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Abstract Mifepristone and misoprostol are globally used medications that have become disparaged through the stigmatization of reproductive healthcare. Patients are hindered from receiving prompt treatment in clinical scenarios where misoprostol and mifepristone are the drugs of choice. It is no exaggeration to emphasize that in cases where reproductive healthcare is concerned. The aim of this paper is to discuss the different indications of mifepristone and to delineate where the discrepancy in accessibility arises. For this systematic review, we included publications citing clinical trials involving the use and efficacy of mifepristone published in English within the date range of 2000 to 2023. Five databases were searched to identify relevant sources. These databases are Google Scholar, MEDLINE with full text through EBSCO, and three National Center for Biotechnology Information (NCBI) databases (NCBI Bookshelf, PubMed, and PubMed Central). Twenty-three records were ultimately included in this review. Mifepristone has been shown to have therapeutic effects in the treatment of psychiatric disorders, such as major depressive disorder and psychotic depression. There was a significant decrease in depression and psychiatric rating symptoms for patients taking mifepristone versus placebo with no adverse events. Mifepristone has also been shown to improve treatment course in patients with Cushing’s disease (CD) who failed or are unable to undergo surgical treatment. In addition, mifepristone has been shown to be a successful treatment option for adenomyosis and leiomyomas. Patients had a statistically significant decrease in uterine volumes following mifepristone treatment, which aided in the alleviation of other symptoms, such as blood loss and pelvic discomfort. Mifepristone is a synthetic steroid that has immense potential to provide symptomatic relief in patients suffering from a wide array of complicated diseases. Historically, mifepristone has been proven to have an incredible safety profile. While further research is certainly needed, the politicization of its medical use for only one of its many indications has unfortunately led to the willful ignorance of its potential despite its evidence-based safety profile and efficacy. Introduction & Background Mifepristone is a synthetic steroid derived from norethindrone and therefore has antagonistic activity against progesterone and glucocorticoid receptors. Misoprostol is a synthetic prostaglandin E1 analog that works through the direct stimulation of prostaglandin E1 receptors. Recently, these medications have become disparaged due to their associations with the controversial medical procedure known as abortion. Abortions, however, have been so common that one out of four women will have had an abortion by the time they reach the age of 45 [1]. It is estimated that 3.7 million women have used mifepristone and misoprostol for medication abortions since they were first approved by the Food and Drug Administration (FDA) in 2000 [1]. Mifepristone followed by misoprostol is up to 14 times safer than carrying the patient’s pregnancy to term [1]. Aside from abortion, mifepristone is used for both gynecologic and obstetric conditions. Obstetric conditions include induction of labor, postpartum hemorrhage, intrauterine fetal demise, ectopic pregnancies, and miscarriages [2]. Gynecological conditions that can be treated with mifepristone include abnormal uterine bleeding, post-coital contraception, and treatment of gynecological cancers [3]. Due to the stigmatized nature of abortion, however, patients are hindered from receiving prompt treatment in clinical scenarios where mifepristone is the drug of choice. It is no exaggeration to emphasize that in cases where reproductive healthcare is concerned, every second counts [3]. Legislation that varies across states further impacts patients who risk their lives and health as they attempt to navigate their care plan across borders. Travel costs, time-off, childcare, transportation, and living accommodations are just a few more of the factors patients must take into consideration when they are forced to seek life-saving care outside of their homes [3]. Mifepristone is a medication that has multiple therapeutic applications, such as treating leiomyomas, psychotic depression, and post-traumatic stress disorder (PTSD). However, its use is restricted in many countries because of its abortifacient effect. This is a logical fallacy that deprives patients of a beneficial and safe treatment option. This systematic review aims to explore the evidence-based uses of mifepristone and how it can improve patients' health outcomes. The clinical indications that will be discussed are adenomyosis, leiomyomas, psychotic depression, PTSD, and Cushing's disease (CD). Review Methods Eligibility Criteria For this systematic review, we included publications of clinical trials and systematic reviews citing clinical trials relating to the clinical use of mifepristone and published in English within the date range of 2000 to 2023. Info Sources Five databases were searched to identify relevant sources. These databases include Google Scholar, MEDLINE with full text through EBSCO, and three National Center for Biotechnology Information (NCBI) databases (NCBI Bookshelf, PubMed, and PubMed Central). Search Strategy For each database, we inputted “clinical use of mifepristone” as our search term. The populated results were then narrowed down to those published in the English language and within the date range of 2000 to 2023 using automated search tools. Selection Process The titles and abstracts of the remaining records were then screened, and those deemed relevant to clinical uses of mifepristone and its efficacy were included for comprehensive review. This initial record search in three of the four databases (Google Scholar, MEDLINE, and PubMed) was completed by three separate reviewers. The initial record search in the remaining two databases (NCBI Bookshelf and PubMed Central) was completed by another individual reviewer. Data Collection Process After the initial record search, 60 records were deemed relevant to the study topic and compiled for a more comprehensive review. Two records were found to be duplicates and removed. Each of the four reviewers read the remaining 58 records and voted on the eligibility of the publication for inclusion in our review. Older publications that were expanded upon in more recent study trials were excluded to reduce redundancy. In addition, for records with similar study protocols, only the more recently published record was included. Ten records were excluded from the review due to ineligible study design. For those records that were not unanimously accepted (at least one reviewer voted for exclusion), the record was excluded. To ensure that the data utilized in this review were backed by sufficient evidence, the reviewers organized the remaining records into groups based on the disease mifepristone was being studied to treat. After further discussion, it was decided to exclude the records in the groups that lacked at least three separate clinical trials on the use of mifepristone in the treatment of the disease. Thirty articles were excluded. Seven of the 18 remaining records were systematic reviews, and citation searching of the records found four additional records that met the eligibility criteria. The remaining 23 records were included for further review. Data Items Of the remaining 23 records deemed acceptable for inclusion, only studies with statistically significant findings regarding the clinical use of mifepristone were included for detailed analysis. One record was excluded due to early termination of the trial. Our records include two open-label studies, four retrospective studies, seven reviews (systematic, meta-analysis), one wet lab (human specimen was used), five long-term safety extension articles, and seven randomized control experimental trials. Study Risk-of-Bias Assessment We assessed the risk of bias (RoB) in the studies included in the review using the revised Cochrane RoB tool for randomized trials (RoB 2). The five domains assessed were (1) RoB arising from the randomization process, (2) RoB due to deviations from the intended interventions (effect of assignment to intervention and effect of adhering to intervention), (3) missing outcome data, (4) RoB in the measurement of the outcome, and (5) RoB in the selection of the reported result. Each randomized control trial included in this review was assessed for RoB by two authors working independently using the RoB 2. For those studies in which the assessing authors came to different conclusions, the remaining two authors completed independent RoB 2 assessments of the study in question, and the majority of findings was accepted. Utilizing the methodology for assigning the overall RoB for each study as outlined by the RoB 2 tool, each study was designated as having “low risk of bias” or “high risk of bias.” After an initial assessment, both authors deemed the nine randomized control studies had a low RoB. Effect Measures Analysis of the studies included a focus on statistically significant findings that varied between control and intervention groups as defined by a p-value less than 0.5. As each study had its own parameters and primary and secondary endpoints, we focused our analysis on the safety and clinical efficacy of mifepristone as measured and reported by the authors of the studies included. Synthesis Methods As previously mentioned, as the studies included in this review vary widely in their study population and intervention design, our analysis focused on qualitative synthesis of study outcomes. These outcomes were categorized as the clinical efficacy and safety of mifepristone for CD, psychiatric disorders, and select gynecological diseases (adenomyosis and leiomyomas). Certainty Assessment To assess the certainty of the body of evidence regarding the studies included in our review, two reviewers applied the five Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) considerations (study limitations, inconsistency of results, indirectness of evidence, imprecision, and publication bias) to each study. Accordingly, the included studies were categorized as having high, moderate, low, or very low certainty of evidence based on the GRADE criteria. After the assessment, both reviewers deemed that all records had high certainty of evidence. Figure 1: PRISMA 2020 flow diagram for new systematic reviews that included searches of databases, registers, and other sources *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Results Psychiatric Implications Based on the analyses, numerous trials demonstrated the profound therapeutic effect that mifepristone can have on psychiatric disorders. In a double-blind study following 19 patients with bipolar disorder, researchers studied neurocognitive function and mood in patients treated with mifepristone vs. the placebo [4]. Significant improvements in verbal fluency and spatial working memory were seen in the group treated with mifepristone. The Hamilton Depression Rating Scale (HDRS) and Montgomery-Asberg Depression Rating Scale (MADRS) scores also improved from baseline (i.e., lower scores) measurements in these patients. It is worth noting that these improvements were seen in as little as two weeks, which is quicker than what is normally seen with typical therapeutic agents for bipolar disorder (lithium/valproic acid) [4]. The most extensive research demonstrated the benefits of using mifepristone with major or psychotic depression [5]. It is important to note that approximately 20% of patients living with major depression experience psychotic symptoms [6]. A randomized, double-blind study looked at 30 participants with psychotic major depression (PMD) and treated them with mifepristone 600 mg or a placebo for eight days. Using the HDRS and Brief Psychiatric Rating Scale (BPRS) to quantify baseline levels of symptoms, results from eight days later showed that mifepristone was significantly more effective in reducing psychotic symptoms compared to the placebo group [6]. By day 8, nearly half of the participants attained a 50% reduction in the BPRS compared to the placebo group (p<0.046) in addition to lower HDRS scores (although this was not found to be significant). Moreover, when researchers looked further into the use of mifepristone in psychotic depression disorders, they discovered a correlation between higher plasma levels of mifepristone and a reduction in psychotic symptoms [7]. More specifically, the strongest reduction in psychosis symptoms was found to be associated with doses of 1200 mg/day of mifepristone, which resulted in a statistically significant reduction in psychotic symptoms (p<0.0004) [7]. The drug was also well tolerated and demonstrated a large safety margin in contrast to the numerous common adverse effects that patients experience when placed on standard treatment options (i.e., antipsychotics). In another double-blind, placebo-controlled study that took place over four days, five participants diagnosed with psychotic major depression were administered 600 mg of mifepristone [5]. The HDRS and BPRS scores were used, and the results showed that all five participants' depression ratings decreased - a nearly statistically significant finding (p<.07) [5]. Likewise, four out of the five BPRS scores declined, approximating to a 32.5% decline, which is comparable to the 40% decline seen with traditional antipsychotic treatments that span six to eight weeks. Once again, no adverse effects were reported. The use of mifepristone has been explored in many cognitive disorders, including Alzheimer's disease. One study found that patients with mild to moderate Alzheimer’s disease displayed improvement on the Alzheimer’s disease assessment cognitive subtest - by 2.67 as opposed to the 1.67 decline in patients treated with a placebo [5]. Although not statistically significant, this finding encourages further studies to continue exploring the psychiatric and neurologic use of mifepristone. Cushing’s Disease Multiple trials have been conducted regarding the use and efficacy of mifepristone in the treatment of CD. Although surgical intervention to remove the source of excess cortisol production is the current mainstay of treatment, clinical trials have focused on the treatment with mifepristone for medical therapy, especially in patients who have failed surgical intervention or for those who are not good candidates for surgery. Accordingly, a retrospective study of 20 patients with hypercortisolism (12 with adrenocortical carcinoma, three with ectopic adrenocorticotropic hormone (ACTH) secretion, four with CD, and one with bilateral adrenal hyperplasia) found clinically significant improvement in excess cortisol-induced symptoms in 15 out of 20 patients [4]. Patient responses to mifepristone treatment were monitored by clinical signs of hypercortisolism (signs of hypercortisolism, blood pressure measurements, and signs of adrenal insufficiency) and serum potassium and glucose. The study found that 15 out of 20 patients showed significant clinical improvement in excess cortisol-induced symptoms. Psychiatric symptoms and blood glucose levels also improved in the patients [4]. Of note, 11 out of 20 trial participants exhibited moderate to severe hypokalemia as a side effect, although only one patient had to leave the study early due to severe adverse effects [4]. In another well-known study, 50 patients were assessed at baseline and during intervention (total of six times) for 24 weeks, referred to as the SEISMIC study [8]. Changes in oral glucose tolerance tests over time were used to assess the mifepristone effect in type 2 diabetes millets (T2DM)/impaired glucose tolerance patients. Changes in diastolic blood pressure (BP) over time were used to measure the effect of mifepristone in hypertensive cardiogenic shock (CS) patients [8]. Results found a statistically significant improvement in symptoms in both groups: diabetic patients had improvement in response to oral glucose test, decreased A1C, and decreased fasting glucose, and hypertensive patients had decreased diastolic BP or reduction in antihypertensive medications [8]. In addition, the waist circumference and hemoglobin A1C (HbA1C) also improved, and study findings concluded that mifepristone use has an acceptable risk-benefit ratio for six months of treatment [8]. Several extension studies were later performed utilizing the data found during the SEISMIC study [9]. One such study assessing weight loss in patients who participated in the SEISMIC study also found statistically significant improvement in patients with CD. After one-week mifepristone period (patients who chose to participate in this follow-up study had to be assessed to ensure it was safe for them to enroll in this study), 30 patients were enrolled and started on once daily mifepristone at the dose they were taking when the SEISMIC study concluded [9]. The patient's weight was assessed at baseline and week 24 of the SEISMIC study, and for this study, the follow-up weight was taken at months 6, 12, 18, and 24 and a final visit. Data were assessed for 29 of the participants and statistically significant decreases in weight were found for all participants from baseline to end of the SEISMIC study, and the maintenance of weight loss was statistically significant in all participants at their final visit to this study as well [9]. Another SEISMIC extension study focused on monitoring the effects of mifepristone treatment in CD on ACTH levels and pituitary MRI findings [10]. Serum ACTH, urinary, and salivary cortisol levels were monitored during the SEISMIC study (baseline, day 14, and weeks 6, 10, 16, and 24) and once after a six-week mifepristone-free "washout" period. ACTH levels were then monitored one month later and then routinely every three months during the intervention period, which varied per participant [10]. Serum cortisol measures were assessed during the SEISMIC study at the intervals mentioned previously and then every six months during the extension study. Pituitary MRI studies were taken prior to mifepristone administration during the SEISMIC study and at weeks 10 and 24 [10]. Repeat imaging was then taken every six months during the extension study. On average, ACTH levels increased greater than twofold (2.76 ± 1.65-fold over baseline; p<0.0001 vs. baseline) in patients during the SEISMIC and extension study periods and decreased to near baseline levels after six weeks of mifepristone discontinuation [10]. Serum cortisol levels in both the initial intervention and extension period increased as well, although a higher mean cortisol level was seen during the extension study intervention (SEISMIC: 1.97 ± 1.02-fold increase; p<0.0001 vs. baseline; extension study: 2.85 ± 1.05-fold increase; p<0.0001 vs. baseline) [10]. In comparing the baseline and post-intervention MRI images, 30 out of 36 patients showed no progression in pituitary tumor size with mifepristone intervention, two patients showed regression of tumor size, and three patients showed evidence of tumor progression. One patient was found to have a tumor post-intervention despite a negative initial MRI at baseline [10]. A retrospective analysis of data collected during the SEISMIC study utilized oral glucose tolerance test data to assess the mifepristone treatment effect on the total body insulin sensitivity, beta cell function, weight, waist circumference, and additional parameters [11]. The analysis found improved total body insulin sensitivity in all participants, with the greatest improvement occurring from baseline to week 6. The weight and waist circumference both decreased by week 24 [11]. An additional important six-month study was done on 46 patients with refractory CS and either DM2, impaired glucose tolerance, or diagnosis of HTN in which mifepristone treatment was administered daily [12]. Patients were examined by three separate reviewers using global clinical response assessments (-1 = worsening, 0 = no change, 1 = improving) measured by eight clinical categories: glucose control, lipids, blood pressure, body composition, clinical appearance, strength, psychiatric/cognitive symptoms, and quality of life at weeks 6, 10, 16, and 24. A positive correlation with increasing GCR scores was found by week 24, with 88% of participants showing statistically significant improvement (p<0.001) [12]. Adenomyosis/Leiomyoma Adenomyosis and leiomyomas are common gynecological conditions that affect large portions of the female population. Multiple trials have proven mifepristone’s success in treating endometriosis and various forms of cancer. Current data shows that mifepristone is well tolerated and has mild side effects in certain long-term clinical settings. In one trial following mifepristone and its effects on adenomyosis, 20 patients were treated with 5 mg oral mifepristone/day for three months [13]. After the three-month trial, patients demonstrated a statistically significant (p<0.001) reduction in uterine volume as was measured through transvaginal ultrasound. These patients were also found to have significantly decreased CA-125 markers (a marker of adenomyosis and an increase in uterine size) and significantly increased hemoglobin concentration The patient’s endometrial tissue was then obtained from each patient during their hysterectomy [13]. The endometrial tissue samples were treated with varying concentrations of mifepristone for 48 hours. They found that mifepristone significantly decreased the viability of endometrial epithelial and stromal cells in adenomyosis and can induce their apoptosis as well [13]. This concentration-dependent inhibitory effect was most significantly seen with concentrations of mifepristone above 50 μmol/L at 48 hours. The same study showed that mifepristone demonstrated another dose-dependent relationship in the inhibition of the migration of ectopic endometrial and stromal cells. This finding is significant as the migratory nature of the patient’s endometrial and stromal cells is the pathogenesis behind adenomyosis [13]. Another study looked at the effect of mifepristone in combination with high-intensity focused ultrasound (HIFU) and levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of adenomyosis [13]. Out of 123 patients, 34 patients were treated with HIFU alone, 29 patients were treated with HIFU combined with mifepristone, 10 patients with HIFU combined with LNG-IUS, and 50 patients with HIFU combined with mifepristone and LNG-IUS [13]. In the group treated with HIFU combined with mifepristone and LNG-IUS, the uterine volume was significantly reduced after treatment at 3, 6, 12, and 24 months compared to the previous treatment (p<0.05). Dysmenorrhea was measured using a visual analog score (VAS). In the combination group of mifepristone, HIFU, and LNG-IUS, VAS scores decreased from 80.82 ± 12.49 to 29.58 ± 9.29 at 24 months [13]. This was significantly lower than the three other treatment groups (p<0.05). The combination group of mifepristone, HIFU, and LNG-IUS also demonstrated statistically significant decreases in the menstrual volume and CA-125 serum markers [13]. Hemoglobin levels were not statistically different among the four treatment groups, but it is postulated that this could have been due to the fact that the patients who were anemic had been treated with different medications to improve their Hb aside from the trial medications [13]. Uterine leiomyomas are another gynecological condition that has been found to improve with the use of mifepristone as well. Insulin-like growth factor 1 (IGF-1) has been found to be overexpressed in leiomyomas [14]. This study showed that mifepristone inhibited the gene expression of IGF-1, and the reduction in symptoms correlated with a decrease in IGF-1 expression although the mechanism is not fully understood [14]. A meta-analysis studied the effects of mifepristone on uterine and leiomyoma volumes of 780 women from 11 randomized controlled trials. Mifepristone at doses from 2.5, 5, and 10 mg was found to effectively reduce uterine and leiomyoma volumes and alleviate leiomyoma symptoms at six months [6]. Pelvic pain, pelvic pressure, and dysmenorrhea were found to be alleviated after three months of treatment. Mifepristone also decreased the mean loss of blood during menstruation and a statistically significant increase in hemoglobin. No significant difference was found among varying dosages of 2.5, 5, and 10 mg other than increased frequency of hot flashes in patients of the 10 mg group. Another review investigated six clinical trials involving 166 women and the effects of 5-50 mg mifepristone for three to six months on leiomyomas [3]. The review demonstrated that daily treatment with all doses of mifepristone resulted in reductions in pelvic pain, pelvic pressure, dysmenorrhea, and uterine and leiomyoma volume size by 26-74%. Even doses of 2.5 mg of mifepristone resulted in significant improvement in the quality of life scores although there was little reduction in leiomyoma size at this dose [3]. This review also reported the rapid correction of uterine bleeding, amenorrhea, and increases in hemoglobin levels following treatment with 50 mg of mifepristone on alternating days. Even vaginal mifepristone has demonstrated efficacious results in the improvement of leiomyomas. In one such trial, the effects of daily 10 mg vaginal mifepristone were studied in 33 women from the ages of 30-53 [15]. Vaginal mifepristone significantly reduced leiomyoma volume and reduced the effects of symptoms on the patient’s quality of life as measured by the Uterine-Fibroid Symptoms Quality of Life questionnaire (UFS-QoL). It is important to note that the only significant side effect found in this review of trials was hot flashes at doses of mifepristone at 10 mg or more. Mifepristone was otherwise generally well tolerated with minimal if any adverse effects [15]. Discussion Adenomyosis is a gynecologic condition that is characterized by the growth of endometrial cells into the myometrium, resulting in a globally enlarged uterus and an associated increase in CA-125 [16]. This marker is classically known to be an ovarian tumor marker; however, in this class, it reflects the increase in uterine glandular size. Although it is often labeled as a “benign” disease, it affects around 20% of reproductive-aged women. This condition can lead to dysmenorrhea, infertility, and menorrhagia in addition to detrimental effects on a patient’s mental health [16]. Despite 20% of affected patients being under the age of 40, the gold standard of treatment is a hysterectomy. Hysterectomies may often not be wanted by patients as it is an invasive surgery that comes with several potential complications of its own. It is important to note that due to the large percentage of patients with adenomyosis who are of reproductive age, hysterectomies may not be an appropriate standard method of treatment. To rob patients of their fertility without attempting medication therapy with mifepristone first is an act of injustice. Surgery alone comes with many complications and the possibility of recurrence. The ability of physicians to manage their patient’s pain and symptoms should be guided medically before surgical sterilization is considered. Many of these patients are forced to seek alternative non-invasive treatments instead of medication therapies to preserve their fertility. HIFU and LNG-IUS are noninvasive therapies for adenomyosis that can be used in patients who refuse hysterectomies or for those who are not good candidates [16]. The pitfalls of these procedures include the fact that 20% of patients on HIFU alone end up relapsing, and LNG-IUS cannot be used in patients with a uterine size that is >12 weeks gestation or a uterine cavity depth that is >9 cm. Because adenomyosis is an estrogen-dependent disease, gonadotropin-releasing hormone agonists (GnRH-a) are also often used in combination with HIFU and LNG-US. Through the inhibition of the secretion of estrogen, GnRH-as facilitate reduced pelvic pain, reduced bleeding, and reduced uterine cavity size [16]. Reduction in cavity size is significant as this alone can lead to improved pain and reduced bleeding and allows patients to qualify for LNG-US where their previous uterine cavity size would have prevented their candidacy. Its current limitations include price (>$200/month), induction of premenopausal syndrome, and high rates of relapse following drug cessation [16]. Mifepristone offers a cheaper alternative (<$4/month) with significantly improved outcomes in reduced uterine cavity size, decreased dysmenorrhea pain scale score, and lower menstruation volume scores [16]. Mifepristone is also able to provide such results without the bone loss that is commonly associated with GnRH-analogs [3]. This is because mifepristone allows for serum estradiol to remain within the patient’s physiologic follicular phase range [3]. In addition, mifepristone is able to significantly reduce serum levels of CA-125 and improve hemoglobin levels in patients with menorrhagia. These reductions in CA-125 demonstrate marked reductions in the size of glands of the uterus of these patients. Through the reduction of cavity size, mifepristone can not only offer therapeutic relief but also allow patients to qualify for noninvasive LNG-US procedures, which can offer further therapeutic benefits. Patients should have the option to explore all potential medical therapies before opting for surgical correction. Leiomyomas, or uterine fibroids, are another commonly encountered gynecologic condition and represent the most common benign tumors found in the female population. These benign smooth muscle tumors are estrogen-sensitive and can rarely develop into malignant leiomyosarcomas. Nearly 20-50% of patients with these fibroids experience symptoms, such as abnormal uterine bleeding (AUB), infertility, pelvic pain, and miscarriages [17]. Currently, the only treatment for this common condition is surgery. Two medications that are commonly used for preoperative reductions in leiomyoma size are mifepristone and enantone. Enantone is a gonadotropin-releasing hormone analog that has shown significant improvement in leiomyoma shrinkage, correction of anemia, and correction of AUB [17]. Through its MOA, however, enantone can lead to harmful adverse effects, such as menopausal symptoms and bone mineral loss. Using hormone supplementation to negate these side effects leads to reduced effectiveness of enantone in fibroid size reduction. Several studies have shown that progesterone plays a large role in the proliferation of leiomyoma growth [17]. Mifepristone, therefore, offers an effective alternate solution by producing the same results without enantone’s adverse effects. When comparing enantone to mifepristone, the two medications both resulted in statistically significant reductions in fibroid size, reduction in dysmenorrhea, reduction in non-menstrual abdominal pain, and increased Hgb/Hct/and RBC count despite differences in dosage [17]. However, mifepristone was able to maintain the patients’ premenopausal levels of estrogen, whereas patients on enantone were found to have estrogen levels of menopausal patients. Furthermore, patients who were treated with enantone also reported more adverse events compared to those in the mifepristone group [17]. Vaginal use of mifepristone has also been shown to significantly reduce leiomyoma size and improve symptoms of anemia while lowering systemic bioavailability of mifepristone [15]. Through its concentrated distribution to uterine tissue, vaginal mifepristone can lead to increased improvement in its clinical outcomes. Vaginal mifepristone showed statistically significant improvements in leiomyoma volume change, USF-QoL, and decreased bleeding intensity at the end of the three-month trial and three months after treatment [15]. For these reasons, mifepristone can be used effectively for conservative therapy in patients suffering from leiomyomas and should be considered a viable option for patients not wishing to undergo surgery. CD refers to hypercortisolism that is caused by pituitary adenomas, adrenal neoplasias, or paraneoplastic ACTH secretion. Hypercortisolism in these patients leads to the development of skin changes, HTN, obesity, insulin resistance, dyslipidemia, anovulation, skeletal disorders, and neuropsychiatric disorders [18]. Patients suffering from these conditions endure a severely decreased quality of life and increased morbidity and mortality. The syndromic nature of this disease prompts delayed diagnosis and further increases the mortality and morbidity of this population [18]. CS therefore necessitates effective and rapid treatment options to diminish harm and clinical burden. The current first-line treatment for CD is pituitary surgery despite its nearly ⅓ relapse rate within 10 years postoperatively [18]. In these patients and patients with recurrent CD, further treatment options are necessitated. These options include adrenal surgery, pituitary radiotherapy, or medication therapy. Radiotherapy further delays symptomatic relief as it usually takes years before excess cortisol levels are managed. It also carries the risk of the patient developing hypopituitarism due to subsequent pituitary damage [18]. While surgery of the adrenal glands can quickly achieve control of excess cortisol, it also carries a risk of permanent adrenal insufficiency. Medication therapy can be used preoperatively, postoperatively, and as adjunctive therapy to radiotherapy. These drug classes include somatostatin analogs, dopamine agonists, and adrenal steroidogenesis inhibitors [18]. The most commonly used medication is the adrenal steroidogenesis inhibitor ketoconazole. While it has been proven to be effective and rapid in its success, doses may need to be frequently increased due to the cortisol blockade that occurs in CD patients [8]. In fact, due to the hormonal imbalances in CD patients, many medications often have to be dose adjusted to achieve therapeutic effect. It is also important to note that many of the medications that are used are not easily tolerated when doses are increased or adjusted frequently. The use of mifepristone has demonstrated statistically significant results in weight reduction, insulin resistance, depression, HTN, and quality of life in CD patients [10]. Furthermore, mifepristone can also be used effectively in patients experiencing cortisol-induced psychosis during acute exacerbations of hypercortisolism. While not included in the classes of more commonly used drugs for CD, mifepristone has been approved by the FDA for the treatment of CD when associated with disorders of glucose metabolism. This is undoubtedly due to the stigmatization of mifepristone and the subsequent reluctance of clinicians to incorporate it into their treatment plans. Neuropsychiatric disorders have been investigated for their associations with dysregulations of the hypothalamic-pituitary-adrenal axis (HPA) and increases in cortisol levels. Studies have shown that patients suffering from depression, schizophrenia, and psychotic depression have elevated levels of cortisol and increased activity of their HPA [19]. The role of cortisol in psychiatric disorders is evidenced by the adverse psychiatric effects that patients can develop in response to exogenous glucocorticoid use through subsequent increases in cortisol. These include delirium, depression, mania, or psychosis. When functioning normally, HPA activity and cortisol secretion are maintained through sensitive negative feedback systems involving glucocorticoid receptors (GCRs) and mineralocorticoid receptors (MCR) [19]. At low doses, cortisol preferentially binds to MCR. As cortisol levels rise, it begins to bind to GCR and thereby initiates the negative feedback loop. Antipsychotics that are typically used work by reducing cortisol levels. Mifepristone, when dosed at >200 mg/day, selectively binds only to GCR and has no effect on MCR [19]. Through its sole inhibition of GCR, it ensures that normal cortisol homeostasis is maintained while ensuring that excess high levels of cortisol are blocked. This was evidenced by the statistically significant correlation between rising plasma concentrations of mifepristone and improvement of psychotic symptoms [20]. The hippocampus is a region of the temporal lobe that is most notably recognized for its role in learning and memory. Further studies have shown correlations between hippocampal atrophy and patients with severe depression, PTSD, and schizophrenia. It is postulated that this hippocampal atrophy leads to persistently high levels of cortisol, worsening these patient’s psychiatric symptoms. Administration of mifepristone to patients with combat-related PTSD demonstrated significant benefits in quality of life and psychiatric improvement. Psychotic major depression is another psychiatric condition that affects around 20% of patients with major depression [7]. When mifepristone was used to treat psychotic depression, patients were able to achieve rapid antipsychotic effects that lasted for weeks after the medication therapy ended. It should be noted that patients suffering from PMD generally have increased cortisol levels even with standard antidepressant therapy alone [7]. Some patients are even unresponsive to electroconvulsive therapy. The ability of patients suffering from psychotic depression to achieve rapid relief is imperative as these patients are more susceptible to suicidal ideation, especially during an episode of psychosis [7]. Bipolar disorder is another mood disorder that has been found to be associated with high levels of cortisol, dysfunction of the HPA axis, and GR dysfunction. Several neuroendocrine studies demonstrated that around 43% of bipolar patients with depression were also dexamethasone-suppression-test (DST) nonsuppressors [7]. Further studies found that bipolar patients suffering through relapse and recovery had abnormal dexamethasone/corticotropin-releasing hormone (dex/CRH) test results [21]. These abnormal (dex/CRH) findings were also seen in healthy patients who had certain genetic predispositions for mood disorders [21]. Regarding these HPA dysfunctions, GR has been implicated in being an important modulator of neurocognitive function and mood. This can be evidenced through research findings that report increased GR number and GR binding in brain tissue following the administration of antidepressants in depressed patients [21]. Mifepristone’s unique advantage is that its selective role as a GR antagonist was also found to increase both MR and GR binding in the frontal cortex. In fact, data from Young et al. [21] reveals significant improvement in frontal cortex functioning following clinical mifepristone trials. These results were seen through improvements in spatial working memory function and reductions in the HDRS17 and MADRS. They also demonstrated significant improvement in verbal fluency from baseline. These improvements in neurocognitive functioning were measured when the subjects’ mood was similar to their baseline or did not vary when compared to the placebo group [21]. This key finding suggests that improvements in neurocognitive functioning were not solely related to improvements in mood or depression. Mifepristone achieves these improvements in neurocognitive function through its selective activity towards GR within the frontal cortex. Furthermore, patients are also able to achieve symptomatic improvement two weeks after the initiation of treatment [21]. The rapid nature of mifepristone adds further clinical benefit as classic bipolar treatments take longer to achieve therapy and the fact that treatment plans for patients with bipolar disorder are tricky to individualize. Other commonly known psychiatric disorders are treated with antipsychotics. While these medications often come with a large array of adverse effects, weight gain, metabolic derangements, and glucose intolerance have been a few of the more frequently reported negative effects. While the exact cause of the weight gain is unknown, mifepristone was shown to significantly reduce weight gain in patients when taken alongside risperidone or olanzapine [21]. As discussed previously, mifepristone also has the ability to significantly improve insulin resistance, thereby further improving the AE patients may experience on antipsychotics. Therefore, through mifepristone’s selective activity as a GCR antagonist, it has immense potential as a psychiatric therapeutic agent. Conclusions Mifepristone is a synthetic steroid that has immense potential to provide symptomatic relief in patients suffering from a wide array of complicated diseases. Prednisone, dexamethasone, and anabolic steroids are also synthetic steroids that are commonly used. Despite being a part of the same class as mifepristone, none of these medications fall under as much legal, political, and social duress as mifepristone. This is in spite of the fact that mifepristone has been proven to have an incredible safety profile since its introduction to the public in the 1980s. In fact, its mortality rate is significantly lower than that of Tylenol, NSAIDs, penicillin, and phosphodiesterase inhibitors. While further research is certainly needed, its involvement in politics has unfortunately led to the willful ignorance of its medical potential despite its evidence-based safety profile and efficacy. References Beaman J, Prifti C, Schwarz EB, Sobota M: Medication to manage abortion and miscarriage. J Gen Intern Med. 2020, 35:2398-405. 10.1007/s11606-020-05836-9 Hagey JM, Givens M, Bryant AG: Clinical update on uses for Mifepristone in obstetrics and gynecology. Obstet Gynecol Surv. 2022, 77:611-23. 10.1097/OGX.0000000000001063 Spitz IM: Mifepristone: where do we come from and where are we going? Clinical development over a quarter of a century. Contraception. 2010, 82:442-52. 10.1016/j.contraception.2009.12.012 Castinetti F, Fassnacht M, Johanssen S, et al.: Merits and pitfalls of mifepristone in Cushing's syndrome. Eur J Endocrinol. 2009, 160:1003-10. 10.1530/EJE-09-0098 Belanoff JK, Flores BH, Kalezhan M, et al.: Rapid reversal of psychotic depression using mifepristone. J Clin Psychopharmacol. 2001, 21:516-21. Eisinger SH, Meldrum S, Fiscella K, et al.: Low-dose mifepristone for uterine leiomyomata. Obstet Gynecol. 2003, 101:243-50. 10.1016/S0029-7844(02)02511-5 Flores BH, Kenna H, Keller J, Solvason HB, Schatzberg AF: Clinical and biological effects of mifepristone treatment for psychotic depression. Neuropsychopharmacology. 2006, 31:628-36. 10.1038/sj.npp.1300884 Fleseriu M, Biller BM, Findling JW, Molitch ME, Schteingart DE, Gross 😄 Mifepristone, a glucocorticoid receptor antagonist, produces clinical and metabolic benefits in patients with Cushing's syndrome. J Clin Endocrinol Metab. 2012, 97:2039-49. 10.1210/jc.2011-3350 Fein HG, Vaughan TB 3rd, Kushner H, Cram D, Nguyen 😧 Sustained weight loss in patients treated with mifepristone for Cushing's syndrome: a follow-up analysis of the SEISMIC study and long-term extension. BMC Endocr Disord. 2015, 15:63. 10.1186/s12902-015-0059-5 Fleseriu M, Findling JW, Koch CA, Schlaffer SM, Buchfelder M, Gross 😄 Changes in plasma ACTH levels and corticotroph tumor size in patients with Cushing's disease during long-term treatment with the glucocorticoid receptor antagonist mifepristone. J Clin Endocrinol Metab. 2014, 99:3718-27. 10.1210/jc.2014-1843 Wallia A, Colleran K, Purnell JQ, Gross C, Molitch ME: Improvement in insulin sensitivity during mifepristone treatment of Cushing syndrome: early and late effects. Diabetes Care. 2013, 36:e147-8. 10.2337/dc13-0246 Katznelson L, Loriaux DL, Feldman D, Braunstein GD, Schteingart DE, Gross 😄 Global clinical response in Cushing's syndrome patients treated with mifepristone. Clin Endocrinol (Oxf). 2014, 80:562-9. 10.1111/cen.12332 Che X, Wang J, He J, et al.: A new trick for an old dog: the application of mifepristone in the treatment of adenomyosis. J Cell Mol Med. 2020, 24:1724-37. 10.1111/jcmm.14866 Shen Q, Zou S, Sheng B, et al.: Mifepristone inhibits IGF-1 signaling pathway in the treatment of uterine leiomyomas. Drug Des Devel Ther. 2019, 14:3161-70. Yerushalmi GM, Gilboa Y, Jakobson-Setton A, Tadir Y, Goldchmit C, Katz D, Seidman DS: Vaginal mifepristone for the treatment of symptomatic uterine leiomyomata: an open-label study. Fertil Steril. 2014, 101:496-500. 10.1016/j.fertnstert.2013.10.015 Zhu H, Ma Q, Dong G, Yang L, Li Y, Song S, Mu Y: Clinical evaluation of high-intensity focused ultrasound ablation combined with mifepristone and levonorgestrel-releasing intrauterine system to treat symptomatic adenomyosis. Int J Hyperthermia. 2023, 40:10.1080/02656736.2022.2161641 Liu C, Lu Q, Qu H, et al.: Different dosages of mifepristone versus enantone to treat uterine fibroids: a multicenter randomized controlled trial. Medicine (Baltimore). 2017, 96:e6124. 10.1097/MD.0000000000006124 Pivonello R, De Leo M, Cozzolino A, Colao A: The treatment of Cushing's disease. Endocr Rev. 2015, 36:385-486. 10.1210/er.2013-1048 Hartmann J, Bajaj T, Klengel C, et al.: Mineralocorticoid receptors dampen glucocorticoid receptor sensitivity to stress via regulation of FKBP5. Cell Rep. 2021, 35:109185. 10.1016/j.celrep.2021.109185 Block TS, Kushner H, Kalin N, Nelson C, Belanoff J, Schatzberg A: Combined analysis of mifepristone for psychotic depression: plasma levels associated with clinical response. Biol Psychiatry. 2018, 84:46-54. 10.1016/j.biopsych.2018.01.008 Young AH, Gallagher P, Watson S, Del-Estal D, Owen BM, Ferrier IN: Improvements in neurocognitive function and mood following adjunctive treatment with mifepristone (RU-486) in bipolar disorder. Neuropsychopharmacology. 2004, 29:1538-45. 10.1038/sj.npp.1300471 From https://www.cureus.com/articles/191397-multiple-clinical-indications-of-mifepristone-a-systematic-review#!/

