Overnight Dexamethasone Suppression Test Research Articles

Urinary free cortisol excretion is associated with lumbar bone density in patients with adrenal Cushing's syndrome.

Patients with adrenal Cushing's syndrome have a poor prognosis due to the autonomous hypersecretion of endogenous cortisol from the adrenal gland. Although several clinical examinations have been developed to manifest the autonomous hypersecretion of endogenous cortisol in this syndrome, it is unknown which parameter of cortisol overproduction is best associated with the adrenal cortisol content and bone and vascular complications of this syndrome. Therefore, the present study was undertaken to evaluate the parameter(s) associated with the adrenal cortisol content in patients with adrenal Cushing's syndrome, as well as to assess the associations between these parameters and the vascular and bone complications of this syndrome. Cardiovascular factors such as blood pressure and pulse rate, glucose metabolism, lipid metabolism, renal function, and indices of arteriosclerosis, except for diastolic blood pressure, failed to show an association with the adrenal cortisol content. Twenty-four-hour urinary free cortisol excretion (ρ = 0.893, P = 0.007) and plasma cortisol levels after the 1-mg (ρ = 0.857, P = 0.014) or 8-mg (ρ = 0.900, P = 0.037) overnight dexamethasone suppression test, but not plasma cortisol levels in the morning or late at night or indices of 131I-adosterol single-photon emission computed tomography-computed tomography, were significantly and positively associated with the adrenal cortisol content. Twenty-four-hour urinary free cortisol excretion, and not plasma cortisol levels after the 1- or 8-mg overnight dexamethasone suppression test, was significantly and negatively associated with lumbar spine bone density (lumbar spine bone mineral density, ρ = -0.786, P = 0.036; lumbar spine T score, ρ = -0.883, P = 0.009; and lumbar spine Z score, ρ = -0.883, P = 0.009). These results indicate that 24-h urinary free cortisol excretion is best associated with a decrease in bone density via increased adrenal cortisol overproduction and suggest that it could be used as a marker for osteoporosis in these patients.

Reevaluation of the 1-mg overnight low-dose dexamethasone suppression test in the diagnosis of Cushing's syndrome

Reevaluation of the 1-mg overnight low-dose dexamethasone suppression test in the diagnosis of Cushing's syndrome

A retrospective evaluation of the utility of overnight dexamethasone suppression tests in over 500 patients evaluated for hypercortisolism

A retrospective evaluation of the utility of overnight dexamethasone suppression tests in over 500 patients evaluated for hypercortisolism

Multiple electrolyte disturbances as the presenting feature of multiple endocrine neoplasia type 1 (MEN-1).

SummaryA 49-year-old teacher presented to his general physician with lethargy and lower limb weakness. He had noticed polydipsia, polyuria, and had experienced weight loss, albeit with an increase in central adiposity. He had no concomitant illnesses and took no regular medications. He had hypercalcaemia (adjusted calcium: 3.34 mmol/L) with hyperparathyroidism (parathyroid hormone: 356 ng/L) and hypokalaemia (K: 2.7 mmol/L) and was admitted for i.v. potassium replacement. A contrast-enhanced CT chest/abdomen/pelvis scan revealed a well-encapsulated anterior mediastinal mass measuring 17 × 11 cm with central necrosis, compressing rather than invading adjacent structures. A neck ultrasound revealed a 2 cm right inferior parathyroid lesion. On review of CT imaging, the adrenals appeared normal, but a pancreatic lesion was noted adjacent to the uncinate process. His serum cortisol was 2612 nmol/L, and adrenocorticotrophic hormone was elevated at 67 ng/L, followed by inadequate cortisol suppression to 575 nmol/L from an overnight dexamethasone suppression test. His pituitary MRI was normal, with unremarkable remaining anterior pituitary biochemistry. His admission was further complicated by increased urine output to 10 L/24 h and despite three precipitating factors for the development of diabetes insipidus including hypercalcaemia, hypokalaemia, and hypercortisolaemia, due to academic interest, a water deprivation test was conducted. An 18flurodeoxyglucose-PET (FDG-PET) scan demonstrated high avidity of the mediastinal mass with additionally active bilateral superior mediastinal nodes. The pancreatic lesion was not FDG avid. On 68Ga DOTATE-PET scan, the mediastinal mass was moderately avid, and the 32 mm pancreatic uncinate process mass showed significant uptake. Genetic testing confirmed multiple endocrine neoplasia type 1.Learning pointsIn young patients presenting with primary hyperparathyroidism, clinicians should be alerted to the possibility of other underlying endocrinopathies.In patients with multiple endocrine neoplasia type 1 (MEN-1) and ectopic adrenocorticotrophic hormone syndrome (EAS), clinicians should be alerted to the possibility of this originating from a neoplasm above or below the diaphragm.Although relatively rare compared with sporadic cases, thymic carcinoids secondary to MEN-1 may also be associated with EAS.Electrolyte derangement, in particular hypokalaemia and hypercalcaemia, can precipitate mild nephrogenic diabetes insipidus.

