Aβ) plaques, the hallmark neuropathology of Alzheimer’s disease (AD), begins several decades prior to the onset of cognitive symptoms. The progression of the disease is believed to be driven by this accumulation; therefore, there is interest in identifying factors which trigger or accelerate the aggregation of Aβ. We examined whether changes or elevations in basal cortisol levels predicted the transition to a state of Aβ‐positivity, as determined by Pittsburgh Compound B (PIB) thresholds.MethodData were utilized from the neuroimaging subset of the Baltimore Longitudinal Study of Aging. One‐hundred and fifteen middle‐aged to older adults (mean age 58.39 at baseline) with at least two 24‐hour urinary free cortisol measures collected prior to reaching the threshold for Aβ‐positivity were included.ResultA Cox regression model showed that after controlling for age, the slope of basal cortisol levels over time was significantly associated with the risk of becoming Aβ‐positive, such that each standard deviation unit increase in slope was associated with a 38% increase in Aβ‐positivity risk. Conversely, the average cortisol level during this same period was not significantly associated with Aβ‐positivity risk (HR = 1.03, p = 0.14).ConclusionThese results suggest that increases in basal cortisol levels, regardless of the average level, are associated with increased likelihood of pathological Aβ accumulation. Further investigation is warranted to determine whether basal cortisol increases directly contribute to increased Aβ accumulation and whether this mechanism can be targeted by therapeutic intervention.

Interpretation of Abnormal Dexamethasone Suppression Test is Enhanced With Use of Synchronous Free Cortisol Assessment.

Interpretation of dexamethasone suppression test (DST) may be influenced by dexamethasone absorption and metabolism and by the altered cortisol binding. We aimed to determine the normal ranges of free cortisol during DST in participants without adrenal disorders and to identify the population of patients where post-DST free cortisol measurements add value to the diagnostic workup. Cross-sectional study conducted in a tertiary medical center. Adult volunteers without adrenal disorders (n = 168; 47 women on oral contraceptive therapy [OCP], 66 women not on OCP, 55 men) and patients undergoing evaluation for hypercortisolism (n = 196; 16 women on OCP). Post-DST dexamethasone and free cortisol (mass spectrometry) and total cortisol (immunoassay). Reference range for post-DST free cortisol, diagnostic accuracy of post-DST total cortisol. Adequate dexamethasone concentrations (≥0.1 mcg/dL) were seen in 97.6% volunteers and 96.3% patients. Only 25.5% of women volunteers on OCP had abnormal post-DST total cortisol (>1.8 mcg/dL). In volunteers, the upper post-DST free cortisol range was 48 ng/dL in men and women not on OCP, and 79 ng/dL in women on OCP. When compared with post-DST free cortisol, diagnostic accuracy of post-DST total cortisol was 87.3% (95% CI, 81.7-91.7); all false-positive results occurred in patients with post-DST cortisol between 1.8 and 5 mcg/dL. OCP use was the only factor associated with false-positive results (21.1% vs 4.9%, P = 0.02). Post-DST free cortisol measurements are valuable in patients with optimal dexamethasone concentrations and post-DST total cortisol between 1.8 and 5 mcg/dL.

Two-day low-dose dexamethasone suppression test more accurate than overnight 1-mg in women taking oral contraceptives.

IntroductionLate‐night salivary cortisol (LSaC) and 24‐h urinary free cortisol measurement, and overnight 1‐mg dexamethasone suppression test (1 mg‐DST) are the first‐line screening tests recommended for Cushing's syndrome. Through elevations in the level of cortisol‐binding globulin, oral contraceptive agents lead to increases in the total plasma cortisol concentration, yielding false‐positive 1 mg‐DST results.ObjectiveTo compare the accuracy of the overnight 1‐mg DST and two‐day low‐dose DST (2d‐DST) in female volunteers taking combined oestrogen‐progestin oral contraceptives (COCs).MethodsThis prospective study enrolled 30 healthy participants. Their plasma cortisol response levels were compared after the 1‐mg DST and 2d‐DST and classified into three categories: normal (≤50 nmol/L), doubtful (51–138 nmol/L) and abnormal (>138 nmol/L). Salivary cortisol was also measured at late night and after the DSTs.ResultsFollowing the 1‐mg DST and 2d‐DST, the plasma cortisol concentrations decreased to a median of 69 nmol/L and 37 nmol/L, respectively (p < 0.001). A statistically significant higher proportion of unclear or abnormal results were observed after the 1‐mg DST (63%) than after the 2d‐DST (27%) (p = 0.004). None of the values were >138 nmol/L after the 2d‐DST, while 11% of them were abnormal after the 1‐mg DST (p = 0.25). No LSaC value was abnormal.ConclusionOur results suggest that, when late‐night salivary cortisol is not available, the 2d‐DST could be a better screening option than the 1‐mg DST for women taking oral contraceptive agents who are reluctant to stop them. This finding requires confirmation in those with a suspicion of hypercortisolism.