Abstract Cushing's syndrome is a rare cause of myocardial infarction and heart failure. Herein, we report a female patient who presented acute myocardial infarction and heart failure with reduced ejection fraction. The patient was found to have hypercortisolism secondary to adrenocortical adenoma and responded well to therapy. This case underlines the effects of hypercortisolism on the cardiovascular system. The clinical presentation of this patient is unique because non-atherosclerotic myocardial infarction is rarely reported in Cushing's syndrome patients. Introduction Cushing's syndrome is an endocrine condition associated with excessive secretion of cortisol. Hypertension, vascular atherosclerosis, and chronic cardiac remodelling and dysfunction are commonly recognized cardiovascular complications in Cushing's syndrome patients.1 Herein, we report a rare case of Cushing's syndrome patient with a primary diagnosis of non-atherosclerotic myocardial infarction and heart failure (HF). Case Report A 61-year-old female with a past medical history of chronic obstructive pulmonary disease was admitted with sudden onset chest pain on 6 February 2018. Electrocardiogram showed ST-segment elevation in leads V3–V5. Blood biochemical results of 1 h after the onset of chest pain: cardiac troponin I (cTnI) 0.06 ug/L↑, creatine kinase (CK) 63 U/L, creatine phosphokinase-MB (CK-MB) 22 U/L, aspartate transferase (AST) 19 U/L, and lactic dehydrogenase (LDH) 482 U/L. Myocardial injury markers were markedly elevated at the time point of 18 h after onset: cTnI 13.9 ug/L↑, CK 613 U/L↑, CK-MB 102 U/L↑, AST 112 U/L↑, and LDH 833 U/L↑. Due to the acute ECG changes and elevated myocardial injury markers, the patient was preliminarily diagnosed as ST-segment elevation myocardial infarction (STEMI) and underwent coronary angiography, which showed no stenosis, occlusion or dissection of coronary arteries (Figure 1). Echocardiography showed enlarged left atrial dimension (LAD, 55 mm) and left ventricular end diastolic dimension (LVDd, 57 mm), and reduced ejection fraction (EF, 33%). The patient was treated for STEMI and HF, and was started on aspirin, statin, diuretic of furosemide and spirolactone, metoprolol, and Sacubitril/valsartan (SV, initiated June, 2020). The patient was strictly adherent to the medication prescribed (Table 1). Figure 1 Open in figure viewerPowerPoint Coronary angiogram demonstrating no significant obstruction in coronary artery circulation. Table 1. Echocardiography results 2020-06-22 2020-09-02 2021-03-29 2021-06-02 2021-09-01 2021-10-22 2021-12-21 LAD (mm) 55 55 46 52 47 44 41 LVDd (mm) 57 57 53 55 54 51 55 IVS (mm) 10 10 11 10 10 10 11 LVPW (mm) 11 11 11 10 11 9 10 EF (%) 33 30 31 39 47 49 52.5 EF, ejection fraction; IVS, interventricular septum; LAD, left atrium dimension; LVDd, left ventricular end diastolic dimension; LVPW, left ventricular posterior wall. However, the patient's condition was not improved despite optimized medication. On 26 January 2021, the patient was re-admitted with recurrent chest distress and oedema, with new symptoms of facial plethora, centripetal obesity, and hyperglycaemia (Figure S1). Abdominal CT scan showed a right adrenal adenoma (Figure 2). Cardiac magnetic resonance imaging revealed enlarged LVDd (62 mm), and reduced EF, with delayed myocardial enhancement and evidence of myocardial fibrosis and fatty deposits (Figure 3). Laboratory findings showed hypokalaemia: potassium 3.0 mmol/L, elevated serum cortisol level, low plasma ACTH level, and positive 1-mg overnight dexamethasone suppression test. Based on the above findings, the patient was diagnosed with Cushing's syndrome and started treatment with the glucocorticoid receptor inhibitor mifepristone on 5 February 2021. Figure 2 Open in figure viewerPowerPoint Abdominal CT scan showed adrenal adenoma at the right. Figure 3 Open in figure viewerPowerPoint Cardiac magnetic resonance imaging revealed enlarged LVDd, reduced EF, with delayed myocardial enhancement, evidence of myocardial fibrosis and fatty deposits. With mifepristone added to the previous medical therapy (aspirin, statin, sacubitril/valsartan, metoprolol and diuretic of furosemide and spirolactone, and mifepristone), the patient's condition and cardiac function improved, and echocardiography (21 December 2021) showed increased EF (52.5%). The patient underwent partial adrenalectomy on 22 December 2021. Postoperative pathology confirmed adrenal cortical adenoma. At last follow-up on 29 May 2023, the patient showed marked improvement in face and body shape, with no complaints of chest distress or oedema (Figure S2). Discussion In this case, the patient was first evaluated for STEMI due to her symptoms of chest pain, and the elevated ST-segment on ECG, along with the moderately elevated troponin I and other cardiac enzyme levels. However, coronary atherosclerotic heart disease was ruled out by the normal cardiac catheterization. We presume that a possible reason for acute myocardial infarction (AMI) might be vasospastic angina due to abnormal hormone levels with Cushing's syndrome, leading to increased excessive myocardial metabolic demand and relative myocardial hypoxia, which eventually induced myocardial infarction. Although coronary atherosclerotic heart disease is the main cause of AMI, many non-atherosclerotic processes can lead to an imbalance between decreased coronary blood flow and increased myocardial metabolic demand. To date, non-atherosclerotic myocardial infarction has rarely been reported in Cushing's syndrome patients. Vieira JT et al. reported that a patient with Cushing's disease was considered to have spontaneous coronary artery dissection, which is a rare reason for AMI.2 Cushing's syndrome is associated with an increased risk of cardiac failure,3 with both structural alterations and functional impairment. In our case, the patient's CMR imaging showed typical features of cardiac geometry, function, and fibrosis, in accordance with previous reports.4 The underlying mechanisms may be the enhanced responsiveness to angiotensin II and activation of the mineralocorticoid receptor in direct response to cortisol excess.5 Our patient responded well to the therapy of conventional anti-HF medication of sacubitril/valsartan, metoprolol, and diuretic, once mifepristone was added. This favourable response to the pharmacological regimen supports the benefits of the agents for the normalization of excess cortisol. This case indicates that early diagnosis and effective treatment of Cushing's syndrome may be crucial in preventing irreversible cardiac dysfunction secondary to cardiovascular events and heart failure. Acknowledgements This work was financially supported by the National Natural Science Foundation of China (81900409 and 82172182) and the PLA Youth Training Project for Medical Science (19QNP037). Conflict of interest The authors declares that there is no conflict of interest. From https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14548