Cardiometabolic Disease Burden and Steroid Excretion in Benign Adrenal Tumors : A Cross-Sectional Multicenter Study.

Benign adrenal tumors are commonly discovered on cross-sectional imaging. Mild autonomous cortisol secretion (MACS) is regularly diagnosed, but its effect on cardiometabolic disease in affected persons is ill defined. To determine cardiometabolic disease burden and steroid excretion in persons with benign adrenal tumors with and without MACS. Cross-sectional study. 14 endocrine secondary and tertiary care centers (recruitment from 2011 to 2016). 1305 prospectively recruited persons with benign adrenal tumors. Cortisol excess was defined by clinical assessment and the 1-mg overnight dexamethasone-suppression test (serum cortisol: <50 nmol/L, nonfunctioning adrenal tumor [NFAT]; 50 to 138 nmol/L, possible MACS [MACS-1]; >138 nmol/L and absence of typical clinical Cushing syndrome [CS] features, definitive MACS [MACS-2]). Net steroid production was assessed by multisteroid profiling of 24-hour urine by tandem mass spectrometry. Of the 1305 participants, 49.7% had NFAT (n= 649; 64.1% women), 34.6% had MACS-1 (n= 451; 67.2% women), 10.7% had MACS-2 (n= 140; 73.6% women), and 5.0% had CS (n= 65; 86.2% women). Prevalence and severity of hypertension were higher in MACS-2 and CS than NFAT (adjusted prevalence ratios [aPRs] for hypertension: MACS-2, 1.15 [95% CI, 1.04 to 1.27], and CS, 1.37 [CI, 1.16 to 1.62]; aPRs for use of ≥3 antihypertensives: MACS-2, 1.31 [CI, 1.02 to 1.68], and CS, 2.22 [CI, 1.62 to 3.05]). Type 2 diabetes was more prevalent in CS than NFAT (aPR, 1.62 [CI, 1.08 to 2.42]) and more likely to require insulin therapy for MACS-2 (aPR, 1.89 [CI, 1.01 to 3.52]) and CS (aPR, 3.06 [CI, 1.60 to 5.85]). Urinary multisteroid profiling revealed an increase in glucocorticoid excretion from NFAT over MACS-1 and MACS-2 to CS, whereas androgen excretion decreased. Cross-sectional design; possible selection bias. A cardiometabolic risk condition, MACS predominantly affects women and warrants regular assessment for hypertension and type 2 diabetes. Diabetes UK, the European Commission, U.K. Medical Research Council, the U.K. Academy of Medical Sciences, the Wellcome Trust, the U.K. National Institute for Health Research, the U.S. National Institutes of Health, the Claire Khan Trust Fund at University Hospitals Birmingham Charities, and the Mayo Clinic Foundation for Medical Education and Research.