Not Your Typical Low T - Hypogonadism From a Feminizing Adrenal Carcinoma

Abstract Introduction: Adrenocortical Carcinoma (ACC) is a rare disease, with an incidence of 0.7–2 cases per million people. Approximately 80% of ACC tumors are functional, with the majority of tumors secreting glucocorticoids, however a small proportion concurrently secrete androgens in addition to glucocorticoids. Here, we describe a case of ACC presenting with feminization, without clinical evidence of Cushing’s syndrome. Case Description: A 35 year old male with no significant history presented with sudden onset non-radiating, 7/10, abdominal pain 4 days prior to admission. On exam, the patient had diffuse tenderness to palpation in the right upper quadrant without other abdominal findings. He also was noted to have palpable breast tissue bilaterally. Upon persistent questioning, he reported an 8-month history of gradual breast development, decreased libido and decreased morning erections. He had no history of hypertension, headaches, diabetes, palpitations, flushing, sweating, weight gain, striae, bruising, or muscle weakness. Diagnostic CT imaging of the abdomen and pelvis showed a 14 cm right adrenal mass without invasion or lymphadenopathy. Laboratory testing showed a total testosterone of 37 ng/dL (reference range:249–846 ng/dL), estradiol of 181 pg/mL (8–43 pg/mL), prolactin of 14.5 ng/ml (4.0–15.2), and FSH and LH were both &amp;lt;0.1 mIU/mL. Serum metanephrines and normetanephrines, renin and aldosterone showed no evidence of excess secretion. Urine free cortisol measurement was 111mcg over 24 hrs (&amp;lt;50 mcg/24hr) and ACTH was &amp;lt;1.0 pg/mL (7.2–63.3 pg/mL). Surgical resection was performed with histopathologic diagnosis of an 18cm ACC confined to the adrenal gland. Post-surgical prophylactic hydrocortisone replacement was given. At outpatient follow-up, testing revealed normalization of his estradiol and testosterone levels. The patient had no clinical evidence of adrenal insufficiency and plans were made to assess endogenous adrenal function. Conclusion: This case highlights the importance of discussing symptoms of hypogonadism, virilization or feminization with patients in detail when evaluating for ACC. Careful history and physical exam may be key to identifying sex hormone excess and prompting preoperative workup. In this case of a feminizing ACC, pre-surgical assessment allows for estrogen to be as a marker of tumor progression. A sex steroid producing ACC should be evaluated for cortisol secretion as prompt detection can avoid post-operative adrenal insufficiency.

The Art of Hormone Measurements with Emphasis on Specificity Resulting in Diagnostic and Management Improvements

The Art of Hormone Measurements with Emphasis on Specificity Resulting in Diagnostic and Management Improvements

Bedtime Salivary Cortisol as a Screening Test for Cushing Syndrome in Children.

BackgroundDiagnosing Cushing syndrome (CS) can be challenging. The 24-hour urine free cortisol (UFC) measurement is considered gold standard. This is a laborious test, dependent on correct urine collection. Late-night salivary cortisol is easier and is used as a screening test for CS in adults, but has not been validated for use in children.ObjectiveTo define liquid chromatography tandem mass spectrometry (LC-MS/MS)-based cutoff values for bedtime and morning salivary cortisol and cortisone in children, and validate the results in children with and without CS.MethodsBedtime and morning salivary samples were collected from 320 healthy children aged 4 to 16 years. Fifty-four patients from the children’s outpatient obesity clinic and 3 children with pituitary CS were used for validation. Steroid hormones were assayed by LC-MS/MS. Cutoff levels for bedtime salivary cortisol and cortisone were defined by the 97.5% percentile in healthy subjects.ResultsBedtime cutoff levels for cortisol and cortisone were 2.4 and 12.0 nmol/L, respectively. Applying these cutoff levels on the verification cohort, 1 child from the obesity clinic had bedtime salivary cortisol exceeding the defined cutoff level, but normal salivary cortisone. All 3 children with pituitary CS had salivary cortisol and cortisone far above the defined bedtime cutoff levels. Healthy subjects showed a significant decrease in salivary cortisol from early morning to bedtime.ConclusionsWe propose that bedtime salivary cortisol measured by LC-MS/MS with a diagnostic threshold above 2.4 nmol/L can be applied as a screening test for CS in children. Age- and gender-specific cutoff levels are not needed.

Stress/Immune Biomarkers in Saliva among Children with ADHD Status.

Background. This cross-sectional study aimed to evaluate stress and immune biomarkers in saliva samples of attention-deficit/hyperactivity disorder ADHD compared to healthy non-ADHD children. Material and methods. A total of 132 children under 11 years old (8.5 ± 1.1) enrolled in a cross-sectional study: with confirmed ADHD (n = 60) and healthy controls (n = 72). The clinical evaluation included physical measurements (height, waist, hip circumference, body weight, body mass index BMI, BMI z-score) and unstimulated saliva collection and measurements of free cortisol, salivary alpha-amylase (sAA), and secreted immunoglobulins (sIgA, IgG, and IgM) with quantitative assay (ELISA) analysis. Unpaired t-test, Welch test, or Mann–Whitney U test were applied for group comparisons when appropriate, and the correlation between variables was analyzed with Spearman’s rank coefficient. Results were considered significant at p < 0.05. Results. In the ADHD group, body weight (p ≤ 0.01), BMI (p ≤ 0.009), and hip circumference (p ≤ 0.001) significantly differed, while waist size and BMI z-score did not (p > 0.05). Significant elevation of the salivary sAA (p = 0.03), sIgA (p = 0.02), and IgM (p ≤ 0.001) biomarkers were detected, without differences in the morning cortisol (p > 0.05). Significant correlations between cortisol and BMI, hip size, and IgA, as well as between IgG and sAA and IgA were obtained. Conclusions. Saliva can be used to monitor ADHD status with regard to biomarkers indicating the hypothalamus–pituitary–adrenal axis, as HPA axis, and sympathetic activity. The results indicate that morning collection of saliva in contrast to unchanged salivary cortisol, may evaluate mentioned above system dysregulations by measurements of sAA and immunoglobulins among ADHD children.