Abstract Gastrointestinal perforation is a well-addressed complication of exogenous hypercortisolism; however, patients with endogenous Cushing's syndrome (CS) do not usually experience this condition in clinical practice. The literature on this subject is limited and consists solely of clinical case reports/series with only 23 instances of gastrointestinal perforation occurring in individuals with endogenous Cushing's syndrome. This is mainly attributed to the rarity of Cushing's syndrome itself and the low chance of occurrence of such complications. We report a case of a recently diagnosed adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome in a 30-years-old female who presented initially with a three-month history of progressive weight gain, generalized weakness, acne, menstrual irregularity, and severe hypokalemia, and then developed a gastric ulcer perforation only one month after her ACTH-dependent Cushing's syndrome diagnosis and was managed through emergent surgery. Introduction A disorder of the endocrine system characterized by excessive cortisol production, known as Cushing's syndrome, rarely occurs. The main causes are pituitary tumors, ectopic adrenocorticotropic hormone (ACTH)-secreting tumors, or adrenal tumors that secrete cortisol independently [1]. Patients initially present with a wide range of symptoms, including weight gain, proximal myopathy, skin thinning, and abdominal striae [1]. Additionally, several metabolic disorders, such as diabetes mellitus, hypertension, and dyslipidemia, can occur, especially when the diagnosis is not established at an early stage [2]. There is a possibility of gastrointestinal complications among patients receiving exogenous glucocorticoids. However, there is limited information on gastrointestinal complications associated with endogenous hypercortisolemia [3,4]. Thus far, only 23 instances have been published addressing the co-occurrence of gastrointestinal perforation with endogenous Cushing's syndrome [5-17]. To the best of our knowledge, this is the first case reporting gastric perforation in an ACTH-dependent Cushing's syndrome, while the vast majority reported diverticular, sigmoid, or duodenal perforation with Cushing's syndrome [5-17]. Herein, we describe the medical history, physical examination, and investigatory findings of a 30-year-old female with a recent diagnosis of ACTH-dependent Cushing's syndrome that was complicated by gastric ulcer perforation, necessitating an urgent exploratory laparotomy. The primary motivator of this case report was the rarity of the described condition, the atypical location of the perforation in such patient group, and the relatively young age of the patient. Case Presentation History and examination A 30-year-old female with a history of mental retardation was admitted to our emergency department (ER) with progressive weakness and fatigue. Upon taking the history, she had been having menstrual irregularities, progressive weight gain, and generalized weakness, which was significant enough to limit her physical activity and hinder her movement for the past three months. Initial vital signs showed that the patient had a body temperature of 37°C, a pulse rate of 90 beats per minute, and a blood pressure of 130/80 mmHg. On physical examination, the patient had a moon face with supraclavicular fullness, dorsocervical fat pad, purple abdominal striae, facial signs of hirsutism, and acne all over the face, shoulders, chest, and back. Investigations In the initial laboratory examination, hypokalemia of 2.1 mEq/L, hyperglycemia of 12.1 mmol/L, and metabolic alkalosis were detected (Table 1). The cortisol level after 1 mg dexamethasone suppression test was 2204 nmol/L (normal range 140-690), ACTH 123 pg/mL (normal range 7.2-63.3), DHEA-S 27.85 umol/L (normal range 2.6-13.9), And 24-hour urine cortisol level was 1560 mg/day (normal range 30-350) (Table 1). No suppression was observed in cortisol level with 8 mg dexamethasone suppression test. Parameter Initial presentation Perforation presentation Refrence range Na+ 143 mEq/L 139 mmol/L 135-147 mEq/L Cl- 85 mEq/L 105 mmol/L 98-108 mEq/L K+ 2.1 mEq/L 2.8 mmol/L 3.5-5.0 mEq/L Mg2+ 0.79 mmol/L 0.77 mmol/L 0.85-1.110 mmol/L PO3- 0.88 mmol/L 1.23 mmol/L 0.97-1.46 mmol/L PH 7.54 7.36 7.35-7.45 PCO2 67.5 mmHg 42.7 mmHg 35-45 mmHg PO2 27.7 mmHg 62.2 mmHg 75-100 mmHg HCO3 49.8 mEq/L 23.6 mEq/L 22-26 mEq/L Random blood glucose 12.1 mmol/L 24.1 mmol/L <5.5 mmol/L Hemoglobin 13.5 g/dL 14.9 g/dL 13.7-16.8 g/dL White blood cells 9,720 /uL 11,100 /uL 3,300-8,600 /uL Lymphocyte 0.48% 0.33% - Neutrophil 8.55% 9.66% - Eosinophil 0.0% 0.0% - TSH 0.55 mIU/L Was not ordered 0.4-4.0 mIU/L Cortisol 2204 nmol/L 4842 nmol/L 140-690 nmol/L ACTH 123 pg/mL Was not ordered 7.2-63.3 pg/mL Table 1: Laboratory findings on initial presentation and on perforation day TSH - thyroid stimulating hormone; ACTH - adrenocorticotropic hormone A series of CT scans for the neck, chest, abdomen, and pelvis was performed and failed to localize any tumors acting as an ectopic source. A pituitary MRI was performed, and no adenoma was found. To complete the diagnostic workup, we decided to do an inferior petrosal sinus sampling (IPSS) and PET scan with Gallium 68; however, the patient's family refused and requested discharge and outpatient follow-ups. These results, together with the biochemical and clinical findings, supported the diagnostic hypothesis of ACTH-dependent Cushing's syndrome. Treatment/management When addressing the issue of hypokalemia that the patient presented with initially, it was found to be resistant and difficult to correct. The patient was put on spironolactone 50 mg BID, and potassium chloride 20 mEq q8h, and her potassium level barely reached 3.5 mmol/L after several days. In addition, her magnesium level was corrected with magnesium oxide 800 mg every six hours. Her blood glucose level was controlled with insulin glargine 6 units daily and Novorapid as per the sliding scale. The patient was discharged on spironolactone tablets 50 mg BID (oral), potassium chloride 20 mEq q8h, cholecalciferol, calcium carbonate, insulin glargine 6 units daily, and Novorapid 4 units TID before meals. Follow-up and outcomes Seven days after discharge, she presented to the ER complaining of a new onset of abdominal pain, constipation, and reduced urine output. Her Glasgow Coma Scale (GCS) was 15, her blood pressure measurement was 146/90 mmHg, her pulse rate was 66 beats per minute, her respiratory rate was 21 breaths per minute, and her temperature was 36.7°C. Upon physical examination, the patient had distended non-tender abdomen without any other significant findings. Blood work was done, including renal functions, and all parameters, including potassium, were within normal limits. A chest X-ray was also performed and revealed no evidence of pneumoperitoneum. The patient was clinically stable after managing her abdominal pain with acetaminophen injection and administering fleet enema for constipation. After instructions on when to come again to the ER were given, the patient was discharged home on lactulose and paracetamol, and a close outpatient follow-up appointment was scheduled. Five days after the ER visit, the patient presented again to the ER. She was still complaining of severe non-resolving abdominal pain, constipation, and reduced urine output. Upon physical examination in the ER, the patient was found to have developed a new onset of lower limb edema, abdominal rebound tenderness, and abdominal rigidity and guarding. She was hypotensive with a blood pressure of 91/46 mmHg, pulse rate of 80 beats per minute, respiratory rate of 16 breaths per minute, temperature of 38.2 °C, and SpO2 of 96%. The only significant laboratory finding was her potassium level dropping low to 2.8 mEq/L (Table 1). An X-ray of the chest was requested and showed a large pneumoperitoneum (Figure 1). Figure 1: Posteroanterior chest X-ray at the time of gastric perforation displaying severe air under the diaphragm with bilateral obstruction indicating massive pneumoperitoneum (red arrow) Abdominal CT was also urgently performed and confirmed the presence of gastric perforation likely related to an underlying perforated peptic ulcer with 0.8 cm defect at the distal greater curvature (Figures 2, 3). Figure 2: Coronal-section CT image of abdomen and pelvis at the time of gastric perforation showing features of gastric perforation likely related to the underlying perforated peptic ulcer with 0.8 cm defect at the distal greater curvature Figure 3: Horizontal-section CT image showing features of gastric perforation likely related to the underlying perforated peptic ulcer with 0.8 cm defect at the distal greater curvature The patient underwent an emergent gastric wedge resection for gastric perforation, and the pathology reported evidence of gastric ulcer with no evidence of malignancy. Furthermore, Helicobacter pylori test was performed on the sample, and it came back positive. The patient tolerated the surgery very well, and postoperative recovery was without any complications. Later, the patient was prescribed metyrapone 250 mg Q4h, which was then increased to 500 mg Q4h four days after surgery, and her cortisol level significantly dropped to 634nmol/L. During that time, a gastrin level test was also performed to exclude the presence of gastrinomas, and the level was 45 pg/ml (normal range 13-115). Discussion A small percentage of the population suffers from Cushing's syndrome, which is an endocrine disorder characterized by an endogenous overproduction of glucocorticoids, resulting in hypercortisolemia [1]. It is estimated to affect 0.7 to 2.4 people per million annually [1]. Hypercortisolemia alters psychologic, metabolic, and cardiovascular functions, resulting in increased mortality and morbidity rates, particularly if the diagnosis is delayed and long-term exposure to high cortisol levels occurs [2]. Women are more likely to suffer from this condition than men, and people in their 40s to 60s are most vulnerable to it [1]. Patients initially present with a wide range of symptoms, including weight gain, proximal myopathy, skin thinning, and abdominal striae [1]. Additionally, several metabolic disorders, such as diabetes mellitus, hypertension, and dyslipidemia, can occur [1]. Due to the rarity of this condition, there is often a significant delay in diagnosis and treatment, which could eventually lead to complications from prolonged hypercortisolism. From another standpoint, in a systematic review, the incidence of peptic ulcer perforation ranges from 3.8 to 14 per 100,000 individuals in the general population [18]. In under-developed countries, patients are typically young, tobacco-using males [19]. However, patients in industrialized countries are typically older with multiple co-morbidities and are on long-term non-steroidal anti-inflammatory drugs (NSAIDs) or steroid use [19]. Patients may present with an abrupt onset of abdominal discomfort, abdominal rigidity, and tachycardia in the early stages of a perforated peptic ulcer [19]. Later, abdominal distention, pyrexia, hypotension, fever, and vomiting can occur [19]. Furthermore, when the diagnosis is made early, a perforated ulcer often has a good prognosis. However, the risk of adverse events increases if there is a delay in the diagnosis [20]. Therefore, making an early detection through different imaging modalities is crucial [20]. A history of peptic ulcer disease, NSAIDs, physiological stress, smoking, corticosteroids, and Helicobacter pylori are some of the well-established risk factors for a perforated peptic ulcer [20]. The prevalence of Helicobacter pylori among Saudi patients is high; in one study, the overall prevalence was 46.5% in patients with dyspepsia using gastric biopsy [21]. Several studies have explored the relationship between Helicobacter pylori and gastrointestinal perforation, but the results have been mixed. Some studies have suggested a higher prevalence of Helicobacter pylori infection among individuals with gastrointestinal perforation compared to those without, indicating a potential association. However, other studies have found no significant difference in the prevalence of Helicobacter pylori infection between perforated and non-perforated gastrointestinal ulcer cases [22]. Furthermore, they suggested that the presence of other risk factors like the use of NSAIDs, smoking, and alcohol may interact with Helicobacter pylori infection and contribute to the development of complications such as gastrointestinal perforation [22]. However, in our case, the patient did not have any established risk factors for gastric perforation, such as NSAIDs, smoking, or alcohol. Therefore, considering the low incidence of gastrointestinal perforation and high prevalence of Helicobacter pylori, the conflicting data regarding the association between Helicobacter pylori and gastrointestinal perforation, and the lack of established risk factors for gastrointestinal perforation in our patient, we suggest that prolonged excess glucocorticoids from Cushing's syndrome may have contributed to the gastric perforation either independently or synergistically with Helicobacter pylori since hypercortisolism can lead to a weakened gastrointestinal wall integrity due to decreased collagen turnover and disruption of mucosal protection by prostacyclin [15]. In addition, because of hypercortisolism, perforation may not be contained or healed initially due to the immunosuppressive effects of hypercortisolism, whether endogenous or exogenous [15]. Additionally, high levels of cortisol may delay the diagnosis and treatment since it may mask the symptoms of the perforation [14]. Moreover, our patient was treated for severe hypokalemia with potassium supplementation for an extended period of time. Previous studies have linked potassium chloride supplementation to gastrointestinal ulceration and perforation, making this a possible additive cause of our patient's condition [23,24]. A limited number of studies have addressed gastrointestinal perforations associated with endogenous hypercortisolemia [5-17]. The correlation between Cushing's syndrome and gastrointestinal perforation is highlighted in our study and in the case reports that have been previously published (Table 2). Similar to our case, a female predominance was seen in gastrointestinal perforation among the reported cases of Cushing's syndrome [6,7,12,13,15,16]. Additionally, the average age at which gastrointestinal perforation occurred in patients with endogenous hypercortisolism ranged from 45 to 80, which is a noticeably higher age range than the case we are presenting here (aged 30) [6-10,12]. Furthermore, unlike our case, in which gastrointestinal perforation occurred four months after the onset of Cushing's symptoms, Intestinal perforation occurs approximately 9.8 months after Cushing's symptoms first appear [15]. Furthermore, in our patient, gastric perforation occurred while she was hypercortisolemic and not in a remission state. Hence, in association with Helicobacter pylori infection, severe hypercortisolemia could have been a secondary contributing factor to gastric perforation. The complications of gastric ulceration, specifically with endogenous Cushing's syndrome, have been addressed in two case reports [25,26]. It must be noted, however, that neither case is similar to ours. A case of gastric perforation was reported by Kubicka et al. in a patient who had a confirmed diagnosis of gastrinoma, and the patient was diagnosed with ectopic Cushing's syndrome seven months after gastric perforation [25]. Therefore, since ectopic Cushing's syndrome was diagnosed seven months after the perforation, it is more likely that the gastrinoma contributed to this complication. In contrast, our patient's serum gastrin level was within the normal range, ruling out gastrinoma. Further, Hoshino et al. reported a case of gastrointestinal bleeding in a 39-year-old man with a confirmed diagnosis of Cushing's disease secondary to pituitary adenoma [26]. He was found to have gastric ulceration and bleeding along with Helicobacter pylori infection and elevated cortisol levels [26]. In spite of the patient not developing a gastric perforation, it was suggested by the author that hypercortisolism might be a contributing factor for gastric ulcer complications by slowing down the ulcer healing process [26] Reference Year of publication Age, gender Highest cortisol level plasma cortisol (PC, nmol/L) / UFC (nmol/L) Cause of Cushing's syndrome Time from onset of Cushing's symptoms to perforation (months) Reported site of gastrointestinal perforation Current 2023 30, Female PC 4842 ACTH-dependant 4 Gastric perforation Ishinoda et al. [17] 2023 24, Male PC 1647 Cushing's disease 12 Sigmoid colon perforation Wijewickrama et al. [16] 2021 32, Female PC 1147 Pituitary microadenoma 1 Diverticular perforation Shahidi et al. [15] 2019 72, Female UFC 5296 Pancreatic neuroendocrine tumor 12 Diverticular perforation Shahidi et al. [15] 2019 61, Female PC 1925 Metastatic medullary carcinoma of thyroid 12 Sigmoid colon and diverticular perforation Shahidi et al. [15] 2019 68, Female UFC 410 Cushing's disease 12 Sigmoid colon perforation Shahidi et al. [15] 2019 71, Female UFC 1533 Cushing's disease 4 Diverticular perforation Shahidi et al. [15] 2019 54, Male UFC 374 Cushing's disease 3 Sigmoid colon perforation Shahidi et al. [15] 2019 52, Female UFC 885 Cushing's disease 16 Diverticular perforation Sater et al. [14] 2018 80, Female UFC 5601 Lung carcinoid 36 Diverticular perforation Sater et al. [14] 2018 60, Female UFC 72726 Metastatic islet cell carcinoma 36 Diverticular perforation Sater et al. [14] 2018 31, Male UFC 1297 Cushing's disease 20 Diverticular perforation Sater et al. [14] 2018 52, Female UFC 2371 Lung carcinoid 4 Diverticular perforation Sater et al. [14] 2018 67, Male UFC 3836 Ectopic ACTH 10 Diverticular perforation Sater et al. [14] 2018 51, Male UFC 13552 Metastatic thymic carcinoma 4 Diverticular perforation Kaya et al. [9] 2016 70, Male PC 1432 Small cell lung cancer 1 Diverticular perforation Dacruz et al. [12] 2016 60, Female UFC 4481 Metastatic parotid tumor 5 Sigmoid colon and diverticular perforation Matheny et al. [10] 2016 67, Male UFC 11119 Metastatic medullary carcinoma of thyroid 4 Diverticular perforation Flynn et al. [13] 2016 63, Female UFC 12465 Pheochromocytoma 1 Perforation at the splenic flexure Balestrieri et al. [11] 2016 75, Male PC 2272 Neuroendocrine tumor 1 Intestinal perforation Hara et al, [8] 2013 79, Male PC 1230 Cushing's disease 6 Diverticular perforation De Havenon et al. [7] 2011 71, Female PC 2593 Cushing's disease 9 Diverticular perforation Lutgers et al. [6] 2010 55, Female UFC 10152 Right pheochromocytoma 1 Sigmoid colon and diverticular perforation Drake et al. [5] 1998 35, Male PC 1442 Islet cell tumor 4 Duodenal perforation and rupture of pancreatic pseudocyst Table 2: Current case and previous reported 23 cases of patients with Cushing's syndrome and gastrointestinal perforation UFC - urinary free cortisol; PC - plasma cortisol; ACTH - adrenocorticotropic hormone Conclusions A high blood cortisol level can be associated with various clinical manifestations and diverse sets of complications. This case report sheds light on one of the less common complications of hypercortisolism in patients with Cushing's syndrome, which is gastrointestinal perforation. Our report further supports the published evidence that gastrointestinal perforation is a rare but potentially fatal complication among patients with Cushing's syndrome. Moreover, it highlights the possibility of developing gastric perforations in this patient group, even at younger ages than expected. This should elicit a high clinical suspicion and demand prompt investigation of Cushing's syndrome patients in a hypercortisolism state presenting with modest gastrointestinal symptoms. References Pivonello R, De Martino MC, De Leo M, Lombardi G, Colao A: Cushing's syndrome. Endocrinol Metab Clin North Am. 2008, 37:135-49. 10.1016/j.ecl.2007.10.010 Newell-Price J, Bertagna X, Grossman AB, Nieman LK: Cushing's syndrome. Lancet. 2006, 367:1605-17. 10.1016/S0140-6736(06)68699-6 Goethals L, Nieboer K, De Smet K, De Geeter E, Tabrizi NH, Van Eetvelde E, de Mey J: Cortisone associated diverticular perforation. JBR-BTR. 2011, 94:348-9. 10.5334/jbr-btr.705 Piekarek K, Israelsson LA: Perforated colonic diverticular disease: the importance of NSAIDs, opioids, corticosteroids, and calcium channel blockers. Int J Colorectal Dis. 2008, 23:1193-7. 10.1007/s00384-008-0555-4 Drake WM, Perry LA, Hinds CJ, Lowe DG, Reznek RH, Besser GM: Emergency and prolonged use of intravenous etomidate to control hypercortisolemia in a patient with Cushing's syndrome and peritonitis. J Clin Endocrinol Metab. 1998, 83:3542-4. 10.1210/jcem.83.10.5156 Lutgers HL, Vergragt J, Dong PV, de Vries J, Dullaart RP, van den Berg G, Ligtenberg JJ: Severe hypercortisolism: a medical emergency requiring urgent intervention. Crit Care Med. 2010, 38:1598-601. 10.1097/CCM.0b013e3181e47b7a de Havenon A, Ehrenkranz J: A perforated diverticulum in Cushing's disease. Int J Surg Case Rep. 2011, 2:215-7. 10.1016/j.ijscr.2011.06.009 Hara T, Akutsu H, Yamamoto T, Ishikawa E, Matsuda M, Matsumura A: Cushing's disease presenting with gastrointestinal perforation: a case report. Endocrinol Diabetes Metab Case Rep. 2013, 2013:130064. 10.1530/EDM-13-0064 Kaya T, Karacaer C, Açikgöz SB, Aydemir Y, Tamer A: Severe hypokalaemia, hypertension, and intestinal perforation in ectopic adrenocorticotropic hormone syndrome. J Clin Diagn Res. 2016, 10:OD09-11. 10.7860/JCDR/2016/17198.7127 Matheny LN, Wilson JR, Baum HB: Ectopic ACTH production leading to diagnosis of underlying medullary thyroid carcinoma. J Investig Med High Impact Case Rep. 2016, 4:2324709616643989. 10.1177/2324709616643989 Balestrieri A, Magnani E, Nuzzo F: Unusual Cushing's syndrome and hypercalcitoninaemia due to a small cell prostate carcinoma. Case Rep Endocrinol. 2016, 2016:6308058. 10.1155/2016/6308058 Dacruz T, Kalhan A, Rashid M, Obuobie K: An ectopic ACTH secreting metastatic parotid tumour. Case Rep Endocrinol. 2016, 2016:4852907. 10.1155/2016/4852907 Flynn E, Baqar S, Liu D, et al.: Bowel perforation complicating an ACTH-secreting phaeochromocytoma. Endocrinol Diabetes Metab Case Rep. 2016, 2016:10.1530/EDM-16-0061 Sater ZA, Jha S, McGlotten R, Hartley I, El Lakis M, Araque KA, Nieman LK: Diverticular perforation: A fatal complication to forestall in Cushing syndrome. J Clin Endocrinol Metab. 2018, 103:2811-4. 10.1210/jc.2018-00829 Shahidi M, Phillips RA, Chik CL: Intestinal perforation in ACTH-dependent Cushing's syndrome. Biomed Res Int. 2019, 2019:9721781. 10.1155/2019/9721781 Wijewickrama PS, Ratnasamy V, Somasundaram NP, Sumanatilleke M, Ambawatte SB: A challenging case of Cushing's disease complicated with multiple thrombotic phenomena following trans-sphenoidal surgery; a case report. BMC Endocr Disord. 2021, 21:29. 10.1186/s12902-021-00701-0 Ishinoda Y, Uto A, Meshino H, et al.: Bowel perforation associated with Cushing's disease: a case report with literature review. Endocr J. 2023, 70:933-9. 10.1507/endocrj.EJ23-0110 Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC: Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion. 2011, 84:102-13. 10.1159/000323958 Chung KT, Shelat VG: Perforated peptic ulcer - an update. World J Gastrointest Surg. 2017, 9:1-12. 10.4240/wjgs.v9.i1.1 Weledji EP: An overview of gastroduodenal perforation. Front Surg. 2020, 7:573901. 10.3389/fsurg.2020.573901 Akeel M, Elmakki E, Shehata A, Elhafey A, Aboshouk T, Ageely H, Mahfouz MS: Prevalence and factors associated with H. pylori infection in Saudi patients with dyspepsia. Electron Physician. 2018, 10:7279-86. 10.19082/7279 Thirupathaiah K, Jayapal L, Amaranathan A, Vijayakumar C, Goneppanavar M, Nelamangala Ramakrishnaiah VP: The association between Helicobacter pylori and perforated gastroduodenal ulcer. Cureus. 2020, 12:e7406. 10.7759/cureus.7406 Farquharson-Roberts MA, Giddings AE, Nunn AJ: Perforation of small bowel due to slow release potassium chloride (slow-K). Br Med J. 1975, 3:206. 10.1136/bmj.3.5977.206 Payan H, Blaustein A: Potassium chloride and small bowel perforation. Gastroenterology. 1965, 48:877-8. 10.1016/S0016-5085(65)80073-7 Kubicka E, Zawadzka K, Syrycka J, Kałużny M, Pawluś A, Bolanowski M: A case of gastrinoma associated with ectopic Cushing syndrome. Pol Arch Intern Med. 2020, 130:328-9. 10.20452/pamw.15201 Hoshino C, Satoh N, Narita M, Kikuchi A, Inoue M: Another 'Cushing ulcer'. BMJ Case Rep. 2011, 2011:10.1136/bcr.02.2011.3888 From https://www.cureus.com/articles/196132-adrenocorticotropic-hormone-dependent-cushings-syndrome-complicated-with-gastric-ulcer-perforation-in-a-30-year-old-saudi-female-a-case-report-and-a-review-of-the-literature#!/

Abstract Objective Since Cushing's disease (CD) is less common in the paediatric age group than in adults, data on this subject are relatively limited in children. Herein, we aim to share the clinical, diagnostic and therapeutic features of paediatric CD cases. Design National, multicenter and retrospective study. Patients All centres were asked to complete a form including questions regarding initial complaints, physical examination findings, diagnostic tests, treatment modalities and follow-up data of the children with CD between December 2015 and March 2017. Measurements Diagnostic tests of CD and tumour size. Results Thirty-four patients (M:F = 16:18) from 15 tertiary centres were enrolled. The most frequent complaint and physical examination finding were rapid weight gain, and round face with plethora, respectively. Late-night serum cortisol level was the most sensitive test for the diagnosis of hypercortisolism and morning adrenocorticotropic hormone (ACTH) level to demonstrate the pituitary origin (100% and 96.8%, respectively). Adenoma was detected on magnetic resonance imaging (MRI) in 70.5% of the patients. Transsphenoidal adenomectomy (TSA) was the most preferred treatment (78.1%). At follow-up, 6 (24%) of the patients who underwent TSA were reoperated due to recurrence or surgical failure. Conclusions Herein, national data of the clinical experience on paediatric CD have been presented. Our findings highlight that presenting complaints may be subtle in children, the sensitivities of the diagnostic tests are very variable and require a careful interpretation, and MRI fails to detect adenoma in approximately one-third of cases. Finally, clinicians should be aware of the recurrence of the disease during the follow-up after surgery. From https://onlinelibrary.wiley.com/doi/10.1111/cen.14980