Diagnosis and Management of Cushing's Disease: A Survey of Endocrinologists from the Middle East and North Africa

Abstract Background Cushing's disease is the most prevalent cause of endogenous Cushing's syndrome. This study aimed to scope the current clinical practice pattern in managing Cushing's disease by endocrinologists in the Middle Eastern and North African (MENA) region. Methods A questionnaire dealing with diagnosis, treatment, and follow-up of patients with Cushing's disease was adopted and sent electronically to a convenience sample of endocrinologists from the MENA region. Results Out of 125 responses received, 88 were eligible for inclusion in the analysis. Most respondents selected the overnight dexamethasone suppression test (ONDST) and 24-hour urinary-free cortisol (UFC) as the best screening tests, 58 (66.7%) and 50 (57.5%) respectively, followed by midnight serum cortisol and midnight salivary cortisol. Measurement of serum adrenocorticotropic hormone (ACTH; 86.2%) and classic high-dose dexamethasone suppression test (40.2%) were selected for localization of the primary lesion. The primary choice of treatment was transsphenoidal pituitary surgery (98.8%). For the recurrence of Cushing's disease, medical therapy was the preferred modality followed by repeated pituitary surgery or bilateral adrenalectomy. In case of treatment failure following the first pituitary surgery and ketoconazole treatment, 36.9% selected pasireotide, while 32.1% chose bilateral adrenalectomy. Conclusion ONDST and UFC are the two most common tests used to screen an index case with features of hypercortisolism. Pituitary surgery is the primary choice of treatment in Cushing's disease. However, medical treatment by ketoconazole is preferred for recurrent cases. Bilateral adrenalectomy is followed by pasireotide may be chosen in case of treatment failure after pituitary surgery and ketoconazole.

Should the 1 mg -overnight dexamethasone suppression test be repeated in patients with benign adrenal incidentalomas and no overt hormone excess?

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

A Rare Occurrence of Premature Birth and Recurrent Acute Pulmonary Oedema in the Mother due to Cushing’s Syndrome: A Case Report

Presentation of Cushing’s syndrome during pregnancy is extremely rare. We report a 21-year-old female with Cushing’s syndrome diagnosed at 23 weeks of gestation and had recurrent acute pulmonary oedema during the antepartum and postpartum period. She delivered prematurely via emergency caesarean section at 28 weeks of gestation. This case highlights the rare occurrence of recurrent acute pulmonary oedema during pregnancy and consequential premature birth in a patient with adrenal Cushing’s. She was diagnosed with adrenal Cushing’s during the postpartum period based on unsuppressed serum cortisol after overnight and low-dose dexamethasone suppression test with a suppressed ACTH. CT scan of the adrenal glands revealed a right adrenal cortical adenoma. The risk of complications in infants and mothers who suffer from Cushing’s syndrome needs to be handled carefully. The diagnosis of Cushing’s syndrome in pregnant women often overlaps and is difficult to establish in early pregnancy.

Natural history of nonfunctioning adrenal incidentalomas: a 10-year longitudinal follow-up study.

Most data on the natural history of nonfunctioning adrenal incidentalomas (NFAI) are provided by follow-ups up to 5 years. We conducted a 10.5 (9.1–11.9)-year prospective follow-up study of NFAI in 67 participants (20 (29.9%) males, 47 (70.1%) females) of mean age 57.9 (52.3–63.9) years and BMI 27.42 (24.07–30.56) kg/m2). We also evaluated the associations between baseline BMI and changes of NFAIs’ characteristics at follow-up. Progression to mild autonomous cortisol excess (MACE) was observed in 15 (22 %) patients, with 14 of them having post overnight dexamethasone suppression test (ODST) cortisol between 50 and138 nmol/L and only one > 138 nmol/L. The progression rate was significantly higher in overweight and obese than in normal-weight subjects. Patients that developed MACE had a significantly higher baseline mean cortisol after 1 mg ODST. Tumor enlargement ≥10 mm occurred in 8.9% of patients. In comparison with reports of shorter observational periods, we observed a higher growth rate ≥ 10 mm and higher progression rate from NFAI to MACE, particularly in overweight and obese subjects. All tumors had persistent radiological characteristics typical for adrenal adenoma. We concluded that the duration of the follow-up period is an important factor in characterizing the natural history of NFAI. Higher baseline BMI and higher baseline cortisol after ODST might predict the long-term likelihood of progression in hormonal activity. The magnitudes of observed progressions in growth or hormonal activity were clinically insignificant. Our long-term follow-up, therefore, clearly supports the general view that a long-term monitoring of patients with NFAI is not necessary.