Abstract Cushing’s syndrome is a condition leading to overproducing of cortisol by the adrenal glands. If the pituitary gland overproduces cortisol, it is called Cushing’s disease. Cushing’s syndrome and even Cushing’s disease during and after pregnancy are rare events. There is not enough literature and guidance for managing and treating these patients. The diagnosis of Cushing’s syndrome in pregnancy is often delayed because the symptoms overlap. We presented a thin 31-year-old woman, admitted 2 months after a normal-term delivery, with an atypical presentation of Cushing’s disease, unusual clinical features, and a challenging clinical course. She had no clinical discriminatory features of Cushing’s syndrome. Given that the patient only presented with psychosis and proximal myopathy and had an uncomplicated pregnancy, our case was considered unusual. The patients also had hyperpigmentation and severe muscle weakness which are among the less common presentations of Cushing’s syndrome. Our findings suggest that an early diagnosis of Cushing’s disease is important in pregnancy period for its prevalent fetal and maternal complications, and it should be treated early to optimize fetal and maternal outcomes as there is an increasing trend toward live births in treated participants. Introduction Cushing’s syndrome is a condition that originates from excessive production of glucocorticoids. The condition is most common in women of childbearing age and is characterized by altered distribution of the adipose tissue to the central and upper regions of the trunk (central obesity and buffalo hump), face (moon face), capillary wall integrity (easy bruising), hyperglycemia, hypertension, mental status changes and psychiatric symptoms, muscle weakness, signs associated with hyperandrogenism (acne and hirsutism), and violaceous striae among other signs. Hypercortisolism and hyperandrogenism suppress the production of the pituitary gonadotropins, which in turn leads to menstrual irregularities and infertility.1-3 Moreover, the main common cause of developing Cushing’s syndrome is the use of exogenic steroid.3 Cushing’s disease is a form of Cushing’s syndrome with overproduction of adrenocorticotropic hormone (ACTH) due to pituitary adenoma. The diagnosis is made using clinical features and paraclinical tests including urinary free cortisol (UFC), serum ACTH, dexamethasone suppression tests (DSTs), pituitary magnetic resonance imaging (MRI), and sometimes by inferior petrosal sinus sampling (IPSS).4 Although women with Cushing’s disease are less likely to become pregnant, timely diagnosis and appropriate management are especially important during possible pregnancy, preventing neonatal and maternal complications and death. The diagnosis is challenging due to the overlap of the disease symptoms with the changes associated with a normal pregnancy. Moreover, the hormonal milieu during pregnancy has recently been proposed as a potential trigger for Cushing’s disease in some cases; hence, the term “pregnancy-associated Cushing’s disease” has been used for the disease in the recent literature. In this study, we presented a thin 31-year-old woman who was referred to our clinic 2 months after a normal delivery, with an atypical presentation of Cushing’s disease, unusual clinical features, and a challenging clinical course. Case Presentation Our patient was a 31-year-old woman who presented 2 months after the delivery of her second child. She had a history of type 2 diabetes mellitus and hypertension in the past 2 years prior to her presentation. She had been admitted to another center following an episode of falling and muscle weakness. Two weeks later, she was admitted to our center with an impression of pulmonary thromboembolism due to tachypnea, tachycardia, and dyspnea. During follow-up, she was found to have leukocytosis, hyperglycemia (random blood sugar: 415 mg/d; normal level: up to 180 mg/dL) and hypokalemic metabolic alkalosis (PH: 7.5, HCO3 [bicarbonate]: 44.7 mEq/L, paO2 [partial pressure of oxygen]: 73 mm Hg, pCO2: 51.7 mm Hg, potassium: 2.7 mEq/L [normal range: 3.5-5.1 mEq/L]), which was refractory to the treatment; therefore, an endocrinology consultation was first requested. On physical examination, the patient was agitated, confused, and psychotic. Her vital signs were: blood pressure 155/100 mm Hg, heart rate: 130 bpm, and respiratory rate: 22 bpm, temperature: 39°C. As it has shown in Figure 1A, her face is not typical for moon face of Cushing’s syndrome, but facial hirsutism (Figure 1A) and generalized hyperpigmentation is obvious (Figure 1A-C). She was a thin lady and had a normal weight and distribution of adiposity (Body Mass Index [BMI] = 16.4 kg/m2; weight: 40 kg, and height: 156 cm). Aside from thinness of skin, she did not have the cutaneous features of Cushing’s syndrome (e.g. purpura, acne, and violaceous striae) and did not have supraclavicular and dorsocervical fat pad (buffalo hump), or plethora. In other words, she had no clinical discriminatory features of Cushing’s syndrome despite the high levels of cortisol, as confirmed by severely elevated UFC (5000 μg/24 h and 8000 μg/24 h; normal level: 4-40 μg/24 h). In addition, as will be mentioned later, the patient had axonal neuropathy which is a very rare finding in Cushing’s syndrome. Figure 1. Clinical finding of our case with Cushing’s disease. (A) Hirsutism, (B) muscle atrophy seen in proximal portion of lower limbs, and (C) hyperpigmentation specially on the skin of the abdominal region. OPEN IN VIEWER She had a markedly diminished proximal muscle force of 1 out of 5 across all extremities; the rest of the physical examinations revealed no significant abnormalities (Figure 1B). On the contrary, based on her muscle weakness, hirsutism, psychosis and hyperpigmentation and refractory hypokalemic alkalosis, hyperglycemia, and hypertension, Cushing’s syndrome was suspected; therefore, 24-hour UFC level was checked that the results showed a severely elevated urinary cortisol (5000 μg/24 h and 8000 μg/24 h; normal level: 4-40 μg/24 h). Serum ACTH level was also inappropriately elevated (45 pg/mL; normal range: 10-60 pg/mL). High-dose dexamethasone failed to suppress plasma cortisol level and 24-hour urine cortisol level. A subsequent pituitary MRI showed an 8-mm pituitary mass, making a diagnosis of Cushing’s disease more probable. Meanwhile, the patient was suffering from severe muscle weakness that did not improve after the correction of hypokalemia. Then, a neurology consultation was requested. The neurology team evaluated laboratory data as well as EMG (Electromyography) and NCV (Nerve Conduction Velocity) of the patient, and based on their findings, “axonal neuropathy” was diagnosed for her weakness; so they ruled out the other neuromuscular diseases. A 5-day course of intravenous immunoglobulin (IVIG) was started for her neuropathy; however, the treatment did not improve her symptoms and the patient developed fungal sepsis and septic shock. Therefore, she was processed with broad-spectrum antibiotics and antifungal agents and recovered from the infection. Mitotane was started for the patient before definitive surgical treatment to suppress hormonal production due to her poor general condition. Despite the 8-mm size of the pituitary mass which is likely to be a source of ACTH, our patient was underweight and showed the atypical clinical presentation of Cushing’s disease, making us suspect an ectopic source for the ACTH. Therefore, a Gallium dotatate scan was performed to find any probable ectopic sources; however, the results were unremarkable. The patient underwent Trans-Sphenoidal Surgery (TSS) to resect the pituitary adenoma because it was not possible to perform IPSS in our center. Finally, the patient’s condition including electrolyte imbalance, muscle weakness, blood pressure, and hyperglycemia started to improve significantly. The pathologist confirmed the diagnosis of a corticotropic adenoma. Nevertheless, the patient suddenly died while having her meal a week after her surgery; most likely due to a thromboembolic event causing a cardiac accident. Discussion Our patient was significantly different from other patients with Cushing’s disease because of her atypical phenotype. She was unexpectedly thin and had psychosis, hyperpigmentation, proximal myopathy, axonal neuropathy and no clinical discriminatory features of Cushing’s syndrome such as central adiposity, dorsocervical or supraclavicular fat pad, plethora or striae. She had also a history of type 2 diabetes and hypertension 2 years before her admission. The patient was diagnosed with Cushing’s later. From what was presented, the patient did not know she had Cushing’s until after her delivery and despite the highly elevated UFC, and she completed a normal-term delivery. Given that she only presented with psychosis and proximal myopathy, her pregnancy was considered unusual. Her clinical features such as hyperpigmentation and severe muscle weakness are among less common presentations.5 11β-hydroxysteroid dehydrogenase type 1 (11-βHSD1) is an enzyme responsible for converting cortisone (inactive glucocorticoid) into cortisol (active). It is speculated that this enzyme has a role in obesity (Figure 2).6,7 Figure 2. The enzymatic actions of 11β-hydroxysteroid dehydrogenase on its substrate interconverting inactive and active glucocorticoid. OPEN IN VIEWER In a case reported by Tomlinson, a 20-year-old female was diagnosed with Cushing’s disease despite not having the classical features of the disease. It has been suggested that the mechanism is a partial defect in 11β-HSD1 activity and concomitant increase in cortisol clearance rate. Thus, the patient did not have a classic phenotype; the defect in the conversion of cortisone to cortisol rises cortisol clearance and protects the patient from the effects of cortisol excess. This observation may help explain individual susceptibility to the side effects of glucocorticoids.6 Further studies of Tomlinson et al showed that a deficit in the function of (and not a mutation related to) 11β-HSD2 might have been responsible for the absence of typical Cushing’s symptoms. 11-HSD2 keeps safe the mineralocorticoid receptor from excess cortisol. Mutation in the HSD11B2 gene explains an inherited form of hypertension, apparent mineralocorticoid excess syndrome, in which Cushing’s disease results in cortisol-mediated mineralocorticoid excess affecting the kidney and leads to both hypokalemia and hypertension.8 It is frequent in Cushing’s syndrome that the patients usually have no mineralocorticoid hypertension; however, it is still proposed that a defect in 11β-HSD1 can be responsible for the presence of mineralocorticoid hypertension in a subgroup of patients. In fact, 11β-HSD1 is expressed in several tissues like the liver, kidneys, placenta, fatty tissues and gonads,9 meaning that this enzyme may potentially affect the results of cortisol excess in Cushing’s syndrome/disease. Abnormality in the function of this enzyme could explain the absence of the symptoms like central obesity, easy bruising, and typical striae during Cushing’s disease. Several factors affect the action of glucocorticoids. In this regard, the impact of the different types and levels of impairment in glucocorticoid receptors have been highlighted in some studies, as it can lead to different levels of response to glucocorticoids10 as well as a variety in the symptoms observed in Cushing’s disease. The predominant reaction of the NADP(H)-dependent enzyme 11-Tukey’s honestly significant difference (HSD)1 happens through the catalysis of the conversion of inactive cortisol into receptor-active cortisol. The reverse reaction is mediated through the unidirectional NAD-dependent 11-HSD type 2 (Figure 2).11 In another case reported by Ved V. Gossein, a 41-year-old female was evaluated for hirsutism and irregular menstrual cycles. Her BMI was 22.6 kg/m2. The patient had no signs or symptoms of overnight recurrent Cushing’s syndrome, the 48-hour DST failed to suppress cortisol levels, and 24-hour urinary cortisol levels were persistently elevated on multiple occasions. Adrenocorticotropic hormone levels were unreasonably normal, suggesting ACTH-dependent hypercortisolism. Despite these disorders, she had 2 children. Magnetic resonance imaging (MRI) of the pituitary did not show any abnormalities. Moreover, abdominal MRI did not show adrenal mass or enlargement. Genetic testing to determine glucocorticoid resistance syndrome showed no mutation.12 Primary generalized glucocorticoid resistance is a rare genetic disorder characterized by generalized or partial insensitivity of target tissues to glucocorticoids.13-17 There is a compensatory increase in hypothalamic-pituitary activity due to decreased sensitivity of peripheral tissues to glucocorticoids systems.13-17 Excessive ACTH secretion leads to high secretion of cortisol and mineralocorticoids and/or androgens. However, the clinical features of Cushing’s syndrome do not develop after resistance to the effects of cortisol. Generalized glucocorticoid resistance is a rare condition characterized by high cortisol levels but no scarring of Cushing’s syndrome.18 An important aspect of our case was her pregnancy. Our patient had a history of hypertension and diabetes type 2, 2 years before her presentation to our center that could be because of an undiagnosed Cushing’s disease. The patient’s pregnancy terminated 2 months prior the admission and she had a normal vaginal delivery. So, we suspect that she become pregnant while involved with the disease. Aside from focusing on how this can happen in a patient with such high levels of glucocorticoids, more attention should be paid to occurring pregnancy in the background of Cushing’s disease. In fact, up to 250 patients were reported, of which less than 100 were actively treated.19-22 Cushing’s disease is associated with serious complications in up to 70% of the cases coinciding with pregnancy.21 The most frequent maternal complications reported in the literature are hypertension and impaired glucose tolerance, followed by preeclampsia, osteoporosis, severe psychiatric complications, and maternal death (in about 2% of the cases). Prematurity and intrauterine growth retardation account for the most prevalent fetal complications. Stillbirth, intrauterine deaths, intrauterine hemorrhage, and hypoadrenalism have also been reported.23 Early diagnosis is especially challenging during pregnancy because of many clinical and biochemical shared features of the 2 conditions.23,24 These features include an increase in ACTH production, corticosteroid-binding globulin (CBG) 1 level, level of cortisol (urinary, plasma and free), hyperglycemia, weight gain, and an increased chance for occurrence of bruising, hypertension (mistaken with preeclampsia), gestational diabetes mellitus, weight gain, and mood swings.3 There are some suggestions proposed in the studies that help in screening and differentiation of Cushing’s from the normal and abnormal effects of pregnancy and Cushing’s disease from Cushing’s syndrome in suspected pregnant patients. Contrary to Cushing’s syndrome, the nocturnal minimum level of cortisol is preserved in pregnancy.23,25 There is not yet a diagnostic cut-off determined on mentioned level; however, a few studies elucidate the evaluation of hypercortisolemia in a pregnant patient.26-28 Urinary free cortisol, a measure that reflects the amount of free cortisol in circulation, normally increases during pregnancy, and it can increase up to 8 times the normal level with Cushing’s disease during the second and the third trimesters,23,29 which is a useful tool to evaluate cortisol levels in a suspected pregnant woman. Because the suppression of both UFC and plasma cortisol is decreased in pregnancy,23,30 a low-dose DST is not very helpful for screening Cushing’s disease in pregnant patients. However, a high-dose DST with a <80% cortisol suppression might only indicate Cushing’s disease.3,31 Thus, it helps differentiating between ectopic ACTH syndrome and Cushing’s disease.32 The use of high-dose DST can distinguish between adrenal and pituitary sources of CS in pregnancy. Owing to the limited evidence available and the lack of data on normal pregnancies, the use of corticotropin-releasing hormone (CRH), desmopressin, and high-dose DST in pregnancy is not recommended yet.33 More timely diagnosis as well as timely intervention may have saved the life of our patient. To differentiate between ectopic ACTH syndrome and Cushing’s disease, adrenal imaging should be considered. For higher plasma levels, combined employment of CRH stimulation test and an 8-mg DST can be helpful.3 Bilateral inferior petrosal sinus sampling (B-IPSS) might be needed when the findings are not in accordance with other results, but it is recommended to perform B-IPSS only if the noninvasive studies are inconclusive and only if there is enough expertise, experience, and technique for its performance.3 Although axonal neuropathy has been reported as a rare syndrome associated with paraneoplastic ectopic Cushing’s syndrome and exogenous Cushing’s syndrome, its association with Cushing’s disease has not been reported.5,32 Our patient had severe muscle weakness that we initially attributed it to myopathy and hypokalemia associated with Cushing’s syndrome. In our study, the diagnosis of axonal neuropathy was made based on electrophysiological studies by a neurology consultant and then IVIG was administered; however, the patient’s weakness did not improve after this treatment. The co-occurrence of Guillain-Barré syndrome which may also be classified as axonal neuropathy has also been reported in a pregnant woman with ectopic Cushing’s syndrome.34,35 Whether this finding is coincidental or the result of complex immune reactions driven by Cushing’s disease, or the direct effect of steroids, these results cannot be deduced from current data.36 Some data suggest that the fluctuations and inferior petrosal sinus sampling may trigger the flare of autoimmune processes, specifically when the cortisol levels start to decline during the course of Cushing’s syndrome.35,8 Also, due to COVID-19 pandemic affecting vital organs like kidney, paying attention to COVID-19 is suggested.37-40 Conclusions We presented a thin young female with psychosis, proximal myopathy, and axonal neuropathy with Cushing’s disease who had a recent pregnancy that was terminated without any fetal or maternal complications despite the repeated elevated serum cortisol and 24-hour UFC; therefore, we suggest that she might have glucocorticoid resistance. Glucocorticoid resistance is a rare disease in which the majority, but not all, of patients have a genetic mutation in the hGR-NR3C1 gene. As we did not perform genetic testing for our patient, the data are lacking. Another clue to the absence of the classic Cushing’s disease phenotype in our case is the role of isoenzymes of 11-HSD1 and 11-HSD2. Other mechanisms, such as the defect somewhere in the glucocorticoid pathway of action such as a decreased number of receptors, a reduction in ligand affinity, or a postreceptor defect, play an important role in nonclassical clinical manifestations of Cushing’s syndrome. Acknowledgments The authors thank the patient for allowing us to publish this case report. The authors show their gratitude to the of the staff of the Rasool Akram Medical Complex Clinical Research Development Center (RCRDC) specially Mrs. Farahnaz Nikkhah for its technical and editorial assists. Ethics Approval Our institution does not require ethical approval for reporting individual cases or case series. Informed Consent Written informed consent was obtained from the patient and for her anonymized information to be published in this article. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References 1. Guilhaume B, Sanson ML, Billaud L, Bertagna X, Laudat MH, Luton JP. Cushing’s syndrome and pregnancy: aetiologies and prognosis in twenty-two patients. Eur J Med. 1992; 1(2):83-89. GO TO REFERENCE PubMed Google Scholar 2. Lin W, Huang HB, Wen JP, et al. Approach to Cushing’s syndrome in pregnancy: two cases of Cushing’s syndrome in pregnancy and a review of the literature. Ann Transl Med. 2019; 7(18):490. 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Abstract Cushing’s disease is a rare neuroendocrine disorder with excessive endogenous cortisol, impaired cognition, and psychiatric symptoms. Evidence from resting-state fMRI revealed the abnormalities of static brain connectivity in patients with Cushing’s disease (CD patients). However, it is unknown whether the CD patients’ dynamic functional connectivity would be abnormal and whether the dynamic features are associated with deficits in cognition and psychopathological symptoms. Here, we evaluated 50 patients with Cushing’s disease and 57 healthy participants by using resting-state fMRI and dynamic functional connectivity (dFNC) approach. We focused on the dynamic features of default mode network (DMN), salience network (SN), and central executive network (CEN) because these are binding sites for the cognitive-affective process, as well as vital in understanding the pathophysiology of psychiatric disorders. The dFNC was further clustered into four states by k-mean clustering. CD patients showed more dwell time in State 1 but less time in State 4. Intriguingly, group differences in dwell time in these two states can explain the cognitive deficits of CD patients. Moreover, the inter-network connections between DMN and SN and the engagement time in State 4 negatively correlated with anxiety and depression but positively correlated with cognitive performance. Finally, the classifier trained by the dynamic features of these networks successfully classified CD patients from healthy participants. Together, our study revealed the dynamic features of CD patients’ brains and found their associations with impaired cognition and emotional symptoms, which may open new avenues for understanding the cognitive and affective deficits induced by Cushing’s disease. Introduction Cushing’s disease is characterized by excess endogenous cortisol secretion [1] and served as a unique and natural model for investigating the effects of elevated endogenous cortisol levels on brain functions and structure [2]. It is also a good model for unraveling the linkage between stress-related brain dysfunctions and psychiatric symptoms [3]. Long-term exposure to hypercortisolism negatively affects patients’ physical and mental health, such as depression, anxiety, and psychosis [1, 4], as well as shows deleterious effects on cognitive function including impaired executive function, working memory, and attention [5,6,7]. Research progress on Cushing’s disease, which depends on static resting-state fMRI, revealed that patients with Cushing’s disease showed increased functional connectivity between the default mode network (DMN) and left lateral occipital cortex [2], and hippocampus [8]. Cortisol increase would induce connectivity changes within the DMN and salience network (SN) [9], and the DMN’s activity correlated with the morning cortisol level of patients with Cushing’s disease [10]. Despite these advances leading to an improved understanding of Cushing’s disease, it remains enigmatic how the abnormal brain connectivity within large-scale networks and how the different brain networks interact would contribute to the deficits in impaired cognitive function, as well as psychopathological symptoms. Furthermore, recent years have witnessed an increasing number of studies providing solid evidence that the brain is a dynamic system rather than a static one on a micro-time scale [11, 12]. Dynamic functional connectivity (dFNC), which is implemented by the sliding window method [13], is an ideal approach to characterize the dynamic nature of brain [11], as well as detect and predict diseases [14, 15]. However, to our knowledge, no studies have ever investigated dynamic brain functional connectivity for patients with CD. We focus here on dynamic functional connectivity and emphasize the role of default mode network (DMN), salience network (SN), and central executive network (CEN). These large-scale neurocognitive networks are critical for cognitive and affective processing [16] and are highly related to stress and cortisol level. Deficits or abnormal connectivity within these three networks are associated with a wide range of stress-related psychiatric disorders [17], as well as the high level of cortisol production [18, 19]. For example, the network-connectivity changes between SN and DMN [20, 21], SN and CEN [22] corresponded to increased cortisol levels. Furthermore, our previous studies also identified that CD patients would show dysregulations of resting-state functional connectivity patterns with DMN [10, 23]. Since CD patients also suffer from cognitive impairment and neuropsychological symptoms, including depression and anxiety, which DMN, SN, and CEN mainly modulate, we hypothesized that these three networks are critical to understanding Cushing’s disease and its comorbidity. Here we aimed to investigate two research questions. First, whether there are group differences (CD patients vs. healthy controls) in the dynamic functional connectivity within DMN, SN, and CEN; second, whether the differences can explain the psychiatric symptoms and cognitive impairments in CD patients. We configure our design with a sliding-window approach [11, 13] to portray the features of dynamic functional connectivity (dFNC) within DMN, SN, and CEN among patients with Cushing’s disease (N = 50) and healthy controls (N = 57). We first compared the temporal properties between healthy and CD patients. Then we conducted correlation and mediation analysis to see whether and how the differences in dFNC would contribute to patients’ psychiatric and physiological symptoms and cognitive deficits. We finally implemented a classification machine learning algorithm based on dynamic FNC features within these three networks to see whether these dynamic features would identity CD patients successfully. Materials and methods Ethic approval The experimental protocol was in accordance with principles of the Declaration of Helsinki and approved by a local research ethics Committee of The First Medical Center of Chinese PLA General Hospital (Beijing, China). All participants provided written informed consent after the experimental procedure had been fully explained and were reminded of their right to withdraw at any time during the study. Participants The current study recruited 50 patients with Cushing’s disease (CD patients) and 57 healthy controls (HC) who were matched in age, gender, and education (Table 1). The CD patients were recruited from the Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, between May 2017 and November 2019. The following criteria confirmed Cushing’s disease and its etiology: clinical features (e.g., moon face, supraclavicular fat pad, truncal obesity), elevated 24-h urinary free cortisol (24-h UFC, reference range 98.0–500.1 nmol/24 h), absence of normal cortisol circadian rhythm, elevated ACTH levels (reference range at 0800 h: <10.12 pmol/L), elevated cortisol secretion rates (reference range of cortisol level at 0800 h, 198.7–797.5 nmol/L), absence of normal suppression in midnight (1 mg) dexamethasone suppression test and low dose (2 mg) dexamethasone suppression test (but >50% suppression with a high dose (8 mg) of dexamethasone), and a central to peripheral ACTH ratio >2 for petrosal sinus sampling and pathology after surgery. Healthy controls (HC) were recruited from the local community through poster advertisements and were interviewed by experienced psychiatrists to ensure the absence of current or history of any mental disorder. Demographic information and clinical characteristics of all CD patients and healthy controls were shown in Table 1. Table 1 Demographic and clinical data from healthy controls and CD patients. Full size table Clinical data acquisition, neuropsychological and neuropsychiatric assessment Biometric measurements of the CD patients, including 24-h urinary free cortisol (UFC) levels, plasma Cortisol level (at 0000 h, 0800 h, 1600 h) and adrenocorticotropin (ACTH) level (at 0000 h, 0800 h, 1600 h) from a peripheral vein. Clinical severity of CD patients was obtained using the Cushing Quality of Life Scale (Cushing QOL) [24]. We also included the neuropsychological and neuropsychiatric assessments such as Self-Rating Depression Scale (SDS) [25], Self-Rating Anxiety Scale (SAS) [26], Montreal Cognitive Assessment-Beijing Version (MoCA-BJ) [27], and Chinese version of neuropsychiatric inventory (CNPI) [28]. Image acquisition Functional brain images were acquired using a 3-Tesla GE750 scanner at the First Medical Center of Chinese PLA General Hospital (Beijing, China). Blood oxygen level-dependent (BOLD) gradient echo planar images (EPIs) were obtained using an 8-channel head coil [64 × 64 × 36 matrix with 3.5 × 3.5 × 3.5 mm spatial resolution, repetition time (TR) = 2000 ms, echo time (TE) = 30 ms, flip angle = 90°, field of view (FOV) = 256 × 256 mm2]. A high-resolution T1-weighted structural image (256 × 256 × 144 matrix with a spatial resolution of 1 × 1 × 1 mm, repetition time (TR) = 6700 ms, echo time (TE) = 29 ms, flip angle = 7°) was subsequently acquired. During scanning, all participants were fitted with soft earplugs, and were requested to keep their eyes closed, to stay awake and not to think of anything. Data preprocessing The fMRI data was preprocessed using SPM12 (Wellcome Trust Centre for Neuroimaging, London). The first 10 volume of the functional images were discarded to avoid initial steady-state problems. Then functional images were spatially realigned to the first image for motion correction and corrected for slice acquisition temporal delay. Subsequently, functional images were co-registered to each participant’s segmented gray matter T1 image, then spatially normalized to the Montreal Neurological Institute (MNI) coordinate system, resampled to 3 × 3 × 3 mm voxels. Finally, all functional images were spatially smoothed with an isotropic 4 mm FWHM Gaussian kernel. Group ICA and post-processing Preprocessed data were decomposed into functional components that exhibited a unique time course profile using the group-level spatial independent component analysis, which was implemented in the GIFT toolbox (http://mialab.mrn.org/software/gift/) [29]. First, a subject-specific data reduction principal component analysis (PCA) was performed in which 120 principal components remained. Then at group level, we adopted a high model order ICA to reduce the resting state data into 100 group independent components [30] using the expectation-maximization (EM) algorithm [31] in GIFT. Further, the Infomax ICA algorithm in ICASSO [32] was repeated 20 times [33] to ensure the reliability and stability. Subject-specific spatial maps and time-courses were estimated using the back-reconstruction approach (GICA) [34]. We characterized 50 components as intrinsic connectivity networks (ICNs) by applying the following criteria:[13, 35] whether the peak activation coordinates of the functional components were primarily located in gray matter, and with minimal spatial overlap with white matter structures, vascular, ventricular, edge regions corresponding to artefacts, and susceptibility artifacts. We sorted these 50 meaningful independent components into the interested functional networks including: default mode network (DMN), central executive network (CEN) and salience network (SN) (Fig. 1) according to the spatial correlation values between independent components and the given template [36]. Additional post-processing was conducted to remove remaining noise. Time-courses of the seven components were detrended, despiked and low-pass filtered with a high-frequency cutoff of 0.15 Hz [13]. Moreover, we regressed out the six parameters of head movement. Fig. 1: Composite map of the three networks. And the pipeline of dynamic functional connectivity and clustering analyses. A The three brain networks, default mode network (DMN, including 7 components), central executive network (CEN, including 9 components) and salience network (SN, including 7 components) are derived from group spatial independent components analyses among all participants. B First, for each participant, the dynamic functional connectivity (FNC) matrices are estimated on each sliding window (200 windows) of a set of components within the three networks. Then we applied k-means clustering algorithm on the dynamic FNC matrices across all subjects to assess the reoccurring FNC’s states. Optimal number of states was determined by elbow method. We showed the averaged FNC pattern and the corresponding total number of windows in each state, percentage of each occurrence was presented in parentheses. The color bar represents the z value of FNC. Full size image Dynamic functional connectivity Sliding window approach is the most common way to investigate the nonstationary nature of functional connectivity (FC) of fMRI data. We conducted dynamic FC analysis using the DFC network toolbox in GIFT. In line with previous studies [13, 36], a window of 60 s width (30 TR), sliding in steps of one repetition time was applied to divide the time-courses of each independent components into 200 windows. As covariance estimation using time series of shorter length can be noisy, the regularized inverse covariance matrix (ICOV) was adopted [37]. Following graphic LASSO framework [38], we imposed an additional L1 norm of the precision matrix to enforce sparsity. Clustering analysis Based on previous studies, we applied a k-means clustering algorithm on windowed functional connectivity matrices [39] to assess the frequency and structure of reoccurring functional connectivity patterns (states) across all subjects. We used Manhattan distance function to estimate the similarity between different time windows of FC matrices, which had been demonstrated as an effective measure for high-dimensional data [40]. To obtain the optimal number of states, a cluster validity analysis (silhouette) was conducted on the exemplars of all the subjects. To avoid cost function convergence to the local optimal solution, all clustering analyses were iterated 5 times in GIFT, and the best result was used. Finally, we determined the optimal number of clusters as equal to four (k = 4). According to the clustering results, three temporal properties of dynamic FC states derived from each subject’s state vector were calculated: (i) mean dwell time, measured as the average number of consecutive windows belonging to one state; (ii) fraction of time, measured as the proportions of total windows in one state; (iii) number of transitions, defined as the number of state transitions during the entire scan. Mediation analyses Bootstrapping method was used to estimate the mediation effect. Bootstrapping is a nonparametric approach to effect-size estimation and hypothesis testing that is increasingly recommended for many types of analyses, including mediation [41, 42]. Bootstrapping generates an empirical approximation of the sampling distribution of a statistic by repeated random resampling from the available data and uses this distribution to calculate p-values and construct confidence intervals (5000 resamples were taken for these analyses). Moreover, this procedure supplies superior confidence intervals (CIs) that are bias-corrected and accelerated [43, 44]. Classification analyses using dynamic functional connectivity We conducted classification analyses based on dynamic FNC features [35] to classify each kind of patients. Specifically, we firstly formed a regression matrix, Rgroups × cluster centroids, then regressed out the windowed FNC matrices at each time window using the regression matrix for each participant. These analyses end up with eight β coefficients for each time window for each participant. Next, we computed the mean β coefficients for all time windows. Thus, we got eight mean β coefficients for each participant. These mean β coefficients served as the dynamic FNC features for the classification analysis. The classification analysis using supervised machine learning method, linear support vector machine algorithm (http://www.csie.ntu.edu.tw/~cjlin/libsvm/) with a standard 10-fold cross-validation. We randomly divided the data into 10 subgroups, used the trained classifier from the nine subgroups to predict the performance on the left one subgroup, and repeated the procedure for 100 times. We reported the averaged classification accuracy for each group across these 100 times. Results Neuropsychological and neuropsychiatric difference between healthy controls and CD patients Patients with Cushing’s disease reported higher depression, anxiety, and higher frequency and severity mental illness than healthy controls. Additionally, CD patients also behaved impaired cognitive ability than healthy controls (see Table 1) Functional connectivity within DMN, CEN and SN networks in the four states Spatial map of default mode network, central executive network and salience network identified using the group independent component analysis was shown in Fig. 1A. Independent components were grouped based on their anatomical and presumed functional properties: default mode network (ICs, 9, 12, 27, 28, 32, 44, 74), central executive network (ICs, 15, 21, 26, 48, 50, 63, 85, 89, 97), and salience network (ICs, 20, 43, 57, 59, 76, 82, 92). We adopted a k-means clustering algorithm on the dynamic functional connectivity (dFNC) from all subjects into four connectivity states. Figure 1B shows the cluster centroid and the percentage of occurrences of each state (arranged in the order of emergence). Different temporal properties between HC and CD patients We firstly compared the mean dwell time between healthy controls and CD patients in each state (Fig. 2A–D). Using independent T test, we found that the CD patients had higher mean dwell time than HC in State 1 (CD patients: 89.040 ± 59.216 vs. HC: 57.491 ± 40.671; t(105) = 3.244, p = 0.002), but less mean dwell time than HC in State 4 (CD patients: 31.300 ± 39.413 vs. HC: 66.438 ± 45.734; t(105) = −4.227, p < 0.001). We did not observe significant difference in State 2 (CD patients vs. HC: t(105) = 1.700, p = 0.092), nor in State3 (CD patients vs. HC: t(105) = −1.517, p = 0.132). For the switch time (i.e., the number of transitions), CD patients revealed less transition number than healthy controls did (CD patients: 6.600 ± 3.187 vs. HC: 7.824 ± 3.059; t(105) = −2.205, p = 0.045; Fig. 2E). Multiple comparisons were corrected by false-discovery rate (FDR), p < 0.05. All contrasts remained the same after FDR correction excepted the results of switch time became marginally significant, FDR corrected p = 0.075. Group difference on fraction of time in each state was similar with the mean dwell time (see Supplementary Table S1). Levene’s test is used to check that variances are equal for all samples. Fig. 2: Mean dwell time of dynamic FNC states and number of transitions between CD patients and healthy controls. A In State 1, CD patients engaged higher mean dwell time than healthy control did. B, C In State 2 and State 3, no difference was found between CD patients and healthy controls. D In State 4, CD patients showed significant less mean dwell time than healthy controls. E There was marginally significant difference (after FDR correction) on number of transitions between CD patients and healthy controls. Multiple comparisons were corrected by FDR, p < 0.05 (Error bars represent standard error. p < 0.01**, p < 0.001***, p < 0.08+, N.S not significant). HC Healthy controls, CD patients with Cushing’s disease. Full size image Correlation between dynamic FNC properties and clinical characteristics To examined whether the dynamic FNC properties were associated with clinical characteristics, we did Pearson correlation analyses. Since the group differences were found in State 1 and State 4, we only restricted our analyses on these two states. Notably, we found that the dwell time in State 1 positively correlated with the self-reported anxiety (SAS), and cortisol level at 8:00, 16:00, 00:00, ACTH at 8:00, 16:00, as well as elevated 24-h urinary free cortisol. That is, the longer time spent on State 1 which with more sparsely connected pattern, the worse the mental health and higher cortisol level. We also detected a robust negative correlation between dwell time of State 1 and global cognitive scales (MoCA), which indicated that more time spent in State 1, the worse cognitive ability would be. In the contrary, dwell time in State 4 showed significant negative correlation with the self-reported depression, anxiety, and cortisol level at 8:00, 16:00, 00:00. More dwell time in State 4 predicted better cognitive performance measured by MoCA (all results see Table 2). Multiple comparisons were conducted by FDR, p < 0.05. Table 2 Correlations between dynamic functional connectivity temporal properties in cognitive control network and clinical data. Full size table Dwell time in State 1 and State 4 within cognitive control network mediate group difference in cognitive performance Interestingly, we found the dwell time in State 1 and State 4 significantly mediated the difference between individuals with excessive high cortisol level (CD patients) and healthy controls on cognitive performance. That is, lower cognitive performance in CD patients was linked with more dwell time in State 1 (Fig. 3A), and less dwell time in State 4 (Fig. 3B) within the three networks. Fig. 3: Mediation effect of dwell time in State 1 and State 4 on group difference on cognitive performance. A Dwell time in State 1 and B dwell time in State 4 significant partially mediated the difference between CD patients and healthy controls on cognitive performance measured by MoCA. HC Healthy controls, CD patients with Cushing’s disease. Full size image Distinct network-based functional connectivity between CD patients and healthy controls and its associations with psychiatric symptoms and cognitive performance We have already known that the difference on dwell time in State 1 and State 4 can explain the group difference (i.e., CD patients vs. healthy controls) on cognitive performance. We further characterized the State 1 and State 4 by analyzing functional connectivity between the three networks, as well as the functional connectivity within each network. Results showed that in State 1, the CD patients had weaker connectivity within DMN (t(104)1 = −2.584, p = 0.011), and the connections between CEN and DMN (t(104) = −5.141, p < 0.001), CEN and SN (t(104) = −4.732, p < 0.001) were also weaker than healthy controls. And in State 4, CD patients showed weaker functional connections between DMN and SN (t (84)2 = −4.203, p < 0.001), as well as DMN and CEN (t(84) = −3.547, p = 0.001). Moreover, in State 4, functional connection between DMN and SN was negatively correlated with anxiety level measured by SAS (r(68) = −0.336, p = 0.005), and depression level measured by SDS (r(68) = −0.320, p = 0.008), but positively correlated with cognitive performance measured by MoCA (r(65) = 0.421, p < 0.001). Since CD patients showed decreased connection between DMN and SN, these results may suggest that the connection between DMN and SN was critical for understanding the psychiatric symptoms and cognitive deficits in CD patients. All significant results reported here were survived after FDR (p < 0.05) correction. We did not find significant associations between functional connectivity of neither inter-network and intra-network and psychiatric symptoms and cognitive deficits in State 1. No significant correlation results were found between the inter-network and intra-network connectivity and physiological indices (i.e., cortisol, ACTH, and UFC) in these two states, which may suggest that the dwell time in specific state would be more sensitive to physiological change. Classification results based on dynamic FNC features The support vector machine (SVM) based on dynamic FNC approach (Fig. 4A, details see Method) showed classification accuracy of 84.76% for CD patients, 88.98% for healthy controls (Fig. 4B). The classification scores were evaluated using a receiver operating characteristic (ROC) curve aiming to visualize the performance of the classifier. The classification results may further indicate that the dynamic functional connectivity pattern within these three networks would be the potential biomarker of individuals with excessive higher cortisol level. Fig. 4: The results of classification. A An overview of classification approach. We first extracted the averaged FNC pattern for each state for each group. Then we performed Pearson correlation between the FNC in each window and the FNC pattern in all states among all groups. These procedures ended up with 8 averaged features for each participant. B Receiver Operating Characteristic (ROC) curves for classification. SVM support vector machine, AUC area under the curve. Full size image Discussion In the current study, we adopted independent component analysis (ICA) and dynamic functional connectivity (FNC) approaches to reveal the difference in dynamic FNC within DMN, SN, and CEN networks between CD patients and healthy controls. Using clustering algorithm, we defined four reoccurring FNC states during resting-state scanning. Wherein State 1 and State 4 exhibited significant differences between healthy control and CD patients. Patients generally showed more dwell time in State 1 but less in State 4 than healthy controls. Specifically, in State 1, the CD patients showed weaker connections within DMN, as well as weaker intra-network connectivity between DMN and CEN, SN and CEN than healthy controls. In State 4, connections between DMN and SN, DMN and CEN showed weaker connection in CD patients than in healthy participants. Further correlation and mediation analyses showed that the dwell time in State 1 significantly negatively correlated with cognitive performance. While dwell time in State 4, as well as the connections between DMN and SN in State 4, were found to positively correlate with cognitive performance, and negatively associated with depression and anxiety symptoms. Both states were associated with physiological indices including cortisol, ACTH and 24-hour UFC. Importantly, results from mediation analysis indicated the difference between CD patients and healthy controls on dwell time in State 1 and State 4 can be used to explain their cognitive performance difference. Intriguingly, adopting support vector machine algorithm based on dynamic FNC within DMN, SN and CEN network generally showed ideal classification accuracy for CD patients and healthy controls. These findings begin to delineate the dynamic properties of the three brain networks, which are critical for cognitive and neuropsychiatric, and open new avenues for understanding and explaining the impaired cognitive performance and psychiatric symptoms induced by Cushing’s disease. We found two distinct functional connectivity states across two groups. State 1 can be characterized as having weak connections among the three networks, while State 4 showed relatively strong inter-network and intra-network connections. We observed that in patients with Cushing’s disease, State 1 occurred more often, while State 4 occurred less than in healthy controls. These results help to confirm CD patients’ weaker connections within DMN, SN, and CEN. Previous studies identified that white matter integrity was generally decreased throughout the whole brain rather than just on individual fasciculus [45,46,47]. One possible explanation is that the extensive decline in white matter structural integrity leads to the decreased connectivity of the three networks, which are critical for the cognitive-affective process. We found that in State 1, CD patients showed decreased local synchronization (i.e., within network connectivity) of DMN, and weak inter-network connections between CEN and DMN, CEN and SN. The DMN’s integrity appears crucial for cognitive performance. For example, patients with Alzheimer’s disease showed decreased connectivity within DMN [48]. Since dwell time of State 1 was negatively correlated with MoCA and mediated the group differences on MoCA. We may infer that cognitive deficit may be due to that CD patients engaged more time in State 1 with weak connections of DMN. Interestingly, the more dwell time in State 4, the less anxiety and depression symptoms individuals would have. Moreover, our further analyses found that connections between DMN and SN during State 4 would also negatively affect anxiety and depression. And the CD patients had weaker DMN-SN connections than healthy controls in this state. In line with previous studies, effective connectivity from DMN to SN was lower in major depression disorders compared to healthy controls when processing negative information [49]. And the inter-network connections between the SN and DMN were inversely associated with trait anxiety levels [50]. Therefore, the time engaged in State 4 and the weak inter-network connectivity between SN and DMN may contribute to psychopathological symptoms in CD patients. Dynamic functional connectivity provides time-varying rather than static features over time [11], and it is more effective to capture various aspects of brain connectivity. The dFNC approach has obvious advantages for classification purposes [35]. For example, previous research showed high classification accuracy for psychiatric diseases such as schizophrenia [51], and bipolar [35]. In our study, the SVM based on dynamic functional connectivity features within DMN, SN and CEN showed high classification accuracy for CD patients and healthy controls, which may indicate that the dynamic properties in these three networks would be potential biomarkers for individuals with excessive higher cortisol level. The long-term remitted CD (LTRCD)-patients still suffered from cognitive impairments and emotional symptoms such as anxiety and depression, even though their cortisol levels back to normal after the removal of the adenoma [2, 52, 53]. We revealed that the dynamic features in DMN, SN, and CEN correlate with depression and anxiety symptoms in CD patients and are strongly associated with cognitive performance. Our findings may contribute to developing further neuro-modulation targets to help CD patients improve cognitive ability and mental health. Several limitations of the present study should be mentioned. First, Cushing’s disease is rare, and it is more common in women [1, 3]. We only showed results based on a female sample (healthy controls were all female). Therefore, our conclusion may not be adaptive for the male population. Second, some research suggested that the dynamic functional connectivity analyses should be performed in resting state acquisitions of at least ten minutes [54]. The length of current resting-state scan was eight minutes, although many previous studies studied dynamic FNC based on resting-state data in eight minutes or even less [13, 20, 51], further studies should consider longer scanning to capture more dynamic spontaneous features. Thirdly, our results revealed that cortisol concentrations were significantly associated with dwell time in State 1 and 4 but were not correlated with inter-network or intra-network connections. Human cortisol secretion has apparent circadian rhythmicity [55], but our resting state acquisitions were not collected multiple times. Our conclusions may not be informative to understand the relationships between dynamic functional connections and dynamic cortisol levels. In conclusion, our study delineates the differences in dynamic properties between CD patients and healthy participants. It unravels its associations with cognitive deficits, impaired affective processes, and physiological indices in CD patients. We believe the temporal dynamics of functional connectivity within the three crucial cognitive and affective brain networks could be a promising imaging biomarker to monitor cognitive changes and psychiatric symptoms in Cushing’s disease. Data availability All datasets are available on figshare. https://figshare.com/projects/Dynamic_functional_connectivity_changes_associated_with_psychiatric_traits_and_cognitive_deficits_in_Cushing_s_disease/170343. Code availability All code used for all analyses and plots are publicly available on GitHub at https://github.com/psywalkeryanxy/paper_CD_ICA. References Lacroix A, Feelders RA, Stratakis CA, Nieman LK. Cushing’s syndrome. Lancet. 2015;386:913–27. Article CAS PubMed Google Scholar van der Werff SJA, Pannekoek JN, Andela CD, Meijer OC, van Buchem MA, Rombouts SARB, et al. Resting-state functional connectivity in patients with long-term remission of Cushing’s disease. Neuropsychopharmacology. 2015;40:1888–98. Article PubMed PubMed Central Google Scholar Swearingen B, Biller BMK, editors. Cushing’s disease. vol. 31, US: Springer; 2011. Piasecka M, Papakokkinou E, Valassi E, Santos A, Webb SM, Vries F, et al. 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Article CAS PubMed Google Scholar Download references Acknowledgements This work was supported by the National Natural Science Foundation of China (No. 82001798 and No. 81871087) and China Brain Project (2021ZD0200407). Author information Authors and Affiliations Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, PR China Zhebin Feng, Tao Zhou, Xinguang Yu & Yanyang Zhang Department of Respiratory Medicine, Anhui Provincial Children’s Hospital, Hefei, Anhui, PR China Haitao Zhang Neurosurgery Institute, Chinese PLA General Hospital, Beijing, PR China Xinguang Yu & Yanyang Zhang Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA Xinyuan Yan Contributions YZ and XGY, TZ conceived the project and designed research, HZ performed research, XY and ZF, YZ analyzed data and interpreted results, ZF and XY wrote the paper. All authors approved the final version of the manuscript for submission. Corresponding authors Correspondence to Yanyang Zhang or Xinyuan Yan. Ethics declarations Competing interests The authors declare no competing interests. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary information Supporting information From https://www.nature.com/articles/s41398-023-02615-y

Abstract Summary This case report describes a rare presentation of ectopic Cushing’s syndrome (CS) due to ectopic corticotropin-releasing hormone (CRH) production from a medullary thyroid carcinoma (MTC). The patient, a 69-year-old man, presented with symptoms of muscle weakness, facial plethora, and easy bruising. An inferior petrosal sinus sampling test (IPSS) demonstrated pituitary adrenocorticotrophic hormone (ACTH) secretion, but a whole-body somatostatin receptor scintigraphy (68Ga-DOTATOC PET/CT) revealed enhanced uptake in the right thyroid lobe which, in addition to a grossly elevated serum calcitonin level, was indicative of an MTC. A 18F-DOPA PET/CT scan supported the diagnosis, and histology confirmed the presence of MTC with perinodal growth and regional lymph node metastasis. On immunohistochemical analysis, the tumor cell stained positively for calcitonin and CRH but negatively for ACTH. Distinctly elevated plasma CRH levels were documented. The patient therefore underwent thyroidectomy and bilateral adrenalectomy. This case shows that CS caused by ectopic CRH secretion may masquerade as CS due to a false positive IPSS test. It also highlights the importance of considering rare causes of CS when diagnostic test results are ambiguous. Learning points Medullary thyroid carcinoma may secrete CRH and cause ectopic CS. Ectopic CRH secretion entails a rare pitfall of inferior petrosal sinus sampling yielding a false positive test. Plasma CRH measurements can be useful in selected cases. Keywords: Adult; Male; White; Denmark; Pituitary; Pituitary; Thyroid; Error in diagnosis/pitfalls and caveats; September; 2023 Background The common denominator of Cushing’s syndrome (CS) is autonomous hypersecretion of cortisol (1) and it is subdivided into ACTH-dependent and ACTH-independent causes. The majority of CS cases are ACTH-dependent (80–85%) with a pituitary corticotroph tumor as the most prevalent cause (Cushing’s disease), and less frequently an ectopic ACTH-producing tumor (2). The gold standard method to ascertain the source of ACTH secretion in CS patients is inferior petrosal sinus sampling (IPSS) with measurement of plasma ACTH levels in response to systemic corticotropin-releasing hormone (CRH) stimulation (3). The IPSS has a very high sensitivity and specificity of 88–100% and 67–100%, respectively (4), but pitfalls do exist, including the rare ectopic CRH-producing tumor, which may yield a false positive test result (3). Here, we describe a very rare case masquerading as CS including a positive IPSS test. Case presentation A 69-year-old man presented at a local hospital with a 6-month history of progressive fatigue, muscle weakness and wasting, easy bruising, facial plethora, and fluid retention. His serum potassium level was 2.6 mmol/L (reference range: 3.5–4.2 mmol/L) without a history of diuretics use. His previous medical history included spinal stenosis, benign prostatic hyperplasia, and hypertension. An electromyography showed no sign of polyneuropathy and an echocardiography showed no signs of heart failure with an ejection fraction of 55%. MRI of the spine revealed multiple compression fractures, and the patient underwent spinal fusion and decompression surgery; during this admission he was diagnosed with type 2 diabetes (HbA1c: 55 mmol/mol). After spine surgery, the patient developed a pulmonary embolism and initiated treatment with rivaroxaban. Establishing the diagnosis of ACTH-dependent CS Six months after his spine surgery, the patient was referred to the regional department of endocrinology for osteoporosis management. Blood tests revealed a low serum testosterone level with non-elevated luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels (Table 1). An overnight 1 mg dexamethasone suppression test was positive with a morning cortisol level of 254 nmol/L and three consecutive 24-h urinary cortisol levels were markedly elevated with mean level of ≈600 nmol/24 h (reference range: 12–150 nmol/24 h). A single plasma ACTH was 37 ng/L (Table 1). Table 1 Baseline endocrine assessment. Parameters Patient’s values Reference range ACTH, ng/L 37 7–64 UFC, nmol/day 588 12–150 Urinary cortisol, nmol/L 600 171–536 OD, nmol/L 254 <50 Free testosterone, nmol/L 0.061 0.17–0.59 HbA1c, mmol/mol 55 <48 FSH, IU/L 7.4 1.2–15.8 LH, IU/L 2.2 1.7–8.6 ACTH, adrenocorticotropin; FSH, follicle-stimulating hormone; IU, international units; LH, luteinizing hormone; OD, plasma cortisol levels after a 1 mg overnight dexamethasone suppression test; UFC, urine free cortisol hormone. Differential diagnostic tests The patient was referred to a tertiary center for further examinations. Ketoconazole treatment was started to alleviate the consequences of hypercortisolism. A pituitary MRI revealed an intrasellar microtumor with a maximal diameter of 6 mm and an IPSS was ordered. A whole-body somatostatin receptor scintigraphy (68Ga-DOTATOC PET/CT) was also performed to evaluate the presence of a potential neuroendocrine tumor. This revealed multiple areas of enhanced uptake including the right thyroid lobe and cervical lymph nodes in the neck (with CT correlates), as well as in the duodenum (with no CT correlate). Concomitantly, a grossly elevated serum calcitonin level of 528 pmol/L (reference range <2.79 pmol/L) was measured. Subsequently, the IPSS revealed pituitary ACTH secretion with a central-to-peripheral ACTH ratio >3 (Table 2). The right petrosal sinus was not successfully catheterized; thus, lateralization could not be determined. To corroborate the diagnosis MTC, a 18F-DOPA PET/CT scan (FDOPA) was performed (5), which showed pathologically enhanced uptake in the right thyroid lobe and regional lymph nodes (Fig. 1). An ultrasound-guided core needle biopsy from the thyroid nodule was inconclusive; however, the patient underwent total thyroidectomy and regional lymph node resection, from which histology confirmed the diagnosis of disseminated MTC. Standard replacement with levothyroxine, calcium, and vitamin D was initiated. A blood sample was collected, and genomic DNA was extracted. The DNA analysis for RET germline mutation was negative. View Full Size Figure 1 18F-DOPA PET/CT scan with pathologically enhanced uptake in the right thyroid lobe (large blue arrow on the left side) and regional lymph nodes (small blue arrows). Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 3; 10.1530/EDM-23-0057 Download Figure Download figure as PowerPoint slide Table 2 Results from the inferior petrosal sinus sampling.* Time (min) Left IPSS Peripheral L/P -5 42 36 1.2 -1 116 33 3.5 2 120 32 3.8 5 209 28 7.5 7 180 43 4.2 10 529 34 15.6 15 431 37 11.6 *Data represents ACTH levels in ng/L. IPSS Inferior petrosal sampling ACTH Adrenocorticotropin hormone CRH Corticotropin-releasing hormone, L/P Ratio of left (L) inferior petrosal sinus to peripheral venous ACTH concentrations. Pathology Total thyroidectomy and bilateral cervical lymph node dissection (level six and seven) were performed. Macroscopic evaluation of the right thyroid lobe revealed a 24 mm, irregular solid yellow tumor. Microscopically the tumor showed an infiltrating architecture with pseudofollicles and confluent solid areas. Calcification was prominent, but no amyloid deposition was seen. The tumor cells were pleomorphic with irregular nuclei and heterogenic chromatin structure. No mitotic activity or necrosis was observed. On immunohistochemical analysis, the tumor cells expressed thyroid transcription factor 1 and stained strongly for carcinoembryonic antigen and calcitonin; tumor cells were focally positive for cytokeratin 19. The tumor was completely negative for ACTH, thyroid peroxidase, and the Hector Battifora mesothelial-1 antigen. Further analysis revealed positive immunostaining for CRH (Fig. 2). The Ki-67 index was very low (0–1%), indicating a low cellular proliferation. Molecular testing for somatic RET mutation was not performed. View Full Size Figure 2 Histopathological findings and immunohistochemical studies of MTC. (A) Microscopic features of medullary thyroid carcinoma. (B) Polygonal tumor cells (hematoxylin and eosin, ×40). (C) Tumor cells stain for calcitonin (×20). (D) Immunohistochemical stain (×400) for CRH showing cells being positive (brown). (E) Pituitary tissue from healthy control staining positive for ACTH in comparison to (F) ACTH-negative cells MTC tissue from the patient (×20). Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 3; 10.1530/EDM-23-0057 Download Figure Download figure as PowerPoint slide No malignancy was found in the left thyroid lobe and there was no evidence of C-cell hyperplasia. Regional lymph node metastasis was found in 13 out of 15 nodes with extranodal extension. Outcome and follow-up Follow-up Serum calcitonin levels declined after neck surgery but remained grossly elevated (118 pmol/L 3 weeks post surgery) and cortisol levels remained high. Ketoconazole treatment was poorly tolerated and not sufficiently effective. Plasma levels of CRH were measured by a competitive-ELISA kit (EKX-KIZI6R-96 Nordic BioSite), according to the instructions provided by the manufacturer. The intra- and interassay %CV (coefficient of variability) were below 8% and 10%, respectively, and the assay sensitivity was 1.4 pg/mL. The plasma CRH was distinctly elevated compared to in-house healthy controls both before and after thyroid surgery (Fig. 3). View Full Size Figure 3 Plasma CRH levels before and after total thyroidectomy compared to three healthy controls. Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 3; 10.1530/EDM-23-0057 Download Figure Download figure as PowerPoint slide The patient subsequently underwent uneventful bilateral laparoscopic adrenalectomy followed by standard replacement therapy with hydrocortisone and fludrocortisone. The symptoms and signs of his CS gradually subsided. Pathology revealed bilateral cortical hyperplasia as expected. The patient continues follow-up at the Department of Oncology and the Department of Endocrinology and Internal Medicine. At 13-month follow-up, 68Ga-DOTATOC shows residual disease with pathologically enhanced uptake in two lymph nodes, whereas the previously described focal DOTATOC uptake in the duodenum was less pronounced (still no CT correlate). Serum calcitonin was 93 pmol/L at the 13-month follow-up. Discussion Diagnostic challenges remain in the distinction between pituitary and ectopic ACTH-dependent CS, and several diagnostic tools are used in combination, none of which is infallible, including IPSS (6). Our case and others illustrate that ectopic CRH secretion may yield a false positive IPSS test result (3). Measurement of circulating CRH levels is relevant if an ectopic CRH producing tumor is suspected, but the assay is not routinely available in clinical practice (Lynnette K Nieman M. Measurement of ACTH, CRH, and other hypothalamic and pituitary peptides https://www.uptodate.com/contents/measurement-of-acth-crh-and-other-hypothalamic-and-pituitary-peptides: UpToDate; 2019). In our case, the presence of elevated plasma CRH levels after thyroidectomy strengthened the indication for bilateral adrenalectomy. The most common neoplasm causing ectopic CS is small-cell lung cancer, whereas MTC accounts for 2–8% of ectopic cases (7). The development of CS in relation to MTC is generally associated with advanced disease and poor prognosis of an otherwise relatively indolent cancer (8), and the clinical progression of CS is usually rapid, why an early recognition and rapid control of hypercortisolemia and MTC is necessary to decrease morbidity and mortality (7, 9). Our case does have residual disease; however, he remains progression-free with stable and relatively low calcitonin levels within 1-year follow-up. Only a very limited number of cases of ectopic tumors with either combined ACTH and CRH secretion or isolated CRH secretion have been reported, with ectopic CRH secretion accounting for less than 1% of CS (9). An ACTH- or CRH-producing tumor can be difficult to localize and may include gastric ACTH/CRH-secreting neuroendocrine tumors (9). In our case, the 68Ga-DOTATOC identified a possible duodenal site, in addition to the MTC, but an upper gastrointestinal endoscopy revealed no pathological findings and there was no CT correlate. Thus, we concluded that the most likely and sole source of ectopic CRH was the MTC and its metastases. To our knowledge, no official guidelines for managing ectopic ACTH-dependent CS have been established. In a recent publication by Alba et al. (10), the authors demonstrated a clinical algorithm (The Mount Sinai Clinical Pathway, MSCP) and recommendation for the management of CS due to ectopic ACTH secretion. Essentially, our approach in this particular case followed these recommendations, including source location by CT and 68Ga-DOTATATE PET/CT imaging, acute management with ketoconazole, and finally, bilateral adrenalectomy as curative MTC surgery was not possible. In retrospect, performance of the IPSS could be questioned in view of the MTC diagnosis. In real time, however, a pituitary MRI performed early in the diagnostic process revealed a microadenoma, which prompted the IPSS. In parallel, a somatostatin receptor scintigraphy (68Ga-DOTATOC PET/CT) was also done, which raised the suspicion of an MTC. Conclusion We report a very rare case of an ectopic CS caused by a CRH-secreting MTC. Although IPSS has stood the test of time in the differential diagnosis of ACTH-dependent CS, this case illustrates a rare pitfall. Declaration of interest The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. Funding This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector. Patient consent Written informed consent for publication of their clinical details was obtained from the patient. Author contribution statement JOJ and MJO are the physicians responsible for the patient. LR performed the thyroidectomy and bilateral adrenalectomy. SHM and SLA assessed and reassessed the histopathology and the immunohistochemical analysis. MB measured plasma CRH. VM, JOJ, and MJO drafted the manuscript. All authors contributed to critical revision of the manuscript. References 1↑ Raff H, & Carroll T. Cushing's syndrome: from physiological principles to diagnosis and clinical care. Journal of Physiology 2015 593 493–506. (https://doi.org/10.1113/jphysiol.2014.282871) PubMed Search Google Scholar Export Citation 2↑ Hatipoglu BA. Cushing's syndrome. Journal of Surgical Oncology 2012 106 565–571. 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(https://doi.org/10.1007/BF03401514) PubMed Search Google Scholar Export Citation 8↑ Corsello A, Ramunno V, Locantore P, Pacini G, Rossi ED, Torino F, Pontecorvi A, De Crea C, Paragliola RM, Raffaelli M, et al.Medullary thyroid cancer with ectopic Cushing's syndrome: a case report and systematic review of detailed cases from the literature. Thyroid 2022 32 1281–1298. (https://doi.org/10.1089/thy.2021.0696) PubMed Search Google Scholar Export Citation 9↑ Sharma ST, Nieman LK, & Feelders RA. Cushing's syndrome: epidemiology and developments in disease management. Clinical Epidemiology 2015 7 281–293. (https://doi.org/10.2147/CLEP.S44336) PubMed Search Google Scholar Export Citation 10↑ Alba EL, Japp EA, Fernandez-Ranvier G, Badani K, Wilck E, Ghesani M, Wolf A, Wolin EM, Corbett V, Steinmetz D, et al.The Mount Sinai clinical pathway for the diagnosis and management of hypercortisolism due to ectopic ACTH syndrome. Journal of the Endocrine Society 2022 6 bvac073. 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Ball-and-stick model of the cortisol (hydrocortisone) molecule. Credit: Public Domain A first-of-its kind hormone replacement therapy that more closely replicates the natural circadian and ultradian rhythms of our hormones has shown to improve symptoms in patients with adrenal conditions. Results from the University of Bristol-led clinical trial are published today in the Journal of Internal Medicine. Low levels of a key hormone called cortisol is typically a result of conditions such as Addison's and congenital adrenal hyperplasia. The hormone regulates a range of vital processes, from cognitive processes such as memory formation, metabolism and immune responses, through to blood pressure and blood sugar levels. When low, it can trigger symptoms of debilitating fatigue, nausea, muscle weakness, dangerously low blood pressure and depression. Although rare, these adrenal conditions require lifelong daily hydrocortisone replacement therapy. Although existing oral hormone replacement treatment can restore cortisol levels, it is still associated with an impaired quality of life for patients. Scientists believe this is because the current treatment does not mimic the body's normal physiological timing, missing cortisol's anticipatory rise and lacking its underlying ultradian and circadian rhythms. The new "pulsatility" therapy, the culmination of ten years' research by the Bristol team, is designed to deliver standard hydrocortisone replacement to patients via a pump which replicates more closely cortisol's natural rhythmic secretion pattern. The pulsatile subcutaneous pump has now revealed promising results in its first clinical trial. Twenty participants aged 18 to 64 years with adrenal insufficiency conditions were assessed during the double-blinded PULSES six-week trial and treated with usual dose hydrocortisone replacement therapy administered either via the pump or the standard three times daily oral treatment. While only psychological and metabolic symptoms were assessed during the trial, results revealed the pump therapy decreased fatigue by approximately 10%, improved mood and increased patient energy levels by 30% first thing in the morning—a key time frame when many patients struggle. Patient MRI scans also revealed alteration in the way that the brain processes emotional information. Dr. Georgina Russell, Honorary Lecturer at the University's Bristol Medical School, and the lead author, explained, "Patients on cortisol replacement therapy often have side effects which makes it difficult for them to lead normal lives. We hope this new therapy will offer greater hope for the thousands of people living with hormone insufficiency conditions." Stafford Lightman, a neuroendocrinology expert and Professor of Medicine at Bristol Medical School: Translational Health Sciences (THS), and the study's joint lead author, added, "Besides reduction in dosage, cortisol replacement has remained unchanged for many decades. It is widely recognized that current replacement therapy is unphysiological due to its lack of pre-awakening surge, ultradian rhythmicity, and post dose supraphysiological peaks. The new therapy clearly shows that the timing of cortisol delivery- in line with the body's own rhythmic pattern of cortisol secretion—is important for normal cognition and behavior. "Our findings support the administration of hormone therapy that mimics natural physiology, and is one of the first major advances in adrenal insufficiency treatment to date." Joe Miles, a participant on the PULSES trial, explained, "The Crono P pump has been life-changing. I noticed a very quick improvement compared to tablets when I was on the PULSES study. I went from feeling tired all the time to having sudden energy. "When the PULSES study ended and I had to return the pump, I simply couldn't cope with going back to how I used to be, so I made it my mission to write to as many doctors to have it prescribed privately. "I've now been on it for six years and have introduced a number of other people with Addison's disease to the pump, and all of them have said it's life changing. Some have gone from being seriously ill to feeling better than they have done for years." Dr. Russell said, "Approximately 1% of the UK population is taking steroids at any moment in time; these individuals can experience debilitating psychological side effects. This trial has shown that even at physiological levels, brain functioning is disrupted and that we need to explore not only the dose but the pattern of steroids delivery when considering any type of steroid treatment." More information: Ultradian hydrocortisone replacement alters neuronal processing, emotional ambiguity, affect and fatigue in adrenal insufficiency: The PULSES trial, Journal of Internal Medicine (2023). DOI: 10.1111/joim.13721 Journal information: Journal of Internal Medicine Provided by University of Bristol From https://medicalxpress.com/news/2023-10-first-of-its-kind-hormone-treatment-patient.html