Synacthen Stimulation Test Following Unilateral Adrenalectomy Needs to Be Interpreted With Caution.

BackgroundCortisol levels in response to stress are highly variable. Baseline and stimulated cortisol levels are commonly used to determine adrenal function following unilateral adrenalectomy. We report the results of synacthen stimulation testing following unilateral adrenalectomy in a tertiary referral center.MethodsData were collected retrospectively for 36 patients who underwent synacthen stimulation testing one day post unilateral adrenalectomy. None of the patients had clinical signs of hypercortisolism preoperatively. No patient received pre- or intraoperative steroids. Patients with overt Cushing’s syndrome were excluded.ResultsThe median age was 58 (31-79) years. Preoperatively, 16 (44%) patients had a diagnosis of pheochromocytoma, 12 (33%) patients had primary aldosteronism and 8 (22%) patients had non-functioning adenomas with indeterminate/atypical imaging characteristics necessitating surgery. Preoperative overnight dexamethasone suppression test results revealed that 6 of 29 patients failed to suppress cortisol to <50 nmol/L. Twenty (56%) patients achieved a stimulated cortisol ≥450 nmol/L at 30 minutes and 28 (78%) at 60 minutes. None of the patients developed clinical adrenal insufficiency necessitating steroid replacement.ConclusionsSynacthen stimulation testing following unilateral adrenalectomy using standard stimulated cortisol cut-off values would wrongly label many patients adrenally insufficient and may lead to inappropriate prescriptions of steroids to patients who do not need them.

Nonfunctional adrenal adenomas and impaired glucose metabolism: a systematic review and meta-analysis.

Evidence on nonfunctioning adrenal incidentaloma's (NFAI) associated comorbidities and in particular, glucose disorders, is unclear in contrast to adrenal tumors with mild autonomous cortisol secretion. The current systematic review and meta-analysis aimed to assess the burden of impaired glucose metabolism including diabetes mellitus type 2 (T2DM), fasting blood glucose (FBG), and fasting blood insulin (FBI) levels in patients with NFAI and 1-mg overnight dexamethasone suppression test (ODST) ≤ 1.8 μg/dl across published studies. We searched PubMed, Cochrane, and Scopus databases for identifying studies published between 1956 and March 2021. Twenty-five studies met the selection criteria including prospective, retrospective, and case-control studies. Two reviewers independently extracted studies, participants' characteristics and outcome data in a total pooled sample of 1548 patients. Patients with NFAI had twofold [(odds ratio (OR) (95% confidence interval (CI)): 2.03 (1.39-2.98)] increased odds to present T2DM as well as higher FBG [weighted mean difference (WMD) (95% CI): 3.85 (1.96-5.74)] and homeostasis model assessment (HOMA) [WMD (95% CI): 0.68 (0.23-1.12)] with respect to controls. On the contrary, the WMD of FBI levels did not differ between the two groups. The incidence of T2DM in a subgroup analysis of patients with NFAI without glucose disorders at baseline was 6% [pooled incidence (95% CI): 0.06 (0.04-0.09)]. Patients with NFAI and 1-mg ODST ≤ 1.8 μg/dl presented higher odds of T2DM and higher levels of FBG and HOMA index than healthy controls.