I'm not sure I like this! STORY: Could artificial intelligence be used to make brain surgery safer? At this university in London, trainee surgeon Danyal Khan is taking part in a mock operation during which he's assisted by a real-time video feed, as is typical in brain surgery. But what's new here is that the footage is being analyzed by AI to help Khan better understand what he's seeing. The AI system, which is under development at University College London (UCL), highlights sensitive or critical structures in the brain. Neurosurgeon Hani Marcus believes it has the potential to make brain surgery safer and more effective: "So I'm very bullish that in the medium to long term, the A.I. will be helping lots of surgeons do lots of operations better than they otherwise can." Marcus says the AI system analyzed video of more than 200 pituitary gland tumor operations, and gained around 10 years-worth of experience in a fraction of the time. That knowledge means the AI can now not only help navigate to the correct area of the brain, but also know what should be happening at any stage of the procedure, making it a valuable training aid. "So, what we're really trying to do is apply AI or artificial intelligence to support surgeons doing brain tumor surgery at the base of the brain. And what this practically entails is us training the AI with hundreds of videos, telling it, if you like, what structures are what and then at some point over that period, the AI becomes really good itself at recognising things, and able to support other surgeons who're perhaps less experienced in advising them what to do next." Assistant Professor of Robotics and A.I. Sophia Bano explains how that might look in a real operation: "There can be scenarios where clinicians, unintentionally, are very close to a very critical structure such as the optic nerve. This can have, any damage or a slight more pressure on the optic nerve, can have long term complications on the patient side. So, this whole tool will alert the surgeon during the procedure if there is any risk of potential complication so they can recalibrate themselves during the procedure." Khan, who was also involved in developing the software that is now helping him learn, says the A.I. system has been a valuable tool in his training. It could also provide him with step-by-step guidance during a procedure, similar to having a senior surgeon standing over your shoulder. "I think as I progress as a surgeon, there might be stages where I wonder, you know, have I done enough of a particular part of the procedure and should I move on? And actually having that sort of assistant in the background as a reassurance to look at and say, 'well, yeah, actually, at this stage, out of the hundreds of videos of experts that this algorithm has watched, the experts would probably start moving on to the next phase'. It's a useful double check." According to UCL, the system could be ready to be used in operating theaters within two years. From https://news.yahoo.com/ai-could-help-brain-surgery-080156167.html

In a recent study published in Hypertension Research, scientists examine the endocrine causes of hypertension (HTN) and investigate the efficacy of treatments to alleviate HTN. What is HTN? About 30% of the global population is affected by HTN. HTN is a modifiable cardiovascular (CV) risk factor that is associated with a significant number of deaths worldwide. There are two types of HTN known as primary and secondary HTN. As compared to primary HTN, secondary HTN causes greater morbidity and mortality. The most common endocrine causes of HTN include primary aldosteronism (PA), paragangliomas and pheochromocytomas (PGL), Cushing’s syndrome (CS), and acromegaly. Other causes include congenital adrenal hyperplasia, mineralocorticoid excess, cortisol resistance, Liddle syndrome, Gordon syndrome, and thyroid and parathyroid dysfunction. What is PA? PA is the most common endocrine cause of hypertension, which is associated with excessive aldosterone secretion by the adrenal gland and low renin secretion. It is difficult to estimate the true prevalence of PA due to the complexity of its diagnosis. Typically, the plasma aldosterone-to-renin ratio (ARR) is measured to diagnose PA. The diagnosis of PA can also be confirmed using other diagnostic tools like chemiluminescent enzyme immunoassays (CLEIAs) and radio immune assay (RIA). Continuous aldosterone secretion is associated with organ damage due to chronic activation of the mineralocorticoid (MR) receptor in many organs, including fibroblasts and cardiomyocytes. An elevated level of aldosterone causes diastolic dysfunction, endothelial dysfunction, left ventricular hypertrophy, and arterial stiffness. Increased aldosterone secretion also leads to obstructive sleep apnea and increases the risk of osteoporosis. This is why individuals with PA are at a higher risk of cardiovascular events (CVDs), including heart failure, myocardial infarction, coronary artery disease, and atrial fibrillation. PA is treated by focusing on normalizing potassium and optimizing HTN and aldosterone secretion. Unilateral adrenalectomy is a surgical procedure proposed to treat PA. Young patients who are willing to stop medication are recommended surgical treatment. The most common pharmaceutical treatment for PA includes mineralocorticoid receptor antagonists such as spironolactone and eplerenone. Pheochromocytomas and paragangliomas PGL are tumors that develop at the thoracic-abdominal-pelvic sympathetic ganglia, which are present along the spine, as well as in the parasympathetic ganglia located at the base of the skull. The incidence rate of PGL is about 0.6 for every 100,000 individuals each year. PGL tumors synthesize excessive catecholamines (CTN), which induce HTN. Some of the common symptoms linked to HTN associated with PGL are palpitations, sweating, and headache. PGL can be diagnosed by determining metanephrines (MN) levels, which are degraded products of CTN. Bio-imaging tools also play an important role in confirming the diagnosis of PGL. Excessive secretion of CTN increases the risk of CVDs, including Takotsubo adrenergic heart disease, ventricular or supraventricular rhythm disorders, hypertrophic obstructive or ischaemic cardiomyopathy, myocarditis, and hemorrhagic stroke. Excessive CTN secretion also causes left ventricular systolic and diastolic dysfunction. Typically, PGL treatment is associated with surgical procedures. Two weeks before the surgery, patients are treated with alpha-blockers. For these patients, beta-blockers are not used as the first line of treatment without prior use of alpha-adrenergic receptors. Patients with high CTN secretion are treated with metyrosine, as this can inhibit tyrosine hydroxylase. Hydroxylase converts tyrosine into dihydroxyphenylalanine, which is related to CTN synthesis. What is CS? CS, which arises due to persistent exposure to glucocorticoids, is a rare disease with an incidence rate of one in five million individuals each year. The most common symptoms of CS include weight gain, purple stretch marks, muscle weakness, acne, and hirsutism. A high cortisol level causes cardiovascular complications such as HTN, hypercholesterolemia, and diabetes. CS is diagnosed based on the presence of two or more biomarkers that can be identified through pathological tests, such as salivary nocturnal cortisol, 24-hour urinary-free cortisol, and dexamethasone suppression tests. CS is treated through surgical procedures based on the detected lesions. Patients with severe CS are treated with steroidogenic inhibitors, such as metyrapone, ketoconazole, osilodrostat, and mitotane. Pituitary radiotherapy and bilateral adrenalectomy are performed when other treatments are not effective. Acromegaly Acromegaly arises due to chronic exposure to growth hormone (GH), leading to excessive insulin-like growth factor 1 (IGF1) synthesis. This condition has a relatively higher incidence rate of 3.8 million person-years. Clinical symptoms of acromegaly include thickened lips, widened nose, a rectangular face, prominent cheekbones, soft tissue overgrowth, or skeletal deformities. Prolonged exposure to GH leads to increased water and sodium retention, insulin resistance, reduced glucose uptake, and increased systemic vascular resistance. These conditions increase the risk of HTN and diabetes in patients with acromegaly. Acromegalic patients are also at a higher risk of cancer, particularly those affecting the thyroid and colon. Acromegaly is diagnosed using the IGF1 assay, which determines IGF1 levels in serum. After confirming the presence of high IGF1 levels, a GH suppression test must be performed to confirm the diagnosis. Bioimaging is also conducted to locate adenoma. Acromegaly is commonly treated through surgical procedures. Patients who refuse this line of treatment are treated with somatostatin receptor ligands, growth hormone receptor antagonists, dopaminergic agonists, or radiotherapy. Journal reference: De Freminville, J., Amar, L., & Azizi, M. (2023) Endocrine causes of hypertension: Literature review and practical approach. Hypertension Research; 1-14. doi:10.1038/s41440-023-01461-1 From https://www.news-medical.net/news/20231015/Hormones-and-high-blood-pressure-Study-reveals-endocrine-culprits-and-targeted-treatments.aspx

Niall Cavanagh, now aged 48, bravely fought and beat a brain tumour diagnosis when he was a teenager. He shared his experience with The Kerryman in an interview conducted ahead of the seventeenth annual International Brain Tumour Awareness Week. This week-long event, running from October 28th to November 4th, aims to raise awareness about brain tumours and support those affected by them. Niall’s journey was not an easy one. Leading up to his diagnosis in 1992, he experienced symptoms such as excessive thirst, urination, severe headaches, vomiting, and stunted growth. It was when he went for an eye examination for double vision that the examiner noticed something seriously wrong with his retinas. Further tests revealed a germinoma brain tumour pressing on the pituitary gland. To relieve the pressure caused by the tumour, Niall underwent an emergency ventriculoperitoneal shunt procedure. This involved inserting a tube from his brain to his abdomen to drain the excess cerebrospinal fluid. He also underwent extensive radiotherapy to shrink the tumour and prevent its spread. The tumour affected Niall’s pituitary gland, resulting in a condition known as hypopituitarism. This condition causes a deficiency in various hormones, including growth hormone and anti-diuretic hormone. Niall experienced adverse effects on his physical and mental health due to the tumour and subsequent treatments. Despite the challenges, Niall gained a clearer perspective on life. He learned to appreciate what is truly important and developed compassion through his own struggles with depression and anxiety. He emphasized that each person’s experience with a brain tumour is unique, and it’s essential to show support and understanding to others facing similar battles. Niall’s health has gradually improved over the years, although he still faces challenges due to a weakened immune system. However, he remains resilient and has pursued higher education, obtaining two degrees in IT and a Masters in information systems. He currently works part-time in an administrative role with the Renewable Energy Centre in Killarney. Throughout his journey, Niall received invaluable support from his family and various organizations, including the Cork Brain Tumour Support Group (now Brain Tumour Ireland), the Pituitary Foundation, and Headway in Tralee. Niall’s story serves as an inspiration and a reminder of the importance of raising awareness and providing support to those affected by brain tumours. International Brain Tumour Awareness Week aims to continue spreading awareness and fostering understanding of this life-changing condition. Sources: – The Kerryman From https://www.expresshealthcaremgmt.com/news2/kerry-man-reflects-on-beating-brain-tumour-diagnosis-as-a-teenager-you-have-to-sink-or-swim/156637/

Abstract Background and Objectives Crooke cell adenomas (CCA) are a rare, aggressive subset of adrenocorticotrophin secreting pituitary corticotroph adenomas (sCTA) found in 5–10% of patients with Cushing’s disease. Multiple studies support worse outcomes in CCA but are limited by small sample size and single-institution databases. We compared outcomes in CCA and sCTA using a multicenter, international retrospective database of high-volume skull base centers. Methods Patients surgically treated for pituitary adenoma from January 2017 through December 2020 were included. Results 2826 patients from 12 international centers were compared (n=20 CCA and n=480 sCTA). No difference in baseline demographics, tumor characteristics or postoperative complications was seen. Microsurgical approaches (60% CCA vs. 62.3% sCTA) were most common. Gross total resection (GTR) was higher in CCA patients (100% vs. 83%, p=0.05). Among patients that had GTR according to intraoperative findings, fewer CCA patients had postoperative hormone normalization of pituitary function (50% vs. 77.8%, p<0.01) and remission of hypersecretion by 3-6 months (75% vs. 84.3%, p<0.01). This was present despite CCA having better local control rates (100% vs. 96%, p<0.01) and fewer patients with remnant on MRI (0% vs. 7.2%, p<0.01). A systematic literature review of 35 studies reporting on various treatment strategies reiterated the high rate of residual tumor, persistent hypercortisolism, and tumor-related mortality in CCA patients. Conclusion This modern, multicenter series of patients with CCA reflects their poor prognosis and reduced post-surgical hormonal normalization. Further work is necessary to better understand the pathophysiology of CCA to devise more targeted treatment approaches. References (0) Cited by (0) Previous presentations: none Previous publications: none Disclosures No relevant disclosures to report CREDIT statement Matthew Finlay: conceptualization, writing – review and editing Richard Drexler: conceptualization, writing – review and editing All: data curation, writing – review and editing Michael Karsy: conceptualization, data curation, methodology, writing – original draft, writing – review and editing, supervision Funding and Disclosures: none View full text From https://www.sciencedirect.com/science/article/abs/pii/S187887502301344X

Bridget Houser felt despairing. In the months before her 2018 wedding, Houser, who had never struggled with her weight, noticed that it inexplicably began to creep up. In response she doubled the length of her runs to eight miles, took back-to-back high intensity workout classes and often consumed only water, coffee and fruit during the day before a spartan, mostly vegetable, dinner. Yet no matter what Houser did, her weight stubbornly increased and her oval face grew round, a transformation that was glaringly obvious in comparison with her identical twin sister. Houser wondered whether the five pounds she gained despite her herculean effort was a corollary of other problems. For the previous two years she had battled a string of maladies: first daily headaches, then crippling anxiety, followed by insomnia, hair loss and acne, something she’d never endured as a teenager. “Stress was the universal explanation,” recalled Houser, a controller for a small business in Chicago. When doctors suggested that her upcoming marriage might be a cause of her problems, Houser considered, then rejected, the theory. It just didn’t jibe with her feelings. In early 2019, about six months after her wedding, Houser insisted that her doctors perform several tests. They ultimately revealed that her symptoms weren’t the result of stress or marital misgivings but of a serious illness that had been smoldering for years. After successful treatment followed by a long recovery Houser, now 34, feels far better than she did during those miserable years in her late 20s. “I wish I’d been nicer to myself and not blamed myself for what was going on,” she said. Getting through the wedding In 2016 Houser began experiencing daily pain in the back of her head, a common spot for tension headaches. When the headaches failed to improve with dietary changes or nonprescription pain relievers, she consulted her primary care doctor, followed by a neurologist who told her she had migraines. Houser, then 27, noticed that the headaches were worse when she wore contact lenses. “It was affecting my daily life and I talked myself into thinking the problem was my contacts,” she said. She decided Lasik surgery might help and in October 2017 underwent the procedure, which uses a laser to reshape the cornea, reducing or eliminating dependence on contacts or glasses. Her vision improved and the pain disappeared — briefly. A week after eye surgery, her headaches returned. “I wasn’t overly concerned,” Houser said. “I know a lot of people have headaches.” A few months later for no apparent reason Houser developed “really bad anxiety. It wasn’t just like I was anxious,” she recalled. “I couldn’t function. I’m Type A so I knew what anxiety is, but not to this degree.” One weekday morning in early 2018 she felt so overwhelmed that she took a sick day, then called her twin, Molly, and their mother and told them she needed help immediately. They managed to schedule a same-day appointment with a psychiatrist whom Houser began seeing regularly, along with a therapist. The psychiatrist zeroed in on her impending wedding and told Houser that the event can cause “huge anxiety.” She began taking an antidepressant along with Ativan, an anti-anxiety drug she used when things got really bad. She also ramped up her yoga practice, hoping it might calm her. Houser vividly remembers riding the escalator to her office one morning “and in my head I kept saying, ‘I’m in trouble, I’m in trouble,’” although she didn’t know what was wrong. Her changing appearance had become a source of great unhappiness. Although her weight remained in the normal range, Houser couldn’t figure out why she was gaining weight after drastically slashing her food intake and dramatically ramping up exercise. Her normally thick hair had thinned so noticeably that her hairdresser gently advised her to consult a doctor. Houser’s psychiatrist thought her hair loss might be caused by her antidepressant and switched medications. That didn’t seem to help. Houser was particularly bothered by her newly chubby face. “It was like a joke in my family,” she said, adding that she was teased about being overly sensitive. Even her wedding day was colored by unhappiness about her appearance and the intense amorphous anxiety that seemed omnipresent. “Rather than think about how excited I was,” Houser recalled, “it was ‘How can I get through this day?’” Normal thyroid After her wedding Houser felt worse. She developed severe insomnia, night sweats and acne. In February 2019 a nurse practitioner in her primary care practice ordered tests of her thyroid, which were normal. When Houser pressed for additional testing, she was referred to an endocrinologist. He told her she was stressed. Dissatisfied, she saw a second endocrinologist who agreed with the first. “She said ‘I don’t think there’s anything wrong with you’” metabolically, Houser recalled. The second endocrinologist’s nurse even revisited the marriage question in the presence of Houser’s husband, Doug, who had accompanied her to the appointment. “She said ‘I knew on my honeymoon I shouldn’t have gotten married,’” Houser remembered her saying. “‘Are you in a happy marriage?’ I couldn’t believe it.” Months earlier, the nurse practitioner who ordered the thyroid tests briefly mentioned measuring levels of cortisol, a hormone involved in the body’s response to stress and other functions. Elevated levels of cortisol can indicate Cushing’s syndrome, an uncommon hormonal disorder that occurs when the body produces too much of the hormone over a prolonged period. “She had thrown cortisol testing out there and I think it was always in the back of my mind,” Houser said. She asked the second endocrinologist to order cortisol tests. The doctor agreed, but not before telling Houser that she didn’t think she had Cushing’s because she lacked the classic symptoms: major weight gain, purple stretch marks and a fatty hump between the shoulders. Houser did have the “moon face” characteristic of Cushing’s that is also seen in people who take high doses of steroids for long periods to treat various illnesses — but Houser wasn’t taking steroids. Insomnia, headaches, acne and anxiety can be symptoms of Cushing’s. There are several forms of Cushing’s syndrome, which typically results from a tumor — usually benign but sometimes cancerous — in the pituitary or adrenal gland that pumps out excess cortisol. Sometimes tumors develop elsewhere in the body such as the lungs or pancreas. Cushing’s affects roughly five times as many women as men and typically occurs between the ages of 30 and 50. If left untreated, it can be fatal. A trio of tests measuring cortisol levels in Houser’s blood, urine and saliva were significantly elevated; the amount in her urine was eight times higher than normal. The formerly skeptical Chicago endocrinologist told Houser she had Cushing’s and referred her to James Findling, a Milwaukee endocrinologist who is internationally recognized for his treatment of the disease. “I was just so happy to have a diagnosis,” Houser recalled. Revealing photos Findling asked Houser to bring photographs taken several years earlier to her October 2018 appointment. It is a request he makes of patients as a way of spotting telltale physical manifestations. In Houser’s case, the facial change was particularly striking because she is an identical twin. Findling noted that delayed diagnosis is typical, because physical changes and other symptoms tend to occur gradually and insidiously. Houser, he added, “didn’t look like the typical Cushing’s patient. She wasn’t obese and she didn’t have diabetes or hypertension. It was more subtle than many cases.” The next step was determining the location of the tiny tumor. Tests found nothing in Houser’s pituitary or adrenal glands, and CT scans of her pelvis, chest and abdomen were clean. Findling ordered a dotatate PET scan, a highly sensitive CT scan that can find tumors that elude conventional imaging. The scan revealed a nodule in Houser’s left lung. Houser sought a second opinion from a thoracic surgeon in Chicago. While Findling and a thoracic surgeon at Milwaukee’s Froedtert Hospital strongly recommended that she undergo surgery to remove the tumor, the Chicago doctor disagreed. He said he didn’t think the lung nodule was causing Cushing’s and recommended that Houser continue therapy and anti-anxiety medication. “Do you know what it’s like to wake up from surgery and to not be better?” she remembers him asking her. After deliberating with her husband and conferring with her Milwaukee doctors, Houser opted for surgery performed Oct. 30, which removed part of her left lung. A pathologist determined that the nodule was a rare, slow-growing neuroendocrine lung cancer known as a bronchial carcinoid, which can cause Cushing’s. The Stage 2 cancer had spread to a nearby lymph node. “Fortunately I think we got it early,” Findling said. “She’s had a sustained remission and a cure of her Cushing’s.” “The cancer didn’t rock my world,” said Houser, who had previously had a melanoma skin cancer removed. (Doctors have told her they don’t think the cancers are related.) “It was about not having Cushing’s anymore, which was more important.” So why didn’t Houser’s doctors, among them endocrinologists, suspect Cushing’s? Findling, who estimates he has treated as many as 2,000 people with the disease in his 40-year career, said that while doctors are taught that Cushing’s is rare, it’s not. He cites a 2016 study, which that found that 26 of 353 endocrinology patients were found to have the disease. Textbook descriptions, which include the presence of purple stretch marks and a hump, are “almost a caricature,” Findling observed. “It’s pretty well recognized that Cushing’s is more subtle than that … and can cause neuropsychiatric and neurocognitive problems.” Houser’s normal weight and the fact that she didn’t have high blood pressure or diabetes may have misled doctors. “I think we’ve moved the needle a little bit, especially among endocrinologists,” he continued, adding that “the threshold for screening has got to change. Once you tell a primary care doctor that it’s a rare disorder, it goes in one ear and out the other. They think they’ll never see it.” “When you make this diagnosis it can have fabulous outcomes,” he added, citing Houser’s case. “That’s why I’m still doing this at my age.” Houser considers Findling to be her “literal lifesaver.” She spent the next year seeing him as she was slowly weaned off medications to normalize her hormone levels and recover her strength. She is monitored for Cushing’s annually, remains cancer-free and, other than residual fatigue, feels well. In October 2021 she gave birth to a daughter. Her son was born eight weeks ago. Houser regards the help provided by her family, particularly her husband whom she called “my biggest supporter,” as essential. That seems especially ironic because stress about their marriage had been blamed for symptoms that were actually caused by a cancer. “He was a huge help in calling doctors and making the necessary appointments when I didn’t have the energy to fight anymore.” His unwavering love, she said, was “a testament to our strong marriage.” From https://www.washingtonpost.com/wellness/2023/10/07/weight-anxiety-wedding-medical-mysteries/

Highlights The most common cause of ectopic ACTH syndrome is pulmonary carcinoid tumors and squamous cell lung cancer; however it is a relatively uncommon complication of pulmonary neoplasms. The most common cause of Cushing syndrome is iatrogenic corticosteroid use and it should be considered in all patients regardless of clinical background. Low urine cortisol levels may be associated with exogenous glucocorticoid exposure. Occult glucocorticoid exposure is rare but can be evaluated with liquid chromatography. Consumers should be aware of the potential risks of taking supplements, especially those advertised as joint pain relief products. Abstract Background Well differentiated bronchial neuroendocrine neoplasms often follow a clinically indolent course and rarely cause Ectopic ACTH syndrome. Iatrogenic corticosteroid use is the most common cause of Cushing syndrome and should be considered in all patients regardless of clinical background. Case report A 59 year old woman with an 11 year history of a 1.5 cm well differentiated bronchial carcinoid, presented with Cushingoid features. Laboratory results were not consistent with an ACTH dependent Cushing Syndrome and exogenous steroids were suspected. The patient received an FDA alert regarding a glucosamine supplement she had started 4 months prior for joint pain. Discussion Ectopic ACTH production is reported in less than 5% of patients with squamous cell lung cancer and 3% of patients with lung or pancreatic (non-MEN1) neuroendocrine tumors. Factitious corticoid exposure is rare and can be evaluated with synthetic corticosteroid serum testing. Conclusion Cushing syndrome due to supplements containing unreported corticosteroid doses should be considered in patients with typical Cushingoid features and contradictory hormonal testing. 1. Introduction Well differentiated bronchial neuroendocrine neoplasms often follow a clinically indolent course and can rarely exhibit Cushing syndrome due to ectopic production of adrenocorticotropic hormone (ACTH). However the most common cause of Cushing syndrome is iatrogenic corticosteroid use and should be considered in all patients regardless of clinical background (see Fig. 1, Fig. 2, Fig. 3, Fig. 4). Download : Download high-res image (243KB) Download : Download full-size image Fig. 1. DOTATATE PET/CT demonstrates a right upper lobe pulmonary nodule with intense uptake. Download : Download high-res image (201KB) Download : Download full-size image Fig. 2. DOTATATE PET/CT demonstrates intense uptake within a right upper lobe pulmonary nodule, consistent with biopsy-proven carcinoid tumor. There are no distant sites of abnormal uptake to suggest metastatic disease. Download : Download high-res image (399KB) Download : Download full-size image Fig. 3. Artri Ajo King Supplement (Source: FDA). The label claims that the product contains glucosamine, chondroitin, collagen, vitamin C, curcumin, nettle, omega 3, and methylsulfonylmethane. Download : Download high-res image (288KB) Download : Download full-size image Fig. 4. Artri King Supplement (Source: FDA). 2. Case report A 59–year old woman with an 11 year history of a 1.5 cm well-differentiated bronchial carcinoid, presented with 20 lb. weight gain, facial swelling, flushing, lower extremity edema and shortness of breath over 3 months. On exam, the patient was normotensive, centrally obese with mild hirsutism, facial fullness and ruddiness with evidence of a dorsocervical fat pad. Initially there was concern for hormonal activation of her known bronchial carcinoid. Testing resulted in a normal 24-hour urine 5-HIAA (6 mg/d, n < 15 mg/dL), elevated chromogranin A (201 ng/mL, n < 103 ng/mL), normal histamine (<1.5 ng/mL, n < 1.7 ng mL), low-normal 7 AM serum cortisol (5.1 μg/dL, n 3.6–19.3 μg/dL), normal 7 AM ACTH (17 pg/mL, n < 46 pg/mL) and a surprisingly low 24-hr urinary free cortisol (1.8 mcg/hr, n 4.0–50.0 mcg/hr). A late night saliva cortisol was 0.03 mcg/dL (n 3.4–16.8 mcg/dL). Testosterone, IGF-1, glucose and electrolytes were appropriate. An echocardiogram showed an ejection fraction of 60% with no evidence of carcinoid heart disease. A Dotatate PET-CT was obtained to evaluate for progression of the neuro-endocrine tumor and revealed a stable right upper lobe pulmonary nodule with no evidence of metastatic disease. Given low cortisol levels, ectopic Cushing syndrome was excluded and exogenous steroids were suspected, however the patient denied use of oral,inhaled, or injected steroids. A cosyntropin stimulation study yielded a pre-stimulation cortisol 6.2 μg/dL with an adequate post-stimulation cortisol 23.5 μg/dL. At this stage of evaluation, the patient received an FDA alert regarding a glucosamine supplement she had started 4 months prior for joint pain. The notification advised of hidden drug ingredients including dexamethasone, diclofenac, and methocarbamol contained within Artri King Glucosamine supplements not listed on the product label but verified by FDA lab analysis. The FDA had received several adverse event reports including liver toxicity and even death associated with such products. The patient's symptoms gradually improved after discontinuation of the supplement. 3. Discussion 3.1. Ectopic ACTH syndrome This patient's Cushingoid features were initially suspected to be secondary to the known bronchial neuroendocrine tumor. Ectopic ACTH production accounts for about 5–10% of all Cushing Syndrome cases [1]. The most common location of ectopic ACTH is the lungs with pulmonary carcinoid tumors being the most common cause, followed by squamous cell lung cancer [2]. Despite this patient's history of bronchial carcinoid tumor and positive chromogranin histopathological marker, her laboratory results were not consistent with an ACTH dependent Cushing Syndrome. In fact, Cushing syndrome is a relatively uncommon neuroendocrine neoplasm complication. The prevalence of ectopic ACTH production in patients with lung tumors is rare, at less than 5% in squamous cell lung cancer and about 3% in patients with lung or pancreatic (non-MEN1) neuroendocrine tumors1. Patients with ACTH dependent Cushing syndrome not suspected to originate from the pituitary, undergo further testing to evaluate for an ectopic ACTH secreting tumor. These tests include conventional imaging of the chest, abdomen and pelvis, as well as functional imaging such as octreotide scans, fluoride 18-fluorodeoxyglucose-positron emission tomography [18F-FDG PET], and gallium-68 DOTATATE positron emission tomography-computed tomography [Dotatate PET-CT] scan [3]. In our literature review, we found that there was insufficient evidence to determine the sensitivity and specificity of nuclear medicine imaging techniques [4,5]. In this case, the patient had no laboratory evidence for ACTH dependent Cushing Syndrome, but given the known bronchial carcinoid tumor, a repeat Dotatate PET-CT scan was obtained which demonstrated no indication of growth or spread of the known bronchial tumor. 3.2. Supplement induced Cushing Syndrome One of the most remarkable findings in this case was the patient's low urine cortisol level in the setting of her overt Cushingoid features. In our survey of the literature, we found that low urine cortisol levels were associated with exogenous glucocorticoid use [6,7]. The low urine cortisol levels may be reflective of intermittent glucocorticoid exposure. Indeed, this patient's Cushingoid features were determined to be secondary to prolonged use of Artri King supplement. Occult glucocorticoid use is difficult to diagnose even after performing a thorough medication reconciliation as patients may unknowingly consume unregulated doses of glucocorticoids in seemingly harmless supplements and medications. The incidence of supplement induced Cushing Syndrome is currently unknown as supplements are not regularly tested to detect hidden glucocorticoid doses. Additionally, the likelihood of developing supplement induced Cushing syndrome is dependent on dosage and duration of use. In our literature review we found nine published articles describing supplement induced Cushing Syndrome [[7], [8], [9], [10], [11], [12], [13], [14], [15]], one case report of tainted counterfeit medication causing Cushing Syndrome [16], and two cases of substances with probable glucocorticoid-like activity [17,18]. Of the nine published articles of supplement induced Cushing Syndrome, six were associated with supplements marketed as arthritic joint pain relief products including ArtriKing, Maajun, and AtriVid [[7], [8], [9], [10], [11], [12]]. These products later received government issued warnings in Mexico, Malaysia, and Colombia respectively [[19], [20], [21]]. To our knowledge there have been four published reports of ArtiKing supplement induced Cushing Syndrome [[7], [8], [9], [10]]. The first documented cases were reported in 2021 in Vera Cruz, Mexico; since then the Mexican medical community reported seeing a disproportionate increase in cases of iatrogenic Cushing Syndrome due to these supplements [7]. There have also been three American published articles describing a total of 4 cases of ArtriKing supplement induced Cushing syndrome [[8], [9], [10]]. In January 2022 the FDA issued a warning about Atri Ajo King containing diclofenac, which was not listed in the product label [22]. In April 2022 the FDA expanded its warning, advising consumers to avoid all Artri and Ortiga products after the FDA found these products contained dexamethasone and diclofenac [23]. In October 2022 the FDA issued warning letters to Amazon, Walmart, and Latin Foods market for distributing Artri and Ortiga products [24]. Many supplements are not regulated by the government and may contain hidden ingredients such as glucocorticoids. In these cases further evaluation of suspected products [25], medications [16], and patient serum [26] and urine [6] utilizing techniques such as liquid chromatography may be used to confirm occult glucocorticoid exposure. This case highlights the importance of educating patients to exercise caution when purchasing health products both online and abroad. Consumers should be aware of the potential risks of taking supplements, especially those advertised as joint pain relief products. 4. Conclusion Although the most common cause of ectopic ACTH syndrome is pulmonary carcinoid tumors and squamous cell lung cancer, it is a relatively uncommon complication of pulmonary neoplasms. Exogenous Cushing syndrome due to supplements containing unreported corticosteroid doses should be considered in patients with typical Cushingoid features and contradictory hormonal testing. Occult glucocorticoid exposure is rare but can be evaluated with liquid chromatography. This case report emphasizes the importance of teaching patients to be vigilant and appropriately research their health supplements. Patient consent Formal informed consent was obtained from the patient for publication of this case report. Declaration of competing interest The authors (Tomas Morales and Shanika Samarasinghe) of this case report declare that they have no financial conflicts of interest. Shanika Samrasinghe is an editorial member of the Journal of Clinical and Translational Endocrinology: Case Reports, and declares that she was not involved in the peer review and editorial decision making process for the publishing of this article. References [1] A.R. Hayes, A.B. Grossman The ectopic adrenocorticotropic hormone syndrome: rarely easy, always challenging Endocrinol Metab Clin N Am, 47 (2) (2018 Jun), pp. 409-425, 10.1016/j.ecl.2018.01.005 PMID: 29754641 View PDFView articleView in ScopusGoogle Scholar [2] A.M. Isidori, A. 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Adrenal incidentalomas (AI) are associated with an increased risk of cardiometabolic complications due to adrenal hyperfunction. Obtaining accurate prevalence estimates of distinct types of functioning AIs is crucial for efficient resource allocation and effective management strategies. For a study, researchers sought to ascertain the prevalence of various forms of autonomous hormone secretion in individuals diagnosed with adrenal incidentaloma, including autonomous/possible autonomous cortisol secretion (ACS), primary aldosteronism (PA), pheochromocytoma (PHEO), and Cushing syndrome (CS). A comprehensive and systematic search was conducted across multiple databases (PubMed, Ovid MEDLINE, Web of Science) up to February 2022. Among the 1,661 publications initially screened at the title and abstract levels, 161 articles underwent full-text examination, and ultimately, 36 studies were included for analysis. Three independent reviewers meticulously extracted clinical data from these selected studies. The overarching prevalence of functioning adrenal incidentalomas was 27.5% (95% CI 23.0, 32.5). The highest prevalence was observed for ACS/possible ACS, with a rate of 11.7% (95% CI 8.6, 15.7), followed by PA at 4.4% (95% CI 3.1, 6.2). Subgroup analysis unveiled a greater prevalence of PA in patients from Asian regions than those from Europe/America. Conversely, the prevalence of ACS/possible ACS was comparatively lower in Asian countries. Meta-regression analysis elucidated that the proportion of female patients influenced the prevalence of ACS/possible ACS, while PA prevalence positively correlated with the proportion of patients with hypertension and the publication year. PHEO and CS demonstrated prevalences of 3.8% (95% CI 2.8, 5.0) and 3.1% (95% CI 2.3, 4.3), respectively. The comprehensive meta-analysis offered valuable insights into the prevalence rates of diverse types of functioning adrenal incidentalomas and identified influential factors contributing to heterogeneity in these estimates. The findings contributed significantly to understanding clinical implications and aided in devising effective management strategies for individuals diagnosed with these adrenal disorders. Source: academic.oup.com/jcem/article-abstract/108/7/1813/7015785?redirectedFrom=fulltext