Pheochromocytoma as the Etiology of Cushing Syndrome Through Paracrine ACTH Signaling

Abstract Introduction: Pheochromocytomas are rare catecholamine-secreting tumors of the adrenal medulla that may also secrete ACTH. There are approximately 100 cases of ACTH-producing pheochromocytomas reported in the peer reviewed literature, and they typically cause Cushing syndrome by significantly raising circulating ACTH levels. We report a pheochromocytoma causing apparent ACTH-independent Cushing syndrome by paracrine action of locally produced ACTH on ipsilateral adrenal cortex. Case: A 64-year-old female was referred for an incidentally discovered left adrenal mass. The mass was 4 cm and 37 Hounsfield units on non-contrast computed tomography, and the right adrenal gland was unremarkable. The patient’s history was notable for three years of resistant hypertension, and examination revealed stigmata of Cushing syndrome including moon facies, scattered bruises, and wide, pink striae. Three measurements of plasma metanephrines ranged from 3- to 4.5-fold elevated, and 24 h urine metanephrines were 5.2-fold elevated. Urine 24 h epinephrine was 2.7-fold elevated. Three 8 AM cortisol measurements on overnight dexamethasone suppression tests were 16.3–17.4 mcg/dL (&amp;lt; 1.8), and 8 AM dexamethasone on one test was 494 ng/dL (140–295). Two midnight salivary cortisol measurements were 0.348 and 0.416 mcg/dL (&amp;lt; 0.112), and 8 AM ACTH levels on two occasions were 6.8 and 7.9 pg/mL (7.2–63.3). After adrenergic blockade, the patient underwent left adrenalectomy. Her tumor stained for synaptophysin and chromogranin consistent with pheochromocytoma, and focal staining for ACTH was also observed. Hyperplasia of the adjacent adrenal cortex was present. Hypertension resolved after adrenalectomy, and the patient developed secondary adrenal insufficiency (8 AM cortisol and ACTH 1.0 mcg/dL [&amp;gt; 15] and 2.9 pg/mL, respectively). Discussion: There are five published reports of pheochromocytoma and subclinical hypercortisolemia due to paracrine ACTH or IL-6 activity on ipsilateral adrenal cortex, but this case is distinguished by the occurrence of overt Cushing syndrome. Our patient had ACTH &amp;lt; 10 pg/mL on two measurements, her pheochromocytoma showed focal staining for ACTH, and hyperplasia of adjacent adrenal cortex was observed. In contrast, median ACTH level was 5-6x above the upper limit of normal in a recent review of 95 cases of pheochromocytomas with Cushing syndrome due to ectopic ACTH secretion. If Cushing syndrome was due to bilateral adrenal hyperplasia independent of the patient’s pheochromocytoma, cortisol excess would not have resolved after unilateral adrenalectomy. Communication between cortical and medullary circulations through venous radicles provides a mechanism for ACTH produced by the patient’s pheochromocytoma to affect the function of adjacent cortex. This case demonstrates a novel mechanism by which ACTH from a pheochromocytoma can cause Cushing syndrome.

Utility of Plasma Metanephrines in Adrenal Venous Sampling in Primary Aldosteronism

Introduction: Adrenal Venous Sampling (AVS) is the most reliable means of identifying surgically curable subtypes of primary aldosteronism (PA). Cortisol levels are used to determine cannulation success and lateralization. However, cortisol has a variable secretion pattern and long-half life, and can be co-secreted by adrenal adenomas, leading to misinterpretation of results. Plasma metanephrines (MN) are a possible alternative analyte. MN levels are unaffected by stress, have a short half-life of 3–6 minutes and are released continuously by the adrenals, resulting in very high concentration gradients between the adrenal veins (AV) and peripheral veins (PV), thus providing a sensitive means to determine cannulation success. Premise:The objective of this study was to see if MN can be used in lieu of cortisol in AVS. A secondary end-point was to see if the data was particularly useful in patients who are known co-secretors of cortisol. Methods: Data from AVS carried out without cosyntropin stimulation, from October 2018 to March 2020, were analysed retrospectively. Of these, 51 had additional samples drawn for MN at the time of the procedure and were recruited. Six patients were identified as having autonomous cortisol secretion as they failed an overnight dexamethasone suppression test (ONDST). The data was analysed using cortisol and MN separately and then compared with regards to their selectivity and lateralization index. Data was also analysed to see if known co-secretors had an elevated cortisol/MN ratio of more than 2 on the affected side as described in previous papers. Results: When compared to cannulation and lateralization outcomes using cortisol, similar results were obtained using, a MN AV/PV ratio of more than 12 to indicate successful cannulation and an aldosterone/MN ratios of greater than 5 to confirm lateralization. Contralateral suppression to less than 0.5 for aldosterone/MN below the PV was seen in unilateral disease. With regards to the six co-secretors, all had elevated cortisol/MN ratios of more than 2 on the affected side. Three had concordant results but the other three had discrepant results, with MN analysis suggesting unilateral disease and cortisol measurements suggesting bilateral disease. Two had undergone surgery with biopsy confirming unilateral disease that correlated with MN analysis. The third is under medical management. Conclusion: This is the first study evaluating the use of MN to determine lateralisation of aldosterone production in PA. Further studies are needed, but using MN may be a more reliable alternative to cortisol in the analysis of AVS before definitive surgery in particular in patients with cortisol co-secretion.

Treatment of Cushing’s disease with macroadenoma through transsphenoidal surgery

Cushing’s disease (CD) is a rare illness characterized by chronic hypercortisolism secondary to the overproduction of adrenocorticotropic hormone by a pituitary adenoma, which is associated with a high risk of developing serious complications, such as diabetes mellitus, cardiovascular disease, and emotional disorders. Endoscopic transsphenoidal surgery is performed for the treatment of CD, and was initially preferred over other types of treatments. However, the recurrence after pituitary surgery for CD is a common problem after an initial successful surgery. In microadenomas, the remission rates were higher than those of macroadenoma. This patient had a giant tumor that was greater than 4 cm in length on sella magnetic resonance imaging, and panhypopituitarism was detected using a combined pituitary stimulation test. After transsphenoidal surgery, the patient required temporary hormone replacement for a short period of time. After 1 year, he showed a normal cortisol response on the overnight dexamethasone suppression test and low morning cortisol levels. Therefore, we indicated that the patient was cured of giant macroadenoma with panhypopituitarism before surgery, and thus, reported this case. Key words: Cushing disease, Theasinensin A, Adenoma, Pituitary

Invasive giant pituitary macroadenoma causing Cushing disease; a case report

Introduction: Cushing disease is a rare entity, and among them, giant pituitary adenomas causing Cushing disease is rarer. Here we present a case of Cushing disease secondary to a giant pituitary macroadenoma. Case report: A 41-year-old female with poorly controlled diabetes mellitus and hypertension diagnosed for six months presented with a history of unintentional weight loss, polyuria and polydipsia for the same duration. There was change in her facial appearance with increased pigmentation, frontal balding and she also noted increase in the size of her abdomen. There were features of proximal muscle weakness. Symptoms of hypothyroidism, hypoadrenalism or hyperprolactinemia were absent, and she was amenorrhoeic following hysterectomy done a year back. Visual impairment, headache, abdominal pain, features suggestive of internal malignancy, especially lung and renal, including features of pheochromocytoma were absent. She denied a family history of similar illness. Her BMI was 20.44 kg/m–2. She had a prominent abdomen, round facies, hirsutism, male pattern hair loss, facial plethora and generalized pigmentation and thinning of skin. She also had hypertension and proximal muscle weakness. Rest of the examination was normal. Investigations revealed hypokalaemia, poorly controlled hyperglycaemia and, non-suppressed overnight dexamethasone suppression test. She had a elevated ACTH level, and a high dose dexamethasone suppression test showed suppression. Pituitary imaging with MRI revealed a 51x 62x 41 mm size sellar and a para sellar mass with heterogeneous echogenicity extending to the right temporal lobe. Further imaging for ectopic ACTH secretion was negative.She underwent transcranial surgery which was unsuccessful due to intraoperative bleeding, and radiotherapy was given postoperatively. Conclusion: Cushing disease due to giant pituitary macroadenomas are rare and may require secondary therapeutic measures in controlling the disease in case of failed surgery.