Abstract Background As the population ages, the number of elderly patients with an indication for pituitary surgery is rising. Information on the outcome of patients aged over 75 is limited. This study reports a large series assessing the feasibility of surgical resection in this specific age range, focusing on surgical complications and postoperative results. Methods A retrospective cohort study of patients with pituitary adenomas and Rathke’s cleft cysts was conducted. All patients were aged 75 years or over and treated by a single expert neurosurgical team. A control population included 2379 younger adult patients operated by the same surgeons during the same period. Results Between 2008 and 2022, 155 patients underwent surgery. Indication was based on vision impairment in most patients (79%). Median follow-up was 13 months (range: 3–96). The first surgery was performed with an endoscopic transsellar approach, an extended endonasal transtuberculum approach and a microscopic transcranial approach in 96%, 3%, and 1% of patients, respectively. Single surgery was sufficient to obtain volume control in 97% of patients. From Kaplan-Meier estimates, 2-year and 5-year disease control with a single surgery were 97.3% and 86.2%, respectively. Resection higher than 80% was achieved in 77% of patients. No vision worsening occurred. In acromegaly and Cushing’s disease, endocrine remission was obtained in 90% of non-invasive adenomas. Surgical complications were noted in 5% of patients, with 30-day mortality, hematoma, cerebrospinal fluid leak, meningitis, and epistaxis occurring in 0.6%, 0.6%, 1.9%, 0.6%, and 1.3% respectively. New endocrine anterior deficits occurred in only 5%, while no persistent diabetes insipidus was noted. Compared with younger patients, the complication rate was not statistically different. 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Am J Med 135(1):39–48 Article PubMed Google Scholar Download references Author information Authors and Affiliations Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de L’Hôpital, 75013, Paris, France Marta Garvayo, Vincent Reina, Stephan Gaillard & Bertrand Baussart Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland Marta Garvayo & Mahmoud Messerer Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France Chiara Villa, Anne Jouinot, Jérôme Bertherat, Guillaume Assié & Bertrand Baussart Department of Neuropathology, La Pitié-Salpêtière University Hospital, AP-HP, Sorbonne University, Paris, France Chiara Villa Department of Endocrinology, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne Billancourt, France Mirella Hage & Marie-Laure Raffin-Sanson Université de Versailles Saint-Quentin-en-Yvelines UFR Des Sciences de La Santé Simone Veil, Montigny-Le-Bretonneux, France Mirella Hage & Marie-Laure Raffin-Sanson Department of Endocrinology and Reproductive Medicine, Centre de Référence Des Maladies Endocriniennes Rares de La Croissance Et du Développement, CRMERC, Endo-ERN, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France Carine Courtillot & Anne Bachelot Université Paris-Saclay, Inserm, Physiologie Et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d’Endocrinologie Et Des Maladies de La Reproduction, Centre de Référence des Maladies Rares de L’Hypophyse, Le Kremlin-Bicêtre, France Peter Kamenicky & Philippe Chanson Sorbonne University, Endocrine Unit, Reproductive Medicine, Centre de Référence Des Maladies Endocriniennes Rares de La Croissance Et du Développement (CRMERC), Endo-ERN (Id 739527), Saint-Antoine Hospital, AP-HP, Paris, France Camille Vatier & Sophie Christin-Maitre Inserm UMRS938, Saint-Antoine Research Center, Sorbonne University, 75012, Paris, France Camille Vatier INSERM UMR-833, Trousseau Hospital, Paris, France Sophie Christin-Maitre Department of Endocrinology, Center of Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France Jérôme Bertherat & Guillaume Assié Corresponding author Correspondence to Bertrand Baussart. Ethics declarations Conflict of interest The authors declare no competing interests. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. Reprints and Permissions From https://link.springer.com/article/10.1007/s00701-023-05809-x

Abstract Introduction Laparoscopic adrenalectomy is the standard treatment for adrenal tumors caused by Cushing's syndrome. However, few pregnant women have undergone adrenalectomy because of the risk of general anesthesia and surgery. Case presentation A 28-year-old woman presented with gradually worsening Cushing's signs at around 12 weeks of pregnancy. Magnetic resonance imaging displayed a 38-mm left adrenal tumor, which was the cause of the adrenal Cushing's syndrome. Metyrapone was started, which increased androgen levels. Since the management of Cushing's syndrome by medication alone is challenging, unilateral laparoscopic adrenalectomy by a retroperitoneal approach was performed at 23 weeks of the pregnancy. No perioperative complications were noted. Conclusion Adrenalectomy is considered safe in pregnant women with Cushing's syndrome. Laparoscopic adrenalectomy by retroperitoneal approach should be chosen and performed between 14 and 30 weeks of pregnancy to prevent mother and fetal complications. Abbreviations & Acronyms CS Cushing's syndrome MRI magnetic resonance imaging Keynote message We report a rare case of adrenalectomy performed via a retroperitoneal approach for Cushing's syndrome in a pregnant woman. Cushing's syndrome may affect the fetus, and surgery can be considered in addition to medical management. Adrenalectomy should be performed in the second trimester of pregnancy. Pneumoperitoneal pressure, position, and surgical approaches must receive careful attention. Introduction CS is characterized by excessive cortisol secretion and characteristic symptoms such as full moon-like facial features and central obesity. Premenopausal women with CS rarely become pregnant because excessive glucocorticoid secretion inhibits the synthesis of gonadotropins, leading to impaired ovarian and endometrial function, and causing amenorrhea or oligomenorrhea.1 Furthermore, even when women with CS become pregnant, the incidence of severe complications is high. CS can cause maternal hypertension, diabetes/glucose intolerance, osteopenia/osteoporosis, preeclampsia, pulmonary edema, heart failure, opportunistic infections, and even death. Additionally, CS can potentially cause stillbirth, prematurity, and intrauterine fetal growth restriction.1-6 Therefore, CS must be detected at an early stage in pregnancy; however, CS may go undetected because of the overlapping signs of preeclampsia and/or gestational diabetes. A cortisol-secreting adrenal tumor is the underlying cause of CS, and laparoscopic adrenalectomy is the standard treatment to it. Medical treatment of CS can include medications that inhibit 11β-hydroxylase, such as metyrapone and osilodrostat, but surgical treatment is considered if the disease is difficult to control with medical treatment. Nonobstetric surgery during pregnancy is performed in 1%–2% of pregnant women.7 Although general anesthesia is relatively safe during pregnancy, the indication for the surgery must be carefully considered because of potential risks such as neurodevelopmental delay, sudden death, etc. Herein, we present a case of a pregnant woman diagnosed with CS who underwent unilateral laparoscopic adrenalectomy by a retroperitoneal approach without any problems. Case presentation The patient was a 28-year-old primiparous woman. Since around 12 weeks of pregnancy, she has experienced facial and lower limb edema; gained 6-kg weight in 1 month; increased facial acne; and experienced subcutaneous bleeding on the forearms, red abdominal dermatitis, proximal muscle weakness, palpitations, insomnia, and decreased vision in eyes. Her symptoms gradually worsened from 14 weeks, and she was referred to our hospital to clarify the cause at 18 weeks of pregnancy. Adrenal CS was suspected on the basis of her Cushing's signs, cortisol 25 μg/dL, and adrenocorticotropic hormone <1.5 pg/mL. She had hypokalemia, hypogammaglobulinemia, and liver dysfunction, and her condition was rapidly worsening. Given her pregnant state, she was admitted for intensive testing for the case of CS from 19 weeks of pregnancy. MRI revealed a well-defined 38-mm left adrenal tumor, which was the cause of the adrenal CS (Fig. 1). She was started on metyrapone with 250 mg per day, which increased androgens (0.53–0.69 ng/mL in 1 week). We considered that the management of CS by medication alone would be challenging and performed adrenalectomy during her pregnancy. The dose of metyrapone was increased to 1000 mg per day eventually. Fig. 1 Open in figure viewerPowerPoint Magnetic resonance imaging on admission shows a left adrenal tumor with a long axis of 38 mm (arrowhead). Signal reduction was partially observed on opposed-phase images, leading to diagnosis of cortical adenoma. She was admitted to the hospital at 23 weeks and 2 days of gestation, and laparoscopic left adrenalectomy was performed via a retroperitoneal approach in the right lateral and jackknife position on the following day (Fig. S1). During the surgery, blood pressure was carefully controlled by an anesthesiologist and the patient's position and fetal heart rate were monitored by an obstetrician. The operation time, insufflation time, and general anesthesia time were 68, 59, and 123 min, respectively, and the blood loss volume was 75 mL, without any complications. Pathological findings revealed an adrenocortical adenoma. The specimen was positive for one of the nine Weiss criteria (Fig. 2). Fig. 2 Open in figure viewerPowerPoint (a) Intraoperative findings of the retroperitoneal approach. Arrowheads indicate the tumor. (b) Gross appearance of the resected adrenal tumor; a brownish-toned, substantial mass, 60 × 34 × 15 mm in size. (c, d) Hematoxylin–eosin staining showed that nodular lesion with a fibrous capsule, with foci of homogeneous cells with eosinophilic or pale, foamy sporangia and small round nuclei. Postoperatively, metyrapone was discontinued and both lower leg edema, facial acne, fatigue, and muscle weakness improved. Metyrapone was discontinued after surgery. Hydrocortisone, which had been administered at 150 mg/day during the perioperative period, was reduced every few weeks and was taken at 30 mg/day at delivery. She delivered by cesarean section at 38 weeks and 2 days of gestation, with good outcomes for the mother and her infant. Hydrocortisone was discontinued 15 weeks after delivery. We showed the changes in cortisol and ACTH from the first visit to postpartum (Fig. 3). Fig. 3 Open in figure viewerPowerPoint The transition of Cortisol and ACTH. Cortisol decreases rapidly after surgery and rises again before delivery. As cortisol improved, ACTH also increased. Discussion CS seldom occurs during pregnancy. Symptoms such as weight gain, skin striae, fatigue, and a round face can also occur in normal pregnancies. The dexamethasone suppression test can result in false positives because of ACTH produced by placenta in normal pregnancy. During pregnancy, there is a physiological state of high cortisol levels. The disappearance of diurnal rhythm is a useful indicator for diagnosis of CS in pregnancy because circadian rhythm is maintained in normal pregnancy. Useful diagnostic criteria include urine cortisol levels greater than three times the upper limit of normal, loss of diurnal cortisol rhythm, and presence of adrenal tumors on MRI. The pharmacologic treatment of endogenous cortisol is complex, and hormonal management is challenging. While the management of the cortisol levels is important, metyrapone is a risk factor for gestational hypertension and may inhibit fetal cortisol production by crossing the placenta.1-6, 8-12 In this case, because androgens were also elevated and drug management was expected to be challenging, the surgery was aggressively considered. Despite the reports of successful adrenalectomy is after 28 weeks of gestation,6, 13, 14 The surgery should be performed by an experienced team between 14 and 30 weeks of pregnancy, that is, after organogenesis phase and before the fetus grows too large.1, 13, 15 A few pregnant women with adrenal CS undergo adrenalectomy. However, the laparoscopic approach is safe, and maternal and fetal complications were higher in women who did not undergo surgery.16 Less postoperative pain, faster wound healing, and faster postoperative recovery are the main advantages of laparoscopic surgery.17 In pregnant women, pneumoperitoneal pressure should be kept <12 mmHg because increased intraabdominal pressure decreases placental blood flow and can cause fetal acidosis due to the absorption of carbon dioxide used for insufflation. Laparoscopic adrenalectomy can be safely performed through both transperitoneal and retroperitoneal approaches.18 However, in pregnant women, performing the surgery by the retroperitoneal approach in the lateral position is preferable to prevent putting pressure on the fetus during the surgery. The retroperitoneal approach is advantageous, as less pressure is placed on the uterus and adhesions are prevented. After taking the lateral position, the obstetrician is advised to check the position and confirm that the abdomen is not compressed and that the fetal heart rate is normal. Conclusions We present a case of a pregnant woman diagnosed with adrenal CS who underwent a unilateral laparoscopic adrenalectomy by a retroperitoneal approach without any problems. Adrenalectomy is a useful treatment when CS is difficult to control despite metyrapone and other medical support. Author contributions Nobuyoshi Takeuchi: Conceptualization; methodology; project administration; writing – original draft. Yusuke Imamura: Conceptualization; methodology; supervision; writing – review and editing. Kazuki Ishiwata: Data curation; supervision. Manato Kanesaka: Data curation; supervision. Yusuke Goto: Data curation; supervision. Tomokazu Sazuka: Data curation; supervision. Sawako Suzuki: Data curation; supervision. Hisashi Koide: Data curation; supervision. Shinichi Sakamoto: Data curation; supervision. Tomohiko Ichikawa: Data curation; supervision. Conflict of interest The authors declare no conflicts of interest. Approval of the research protocol by an Institutional Reviewer Board Not applicable. Informed consent Informed consent for the release of the case report and accompanying images has been obtained from the patient. Registry and the Registration No. of the study/trial Not applicable. From https://onlinelibrary.wiley.com/doi/10.1002/iju5.12637

Introduction to Endocrinology Endocrinology is a medical specialty that focuses on the diagnosis and treatment of diseases related to hormones. Endocrinologists are experts in managing and treating diseases related to the endocrine system, which includes the thyroid, pituitary, adrenal glands, and pancreas. Endocrinologists are trained to diagnose and treat conditions such as diabetes, thyroid disorders, pituitary disorders, and other conditions related to hormones. Endocrinologists also specialize in reproductive health and fertility issues, including PCOS. Endocrinology is a complex field that requires a deep understanding of the endocrine system and its role in regulating the body’s hormones. Endocrinologists must be able to interpret laboratory tests and understand the underlying causes of endocrine disorders. They must also be able to develop individualized treatment plans to address the specific needs of each patient. Diagnosing PCOS and Diabetes Endocrinologists are experts in diagnosing and managing PCOS and diabetes. PCOS is a hormonal disorder that affects the ovaries, and it is characterized by irregular menstrual cycles, excess facial and body hair, and infertility. To diagnose PCOS, an endocrinologist will perform a physical exam and order laboratory tests to measure hormone levels. The endocrinologist will also ask the patient about her symptoms and family history to determine if PCOS is the cause. Diabetes is a chronic condition that affects the body’s ability to process sugar. To diagnose diabetes, an endocrinologist will perform a physical exam and order laboratory tests to measure blood sugar levels. The endocrinologist may also order imaging tests to check for signs of diabetes-related complications. Treating PCOS and Diabetes Once the endocrinologist has diagnosed PCOS or diabetes, they will develop an individualized treatment plan to address the patient’s specific needs. For PCOS, the endocrinologist may recommend lifestyle changes such as weight loss, exercise, and dietary changes to help manage symptoms. The endocrinologist may also prescribe medications to regulate hormone levels and improve fertility. For diabetes, the endocrinologist may recommend lifestyle changes such as weight loss, exercise, and dietary changes to help manage blood sugar levels. The endocrinologist may also prescribe medications to help regulate blood sugar levels. In addition, the endocrinologist may recommend regular check-ups to monitor the patient’s progress and to adjust the treatment plan if needed. Conclusion Endocrinology plays an important role in managing PCOS and diabetes. Endocrinologists are experts in diagnosing and treating these conditions, and they are trained to develop individualized treatment plans that address the specific needs of each patient. By working with an endocrinologist, patients can get the help they need to manage their PCOS or diabetes and achieve their health goals. Endocrinology is a complex field that requires a deep understanding of the endocrine system and its role in regulating the body’s hormones. An endocrinologist can help patients with PCOS and diabetes manage their conditions and achieve their health goals. By working with an endocrinologist, patients can get the help they need to manage their PCOS or diabetes and achieve their health goals. From https://www.diabetesincontrol.com/the-role-of-endocrinology-in-managing-polycystic-ovary-syndrome-and-diabetes/