The frontal QRS-T angle in patients with incidentally discovered nonfunctional adrenal adenomas.

Few studies have used electrocardiography (ECG) to examine nonfunctional adrenal adenomas (NFAAs). No study has investigated the QRS-T angle in NFAA patients. We analyzed the frontal QRS-T angle of patients with incidentally discovered NFAAs. Adult patients with incidentally discovered NFAAs were included. Patients with chronic diseases other than hypertension or obesity were excluded. The overnight dexamethasone suppression test was performed. Levels of plasma renin and aldosterone, as well as metanephrine fractions in 24-h urine were measured. We performed abdominal magnetic resonance imaging and computed tomography to exclude hormonal hypersecretion and nonadenomas. The frontal QRS-T angle was calculated and verified based on surface ECG. Patients were grouped in terms of QRS-T angle as normal and abnormal, and the abnormal patients were divided into positive and negative subgroups. Of all patients (n=58), six (10.34%) had abnormal QRS-T angles. Hypertension increased the risk of an abnormal QRS-T angle six-fold (odds ratio 6.000; 95% confidence interval 0.982-36.652, p=0.034). The frequency of hypertension was similar between the normal, abnormally positive, and abnormally negative groups (p=0.086). The mean SV1+RV5 value was lower in the abnormal QRS-T angle group (p=0.012). Age, gender, obesity, antihypertensive medication use, prediabetes status, adenoma size or side, hyperlipidemia, and adrenal hormone levels were all not associated with the QRS-T angle. Our study is the first to analyze the association between an abnormal QRS-T angle and NFAA. An abnormal QRS-T angle was found in a significant proportion of patients and was associated with hypertension but seemingly, not with left ventricular hypertrophy. We recommend ECG and blood pressure measurement at the time of diagnosis of an NFAA and on follow-up.

A benign cause of hyperandrogenism in a postmenopausal woman.

SummaryMenopause is a relative hyperandrogenic state but the development of hirsutism or virilizing features should not be regarded as normal. We report the case of a 62-year-old woman with a 9-month history of progressive frontotemporal hair loss and hirsutism, particularly on her back, arms and forearms. Blood tests showed increased total testosterone of 5.20 nmol/L that remained elevated after an overnight dexamethasone suppression test. Free Androgen Index was 13.1 and DHEAS was repeatedly normal. Imaging examinations to study adrenals and ovaries were negative. The biochemical profile and the absence of imaging in favor of an adrenal tumor made us consider the ovarian origin as the most likely hypothesis. After informed consent, bilateral salpingectomy-oophorectomy and total hysterectomy were performed. Gross pathology revealed ovaries of increased volume and histology showed bilateral ovarian stromal hyperplasia. Testosterone levels normalized after surgery and hirsutism had completely subsided 8 months later.Learning pointsMenopause is a relative hyperandrogenic stateHirsutism and/or virilizing features, in a postmenopausal woman, should raise the hypothesis of a malignant causeIn the absence of an identifiable ovarian or adrenal tumor, the ovarian origin remains the most likelyPeripheral aromatization of excess androgen may conduct to high levels of estrogen increasing the risk of endometrial cancerBilateral oophorectomy results in significant clinical improvement.

Preferred screening test for Cushing’s syndrome screening

Background: In our practice 24 hours urine collection for free cortisol (24Hr UFC) and overnight dexamethasone suppression test (ONDST) are initial investigations to screen patients for hyper-cortisolism. I audited our practice to find our clinicians’ and patients’ choice of first screening investigation for hyper-cortisolism. Method &amp; material: Electronic and paper medical records of patients who underwent 24Hr UFC and/or ONDST at our hospital over previous consecutive twenty four months were examined. 62 such patients were identified but 12 patients were excluded from analysis. We tried to contact 30 patients over consecutive 48 hours over the phone who underwent both 24Hr UFC and ONDST. We managed to contact 18 patients and asked them two study questions. Data &amp; results: 33 (66%) patients were female and 17 (33%) were male. 20 (40%) had 24Hr UFC alone and 30 (60%) patients had both. In total 80 such investigations completed 30 being ONDST and 50 24hr UFC. 53 (66%) of the investigations were requested by Endocrinologists, 21 (26%) by Hospital General Physicians and 6 (8%) by General practitioners (GP). For UFC 10 (20%) were true positive, 31 (62%) were false positive, 6 (12%) were true negative and 0% false negative. 3 (6%) 24Hr UFC samples were not collected properly and were not processed for results. Out of the total false positives (31 patients), 6 (19.3%) cases were of alcohol excess, 4 (13%) of dépression, 3 (9.7%) of inhaled steroids and 1 (3.2%) of sleep apnea. For the ONDST 7 (23.3%) true positive, 4 (13.3%) false positive 19 (63.4%) true negative and 0% false negative. All 18 patients contacted over the phone answered both questions. 16 preferred ONDST over 24Hr UFC, 1 patient had no preference and 1 patient preferred 24Hr UFC over ONDST. Conclusion: Patients overwhelmingly preferred ONDST as first screening test in contrast to physician’s choice of 24Hr UFC.

Circannual variation in plasma adrenocorticotropic hormone concentrations and dexamethasone suppression test results in Standardbred horses, Andalusian horses and mixed-breed ponies.

To compare circannual plasma concentrations of adrenocorticotropic hormone (ACTH) and seasonal dexamethasone suppression test (DST) results between three different equine breed groups. Six Standardbred horses, six Andalusian horses and six mixed-breed ponies were followed over a 1-year period, during which time groups were managed identically. Blood samples were collected monthly (around the autumn equinox) or in every second month (other times of the year) for the determination of plasma ACTH concentrations using a chemiluminescent immunoassay. Overnight DSTs were performed quarterly, with suppression of plasma cortisol to below 27 nmol/L at 19 h considered a normal result. Seasonal variation in plasma ACTH concentrations was present among all breed groups with, as expected, higher levels detected around the autumn equinox, from February to April (P < 0.001). Plasma ACTH concentrations were different between breed groups in March, with higher levels in Andalusians compared with Standardbreds (P = 0.048) and in ponies compared with Standardbreds (P = 0.010). Suppression of cortisol during the DST was normal for all animals in winter, spring and summer, but five Andalusians and three ponies returned abnormally high results in autumn, compared with zero Standardbreds. Higher plasma ACTH concentrations and more false-positive DST results were obtained during autumn in ponies and Andalusian horses when compared with Standardbred horses. Potential differences between breeds should be considered when interpreting test results for horses and ponies that are evaluated for pituitary pars intermedia dysfunction. Further work is recommended to establish population-based reference intervals and clinical cut-off values for ACTH in different equine breeds.

Contralateral adrenal thinning as a distinctive feature of mild autonomous cortisol excess of the adrenal tumors.

To identify radiologic features that correlate with mild autonomous cortisol excess using planar and volumetric analysis. Cross-sectional study. In the study, 64 patients with overt Cushing syndrome (CS), 59 patients with mild autonomous cortisol excess (MACE), and 64 patients with nonfunctioning adrenal tumors (NFAT) with evaluable CT scans were included. Patients with NFAT and MACE were BMI-matched with those with overt CS. Planar and volumetric analyses of CT scans were performed in DICOM images using OsiriX software. The mean age was 56.6 ± 1.01 years, and 123 patients (65.1%) were female. In the order of NFAT, MACE, and overt CS, the diameters and volumes of the adenoma increased, while limb widths and volumes of the contralateral adrenal gland decreased. Patients with MACE or overt CS were more likely to have osteoporosis than those with NFAT (P = 0.006), and patients with overt CS were more likely to experience a fragility fracture than those with NFAT or MACE (P = 0.002). Among radiologic features, the limb width of the contralateral adrenal gland correlated with the cortisol level after overnight dexamethasone suppression test (r = -0.583, P < 0.001). The study showed that the contralateral adrenal limb thinning was a distinctive radiologic feature of autonomous cortisol excess in the planar and volumetric analysis.