Abstract Background 18Fluorine-Fluoro-deoxy-glucose (18F-FDG) positron emission tomography (PET) is widely used for diagnosing various malignant tumors and evaluating metabolic activities. Although the usefulness of 18F-FDG PET has been reported in several endocrine diseases, studies on pituitary disease are extremely limited. To evaluate whether dexamethasone (DEX) suppression can improve 18F-FDG PET for the localization of adrenocorticotropic hormone-secreting adenomas in the pituitary gland in Cushing’s disease (CD). Methods We included 22 patients with CD who underwent PET imaging before and after DEX administration. We compared the success rates of PET before and after DEX suppression, magnetic resonance imaging (MRI), and bilateral inferior petrosal sinus sampling (BIPSS). We determined the final locations of adenomas based on intraoperative multiple-staged resection and tumor tissue identification using frozen sections. Standardized uptake value (SUV) were analyzed to confirm the change of intensity of adenomas on PET. Results Twenty-two patients were included (age at diagnosis: 37 [13–56] years), and most were women (90.91%). Pituitary adenomas compared to normal pituitaries showed increased maximum SUV after DEX suppression but without statistical significance (1.13 versus. 1.21, z=-0.765, P = 0.444). After DEX suppression, the mean and maximum SUV of adenomas showed a positive correlation with nadir cortisol levels in high-dose DEX suppression test (Rho = 0.554, P = 0.007 and Rho = 0.503, P = 0.017, respectively). In reference sites, mean SUV of cerebellum was significantly decreased (7.65 vs. 6.40, P = 0.006*), but those of the thalamus and gray matter was increased after DEX suppression (thalamus, 8.70 vs. 11.20, P = 0.010*; gray matter, 6.25 vs. 7.95, P = 0.010*). Conclusion DEX suppression did not improve 18F-FDG PET/CT localization in patients with CD. Introduction Cushing’s disease (CD) is a rare endocrine disease that results from chronic exposure to high cortisol levels because of adrenocorticotropic hormone (ACTH)-secreting pituitary tumors and is associated with increased morbidity and mortality. It represents approximately 80% of all cases of endogenous hypercortisolism [1,2,3]. Accurate localization of primary lesions in CD leads to improved remission rates and reduced adverse events following surgery [4, 5]. A biochemical remission rate of 90–100% has been reported when tumors are localized before surgery, but it can decrease to 50–60% when surgery is performed when the location of the tumor is unknown in patients with CD [6,7,8]. Currently, magnetic resonance imaging (MRI) is the gold standard for detecting pituitary adenomas. Nevertheless, modern MRI modalities, including dynamic or volumetric sequences, can reliably detect corticotrophic adenomas in 50–90% cases of CD [9,10,11,12]. This indicates that complementary imaging strategies are required to improve the localization of primary lesions in CD. One of the most characteristic features of corticotrophic adenomas is a compromised response to negative glucocorticoid feedback, which defines glucocorticoid resistance [13]. ACTH activates the adrenal glands to synthesize and secrete cortisol, which in turn negatively modulates the release of ACTH from the pituitary gland and corticotrophin-releasing hormone (CRH) and vasopressin from the hypothalamus [1]. In CD, a corticotrophic tumor is only partially sensitive to the inhibitory feedback exerted by cortisol, which in turn is not regulating its own production and secretion of ACTH, resulting in both excessive ACTH and cortisol levels. Glucocorticoid resistance is caused by multiple factors including glucocorticoid receptor availability, splice variant expression and affinity, and imbalanced glucocorticoid receptor signaling [14, 15]. Radioactive 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) often demonstrates increased fluorodeoxyglucose (FDG) uptake in nonfunctioning and hormone-secreting pituitary adenomas [16,17,18]. In large observational studies of whole-body 18F-FDG positron emission tomography (PET) scans, incidental sellar 18F-FDG uptake was found in < 1% of cases, and this sign is highly specific for pituitary adenomas [19,20,21]. 18F-FDG PET imaging can detect up to 40% of corticotropinomas, some as small as 3 mm, and the rate of PET detection of corticotropinomas can be increased by CRH stimulation [9, 22]. Here, we evaluated whether DEX suppression could improve the localization of ACTH-secreting adenomas using 18F-FDG PET/CT in patients with CD. The rationale for this is as follows. FDG uptake of corticotrophic adenomas is less suppressed than that of normal pituitary glands after DEX suppression due to glucocorticosteroid resistance. Materials and methods Study design and population In this retrospective cohort study, we enrolled all patients with CD who underwent two rounds of 18F-FDG-PET/CT before and after 8-mg DEX suppression and pituitary MRI before surgery. Total 22 patients were included in this study, of which thirteen had bilateral inferior petrosal sinus sampling (BIPSS) results. All patients were diagnosed with CD by staff of the Department of Endocrinology and/or Neurosurgery at Severance Hospital between 2014 and 2015. The diagnosis of CD was confirmed based on biochemical test results, including the cortisol, 24-hour urine free cortisol (24 h UFC), and serum ACTH levels, overnight dexamethasone suppression test (ON DST) results, and high-dose dexamethasone suppression test (HD DST) results. Immediate remission was defined as hypocortisolism (serum cortisol level < 1.8 µg/dL) within the first 7 days after surgery. Delayed remission was defined as the achievement of hypocortisolism within 6 months, although immediate remission was not confirmed. If patients showed elevated postoperative cortisol levels and needed additional treatment within 6 months after surgery, we defined them as having persistent disease [23,24,25]. A serum cortisol concentration > 1.8 µg/dL for 8 h in the morning after 1 mg of DEX was given at midnight was considered to be a positive result in the ON DST [26]. Suppression of the serum cortisol level by > 50% for 6 h after 2 mg of DEX was administered for 2 days was defined as the suppression on the HD DST [26]. The final diagnosis was confirmed using surgical pathology and clinical follow-up. Endocrinological evaluation All laboratory analyses were performed at the Department of Laboratory Medicine, Severance Hospital. Preoperative cortisol and 24 h UFC were measured by chemiluminescence immunoassay using an automated UniCel DXC880i Synchron analyzer (Beckman Coulter, Pasadena, CA, USA; coefficient of variation [CV] ± 15 nmol/L at < 100 nmol/L and ± 15% at > 100 nmol/L). Preoperative ACTH levels were analyzed by electrochemiluminescence immunoassay using the Roche Cobas 6000 analyzer (Roche Diagnostics GmbH, Mannheim, Germany; CV ± 2.0 pmol/L at < 20 pmol/L and ± 10% at > 20 pmol/L). The serum cortisol concentration at 8:00 am the following day after 1 mg of DEX was administered at midnight was considered positive on the ON DST. We determined the result as “suppression” by the cortisol level of < 1.8 µg/dL. A serum cortisol level suppressed by > 50% of the original level after 6 hourly administrations of 2 mg of DEX for 48 h was defined as suppression on the HD DST [27]. 18F-FDG PET/CT evaluation PET/CT was performed using a GEADVANCE PET scanner (GE, Milwaukee, WI, USA) after the intravenous injection of 7–9 mCi of 18F-FDG. All patients fasted for at least 6 h before the test. Emission scanning was continued for 15 min (4.25-mm axial spatial resolution, 4.8-mm transaxial spatial resolution). Transmission scans were performed for 8 min using triple Ge-68 rod sources to correct attenuation. Gathered data were reconstructed in a 128 × 128 × 35 matrix with a pixel size of 1.95 × 1.95 × 4.25 mm by means of a filtered back-projection algorithm employing a transaxial 8.5-mm Hanning filter and 8.5-mm axial ramp filter. Two specialists independently interpreted the encoded baseline PET images, and after a two-week period, they interpreted the encoded post DEX suppression PET images. Each specialist was blinded to MRI imaging, clinical characteristics, and surgical outcomes of these subjects. Each was tasked with determining whether the PET image indicated a “negative” or “positive” result for pituitary adenoma and its location on a high-resolution computer screen. The scan after DEX suppression was performed 24 h after the oral administration of 8 mg of DEX using the same procedures as for the baseline PET/CT scan. 18F-FDG uptake analysis The Region of interest (ROI) was drawn using MIM software (version 6.5, Software INc., Cleveland, OH, USA) (Fig. 1). PET images were reviewed by experienced by an experienced specialist. The pituitary gland was identified and a circular ROI was drawn. A fixed ROI with a 3-mm diameter was used for all patients. The ROI was placed on the lesion with the highest FDG uptake. If there was no significantly increased FDG uptake, the same sized circular ROI was drawn on the suspected adenoma location. For the normal pituitary gland, the same sized 3 mm ROI was used. Fig. 1 Images of ROI for pituitary adenoma on18F-FDG PET scan Example of ROI definition in pituitary adenomas of 18F-FDG PET scan of the patients with CD. We draw the fixed circular ROI with a 3-mm diameter for pituitary adenomas (red circle) and normal pituitary gland (green circle) ROI, Reason of interest; 18F-FDG PET, 18 F-fluorodeoxyglucose positron emission tomography; CD, Cushing disease Full size image The mean standardized uptake value (SUVmean) and maximum SUV (SUVmax) for pituitary adenomas and normal pituitary glands were automatically measured using MIM, version 6.5 (Software Inc., Cleveland, OH, USA). The standardized uptake value (SUV) of the volume of interest was calculated as follows: (decoy-corrected activity (kBq) / volume (mL)) / (injected dose (kBq) / body weight (g)). SUVmean and SUVmax of pituitary adenomas were divided into the SUVmean of normal pituitary glands for adjustment. We used the ratio of SUVmax to SUVmean to analyze the homogeneity of the pituitary adenomas. MRI evaluation All patients underwent pituitary MRI with a 3.0-Tesla scanner (Achieva, Philips Medical Systems, Best, the Netherlands). Imaging protocols included T1-weighted imaging, T2-weighted imaging, and delayed gadolinium-enhanced T1-weighted imaging. The extent, location, and sizes of the pituitary tumors were reviewed based on official records determined by radiologists. Pituitary tumors were classified based on radiological findings using MRI of the sellar and parasellar regions. Type I refers to tumors < 1 cm in diameter limited to the sella. Type II tumors extend into the suprasellar space, < 1 cm from the diaphragm. Type III includes tumors extending into the suprasellar space > 1 cm from the diaphragm or sphenoid sinus and encroaching on the internal carotid arteries. Lastly, type IV refers to adenomas with obvious invasion into the cavernous sinus, as shown on MRI, and into the medial dural wall of the cavernous sinus, as confirmed during surgery. BIPSS Before surgery, BIPSS was performed to confirm the cause of CD and lateralize the tumors. A catheter was placed in patients using a unilateral femoral venous approach and 3 cc of blood was collected from the peripheral (P) and both inferior petrosal sinuses (IPS) [28]. CRH at a dose of 1 µg/kg was administered, and peripheral and petrosal samples were drawn after 5 and 10 min, respectively. The catheters and sheath were removed, and the groin was compressed under pressure until venous hemostasis was achieved. The IPS:P prolactin ratio was calculated at each time point to confirm the accuracy of the inferior petrosal venous sampling. A value of ≥1.8 was considered successful IPS catheterization. The prolactin-normalized ACTH ratio was calculated by dividing the dominant ACTH IPS:P ratio by the concurrent and ipsilateral IPS:P prolactin ratio. A value of ≥1.3 was considered diagnostic of CD. An intersinus ACTH ratio of ≥1.4 either at baseline or after stimulation was used for lateralization of the pituitary adenoma [29]. Location of the adenoma The final assignment of the true location of the pituitary adenoma was based on intraoperative multiple stage resection and tumor tissue identification using frozen sections. Surgically identified adenomas were histologically evaluated and stained for ACTH immunoreactivity. In cases of multiple specimens obtained during the procedure, the true location of the adenoma was assigned based on the original site of the specimen containing the adenoma [30]. Statistical analysis Data are presented as medians (ranges) or numbers (percentages). The baseline characteristics of the patients were compared using Kruskal–Wallis’ test with Dunn’s procedure for nonparametric continuous variables. Categorical variables were compared using Fisher’s exact test. Spearman’s correlation coefficients were used to determine the correlation between FDG uptake and hormone levels. Wilcoxon’s signed-rank test was used to identify changes in the SUV after DEX administration. The interobserver agreement for image analysis was assessed using κ statistics. κ values were categorized as follows: κ < 0.20 indicated poor agreement, κ of 0.21–0.40 indicated fair agreement, κ of 0.41–0.60 indicated moderate agreement, κ of 0.61–0.80 indicated good agreement, and κ > 0.81 indicated excellent agreement [31]. Statistical significance was set at a two-sided P < 0.05. All statistical analyses were performed using SPSS software (IBM Corp., Armonk, NY, USA). Results Patient characteristics We enrolled all patients with CD who underwent two rounds of the 18F-FDG PET/CT with or without DEX suppression and sellar MRI before transsphenoidal adenectomy (TSA). Twenty-two patients were included (age at diagnosis: 37 [13–56] years), and most were women (90.91%). Patients’ baseline characteristics are shown in Table 1. There were 16 microadenomas and 6 macroadenomas. Immediate remission was achieved in 81.82% of the patients and delayed remission in 13.64%; one patient showed persistent disease after TSA. The median preoperative 24 h UFC, serum ACTH, and cortisol levels were 443.35 (93.00–4452.00) µg/day, 36.16 (6.00–92.00) pg/mL, and 18.55 (6.00–40.00) µg/dL. The size of pituitary adenomas on MRI was 7.85 (2.00–28.00) mm. The Ki-67 index of 47.06% of adenomas ranged from 1 to 2, that of 35.29% was below 1, and that of 17.65% was 2 or higher. Overall, 75.00% of the adenomas were classified as Knosp grade 0, 5.00% as grade 1, 5.00% as grade 3b, and 15.00% as grade 4. In total, 77.27% (17/22) of patients had an ACTH-staining adenoma. Only one patient showed unsuppressed cortisol levels on the HD DST. Table 1 Patients’ imaging and clinical characteristics Full size table MRI negative but PET positive case Two patients showed negative MRI results, and one of them showed FDG uptakes on both 18F-FDG PET scans at baseline and after DEX suppression. A 26-year-old man visited our hospital complaining of weight gain and was diagnosed with ACTH-dependent CD. Cortisol secretion was suppressed on the HD DST; however, sellar MRI did not reveal any suspicious lesions. BIPSS revealed a central tumor (central/peripheral ACTH level of 36.25 after CRH stimulation) lateralized to the right side of the pituitary gland. The patient underwent 18F-FDG-PET/CT before and after DEX suppression to identify the primary lesions. Baseline PET/CT showed diffused FDG uptake with an SUVmax of 1.03 at the pituitary fossa but failed to localize the tumor. After DEX treatment, focal FDG uptake with an SUVmax of 1.06 remained at the right side of the pituitary fossa, which resulted in the successful localization of the corticotrophic adenoma. The MRI and PET/CT images of this case are presented in Fig. 2A–C. During TSA, the surgeon identified solid tumor-like tissues on the right side of the pituitary gland and successfully removed them. Results of pathology and ACTH immunohistochemistry were negative, but the patient achieved immediate biochemical remission and CD-related symptoms were relieved after surgery. We followed the patient for 98 months after the surgery and confirmed that he had lived without recurrence. Fig. 2 Images of a corticotroph with negative MRI but positive18 F-FDG PET/CT after DEX suppression An MRI-negative adenoma was detected on 18F-FDG PET/CT at baseline and after DEX suppression. In this patient, the pituitary adenoma was visible on PET scans at baseline (B) and after DEX suppression (C) at the same location, as confirmed by the surgeon A. Co-registered baseline 18F-FDG PET/CT and MRI images. Diffuse 18F-FDG uptake is detected in the pituitary fossa with an SUVmean of 0.86 and SUVmax of 1.03, but there was failure to localize the adenoma on baseline 18F-FDG PET/CT. B. Co-registered 18F-FDG PET/CT and MRI images after DEX suppression. 18F-FDG uptake is not suppressed in the right side of the pituitary gland with an SUVmean of 1.03 and SUVmax of 1.06. 18F-FDG PET/CT after DEX suppression was successful in localizing the right-sided corticotrophic adenoma C. MRI image. There is no suspicious lesion in the pituitary gland ACTH, adrenocorticotropic hormone; MRI, magnetic resonance imaging; 18F-FDG, 18 F-fluorodeoxyglucose; PET/CT, positron emission tomography/computed tomography; DEX, dexamethasone; SUVmean, mean standardized uptake value; SUVmax, maximum standardized uptake value Full size image Change of 18F-FDG uptake after DEX suppression We included 18 pituitary adenomas that were successfully localized using PET/CT after DEX suppression, and analyzed the change of SUV for 15 adenomas, excluding outliers with SUV over 2.00. The results are presented in Fig. 3A and B. The SUVmean of adenomas did not changed after DEX suppression compared to normal pituitary glands (SUVmean of adenoma/SUVmean of normal pituitary glands: 1.13 [0.85–1.35] vs. 1.14 [0.87–1.39], z=-1.288, P = 0.198). DEX suppression increased SUVmax of adenomas compared to normal pituitary glands but without statistical significance (SUVmax of adenoma/SUVmean of normal pituitary glands: 1.13 [0.96–1.52] vs. 1.21 [0.97–1.56], z=-0.765, P = 0.444). Fig. 3 Changes in the SUVs of corticotrophs between18F-FDG PET/CT before and after DEX suppression The SUVmean (A) and SUVmax (B) of corticotrophic adenomas are shown in this pairwise analysis. The SUVmean did not changed after DEX suppression from (z=-1.288, P = 0.198). The SUVmax of the corticotrophic adenoma increased from 1.13 to 1.21 (z=-0.765, P = 0.444). In this analysis, the SUVmean and SUVmax of pituitary adenomas were adjusted using the SUVmean of the normal pituitary gland. Colored plots and bars presented median and interquartile range in this figure. We presented the tumors with size larger than 5 mm and SUV adjusted by normal pituitary>1 for blue line SUVmean, mean standardized uptake value; SUVmax, maximum standardized uptake value; DEX, dexamethasone; 18F-FDG, 18 F-fluorodeoxyglucose; PET/CT, positron emission tomography/computed tomography Full size image In Fig. 3, the blue line indicates change in SUV of adenomas larger than 5 mm with higher FDG uptake than the surrounding pituitary parenchyma. For these adenomas, DEX suppression did not change the SUV (SUVmean of adenoma/SUVmean of normal pituitary glands: 1.31 [1.04–2.52] vs. 1.33 [1.05–2.38], z=-0.784, P = 0.433; SUVmax of adenoma/SUVmean of normal pituitary glands: 1.36 [1.02–2.61] vs. 1.40 [1.03–2.65], z=-1.022, P = 0.307). The value of SUV increased in 73.33% adenomas, while the SUVmax increased in 66.67% compared with normal pituitary glands after DEX treatment. Correlation between the hormone level and 18F-FDG uptake Table 2 shows the results of the Spearman correlation analysis of the SUV with preoperative cortisol, ACTH, and nadir cortisol levels on the HD DST. On the baseline 18F-FDG PET scan, the SUVmax of the adenomas did not show any correlation with the levels of three hormones. The SUVmean of adenomas showed a positive correlation with nadir cortisol levels on the HD DST (P = 0.014) and preoperative ACTH levels, with marginal significance (P = 0.062). After DEX suppression, the SUVmax and SUVmean of adenomas had a positive correlation with moderate degrees of nadir cortisol on the HD DST (SUVmax: Spearman Rho = 503, P = 0.017; SUVmean: Spearman Rho = 0.554, P = 0.007). Table 2 Correlation between FDG uptakes and hormone levels Full size table FDG uptake of reference sites after DEX suppression We evaluated the FDG uptake for five types of reference areas (normal pituitary gland, cerebellum, thalamus, white matter, and gray matter) (Table 3). Normal pituitary gland and white matter did not affect the unadjusted SUVmean by DEX suppression (all P >0.05). DEX significantly increased SUVmean of the thalamus and gray matter (thalamus, 8.70 [4.40–22.70] vs. 11.20 [6.40–17.5], P = 0.010*; gray matter, 6.25 [2.50–15.00] vs. 7.95 [5.00–11.90], P = 0.010*). However, SUVmean of the cerebellum significantly decreased after DEX administration (7.65 [4.50–10.80] vs. 6.40 [2.60–12.00], P = 0.006*). Table 3 The change of FDG uptake for reference sites after DEX suppression in the patients with CD Full size table Qualitative analysis by diagnostic modalities for CD The qualitative results of localizing pituitary adenomas in CD patients are shown in Table 4 and Fig. 4. Only 13 patients had BIPSS results. The success rates were 90.91% for MRI and 84.62% for BIPSS. Table 4 Qualitative analysis by diagnostic modalities for CD Full size table Fig. 4 Images for corticotroph adenomas that appear different for localization in18F-FDG PET/CT. 9 mm sized adenoma in the left lateral wing of pituitary gland. It was found in the left lateral wing of the pituitary gland, showing an 18F-FDG uptake in the pituitary fossa with an SUVmean of 1.04 and SUVmax of 1.07. However, after DEX suppression, the left side of the pituitary gland did not exhibit suppressed 18F-FDG uptake, with SUVmean 1.05 SUVmax 1.14 (A). Co-registered baseline 18F-FDG PET/CT and MRI images. (B). Co-registered 18F-FDG PET/CT and MRI images after DEX suppression. (C). MRI image 2 mm pituitary adenoma was detected at the left lateral wing, showing diffuse FDG uptake in the pituitary fossa with an SUVmean of 0.86 and SUVmax of 1.04. After DEX suppression, focal FDG uptake was observed, with SUVmean 0.87 and SUVmax 0.98. (D). Co-registered baseline 18F-FDG PET/CT and MRI images. (E). Co-registered 18F-FDG PET/CT and MRI images after DEX suppression. (F). MRI image Full size image In baseline PET scans, the specialists agreed that pituitary adenomas were visible in 17 scans and not visible in 5 scans. They reached a consensus that the tumor was evident in two scans, but there was a discrepancy in their assessments of its location. After DEX suppression, pituitary adenomas showed positive results in 16 scans and negative results in 5 scans. Specialists disagreed on the presence of pituitary adenomas in one case only. Interobserver agreement for localizing adenomas was 0.872 (95%CI: 0.711, 1.033) for baseline PET/CT and 0.938 (95%CI: 0.762, 1.056) for post dexamethasone suppression PET/CT, confirming excellent interobserver agreements, and the result was judged reliable. Among the instances where both opinions agreed, there were no lesions that showed differences in visibility between scans before and after DEX administration. This meant that lesions were either consistently visible or invisible in both scenarios. Discussion We found that DEX suppression did not improve localization of ACTH-secreting pituitary adenomas using 18F-FDG PET/CT. Further, it did not significantly affect FDG uptakes in adrenocorticotrophic adenomas or normal pituitaries in patients with CD. The decision to administer 8 mg dexamethasone was based on the standard high-dose DST, which is internationally recommended for differentiating between ectopic ACTH secretion and CD [26]. This test involved comparing serum cortisol levels at 8 am before and after a single dose of 8 mg dexamethasone administered at 11 pm. Suppression of the serum cortisol level to less than 50% of the baseline value indicated a diagnosis of CD [32, 33]. Previous studies have reported that the 8-mg DST has a sensitivity of 90%, specificity of 100%, accuracy of 96.8%, positive predictive value of 100%, and negative predictive value of 95.5% [34, 35]. Our use of 8 mg dexamethasone was based on the theory that orally administering dexamethasone at this dose can effectively suppress cortisol levels in ACTH-secreting pituitary tumors. We expected that FDG uptake by corticotrophic adenomas would not decrease after DEX administration in patients with CD, and this change may improve the ability to discriminate the tumor location from surrounding tissues on 18F-FDG PET. The SUVmax of pituitary adenomas adjusted for the normal pituitary gland increased from 1.13 to 1.21. However, this change was not statistically significant, and the success rate of localizing corticotrophic adenomas using 18F-FDG PET was not significantly improved after DEX suppression. If the FDG uptake of adenomas changed lesser compared to that of surrounding normal tissues after DEX suppression, the tumor could be more easily visualized because of the difference. In addition, we attempted to evaluate FDG uptakes in other brain areas (cerebellum, thalamus, white matter, and gray matter) according to DEX administration in CD patients. SUVmean of the cerebellum decreased significantly, but that of the thalamus and gray matter increased after DEX suppression. DEX did not change FDG uptake in pituitary adenoma, normal pituitary, or white matter. In a previous study analyzing FDG PET in CD patients, researchers observed varying correlations between FDG uptake and blood cortisol concentration across different brain regions [35, 36]. Nevertheless, the examination did not include an analysis of FDG uptake in the pituitary gland. Additionally, no previous studies have explored the effects of high-dose dexamethasone suppression on brain glucose metabolism in individuals with CD. Further studies are needed to explain the change in FDG uptake after DEX administration in patients with CD. 18F-FDG PET/CT provides information regarding glucose metabolism in the brain in vivo and has been widely used to evaluate brain metabolism in clinical and research settings [37]. Here, the nadir cortisol level on the HD DST correlated with the SUVmean and SUVmax of pituitary adenomas on PET scans after DEX suppression. Cortisol secretion activity is thought to be associated with metabolic activity, and DEX administration altered this. Cortisol levels and FDG uptake in other regions of the brain are correlated in patients with CD, but the correlation between cortisol and FDG uptake in the pituitary glands and/or corticotrophic adenomas themselves has not been discussed [35, 36]. In our study, cortisol levels did not show a correlation with FDG uptake of corticotrophic adenomas, but after DEX suppression FDG uptake showed a correlation with the nadir cortisol level on the HD DST. This indicated that tumors in which cortisol secretion was less suppressed by on the HD DST showed higher FDG uptake than tumors with lower cortisol levels on the HD DST. Although many studies have analyzed FDG uptake of brain tumors, reference sites defined in each study varied without a uniform standard. Gray matter, white matter, or adjacent tumor tissue was defined as a reference site [38,39,40]. We measured SUVmean of normal pituitary tissues, gray matter, white matter, thalamus, and cerebellum as possible references. We defined the SUVmean of normal pituitary tissues as a reference because the localization of adenomas requires an apparent difference between the adenoma and surrounding tissues. Use of fixed ROI to measure FDG uptake caused partial volume effect in this study. However, lesions smaller than 5 mm with intense FDG uptake may still show increased FDG uptake, especially in tumors, albeit with lower SUV values compared with the actual values [41]. This study was performed because pituitary adenomas smaller than 5 mm with higher FDG uptake than the surrounding pituitary parenchyma have been observed in routine clinical practice. To control for the partial volume effect, the analysis was performed again for tumors which were larger than 5 mm and had higher FDG uptake than the surrounding pituitary parenchyma, and the results remained unchanged. PET/CT has been explored as an alternative to or combined with MRI for the localization of corticotrophic adenomas. 18F-FDG PET/CT has a limited role in CD diagnosis, but CRH stimulation can increase its success rate [22, 42]. This study is important for increasing the effectiveness of PET using DEX. In addition, data on DEX effect on brain metabolism in patients with CD will be important for future studies. Conclusions DEX suppression did not improve the localization of 18F-FDG PET/CT in patients with CD. This is considered to have sufficient significance in an effort to increase the diagnostic value of 18F-FDG PET/CT. Data Availability All datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author upon reasonable request. Abbreviations 18F-FDG: 18F-fluorodeoxyglucose PET/CT: Positron emission tomography/computed tomography DEX: Dexamethasone MRI: Magnetic resonance imaging BIPSS: Bilateral inferior petrosal sinus sampling CD: Cushing’s disease SUV: Standardized uptake value ACTH: Adrenocorticotropic hormone CRH: Corticotrophin-releasing hormone FDG: Fluorodeoxyglucose 24hr UFC: 24-hour urine free cortisol ON DST: Overnight dexamethasone suppression test HD DST: High-dose dexamethasone suppression test SUVmean : Mean standardized uptake value SUVmax : Maximum standardized uptake value P: Peripheral IPS: Inferior petrosal sinuses TSA: Transsphenoidal adenectomy References Newell-Price J, Bertagna X, Grossman AB, Nieman LK. Cushing’s syndrome. The Lancet. 2006;367:1605–17. Article CAS Google Scholar Steffensen C, Bak AM, Rubeck KZ, Jørgensen JOL. Epidemiology of Cushing’s syndrome. Neuroendocrinology. 2010;92:1–5. Article CAS PubMed Google Scholar Lacroix A, Feelders RA, Stratakis CA, Nieman LK. 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Author information Authors and Affiliations Endocrinology, Institute of Endocrine Research, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea Kyungwon Kim, Cheol Ryong Ku & Eun Jig Lee Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea Dong Kyu Kim Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea Ju Hyung Moon, Eui Hyun Kim & Sun Ho Kim Contributions Conception and design: EJL, CRK, KK. Acquisition of data: KK, DKK. Analysis and interpretation of data: KK. Drafting the article: KK. Administrative/technical/material support: JHM, EHK, SHK. Study supervision: EJL, CRK. Writing, review, and revision of the manuscript: KK, DKK, SHK, CRK. Final approval of the manuscript: CRK, EJL. Corresponding authors Correspondence to Cheol Ryong Ku or Eun Jig Lee. Ethics declarations Ethics approval and consent to participate The data were collected under the conditions of regular clinical care with approval from the ethics committee of our hospital, and the requirement for written informed consent was waived owing to its retrospective design (institutional review board number: 2023-0110-001). Consent for publication Not applicable. Competing interests The authors declare no conflicts of interest that could be perceived as prejudicing the impartiality of this study. Additional information Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Electronic supplementary material Additional file 1 of Dexamethasone suppression for 18F-FDG PET/CT to localize ACTH-secreting pituitary tumors Additional file 1 Supplementary Material 1 Below is the link to the electronic supplementary material. 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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Reprints and Permissions Cite this article Kim, K., Kim, D.K., Moon, J.H. et al. Dexamethasone suppression for 18F-FDG PET/CT to localize ACTH-secreting pituitary tumors. Cancer Imaging 23, 85 (2023). https://doi.org/10.1186/s40644-023-00600-8 Download citation Received09 May 2023 Accepted08 August 2023 Published12 September 2023 DOIhttps://doi.org/10.1186/s40644-023-00600-8 Share this article Anyone you share the following link with will be able to read this content: Get shareable link Provided by the Springer Nature SharedIt content-sharing initiative Keywords 18F-FDG PET/CT ACTH-secreting pituitary tumor Cushing’s disease Dexamethasone suppression High-dose dexamethasone suppression test From https://cancerimagingjournal.biomedcentral.com/articles/10.1186/s40644-023-00600-8

Cushing syndrome is a metabolic disease caused by chronic exposure to high levels of glucocorticoids. It can present as an endocrine emergency due to a rapid increase in circulating cortisol leading to increased risk of cardiovascular disease and infection. Etomidate rapidly reduces plasma cortisol levels by inhibiting the action of 11β-hidroxilase. We report the case of a patient with severe hypercortisolaemia accompanied by metabolic and psychiatric disorders in whom administration of etomidate reduced preoperative levels of cortisol. Introduction Cushing’s syndrome is a metabolic disease caused by chronic exposure to high levels of glucocorticoids. The main causes are ectopic ACTH secretion, adrenal tumours (adenomas or carcinomas), adrenal hyperplasia, and administration of exognous glucocorticoids—the latter being the most common aetiology.1 In most cases, Cushing’s syndrome presents an indolent course for years before diagnosis is made, although it can sometime present as an endocrine emergency due to a rapid increase in circulating cortisol levels.2 In these cases, treatment to control hypercortisolaemia must be started quickly due to the high morbidity and mortality associated with the potentially life-threatening metabolic, infectious, and neuropsychiatric alterations that occur in this syndrome.1, 2, 3, 4 The options for treating Cushing’s syndrome include surgery, radiotherapy, and pharmacological treatment. The most commonly used drugs are adrenal steroidogenesis inhibitors (ketoconazole, metyrapone),3 but this treatment is not always well tolerated and its efficacy is limited.2 Etomidate is a drug from the imidazole family that inhibits the enzyme 11β-hydroxylase, and can reduce cortisol secretion within 48−72 h.2 Section snippets Case report Our patient was a 27-year-old woman with no known drug allergies or personal history of interest. She was studied in April 2021 for anxious-depressive symptoms with rapidly evolving paranoid ideation and hirsutism. A Nugent test was performed, which was positive (46.1 mcg/dl), and cortisol in urine was measured (2715 mcg/24 h), leading to a diagnosis of Cushing's syndrome. A CT scan showed a large mass on the right adrenal gland, compatible with a primary adrenal gland tumour (Fig. 1). Discussion Endogenous Cushing's syndrome is characterized by over-production of cortisol. In patients such as ours, the syndrome presents in its most serious form, with very high hypercortisolaemia and metabolic, cardiovascular, and neuropsychiatric disorders. Cushing's syndrome is a medical emergency due to its association with several comorbidities and its high rate of mortality.5 The first therapeutic option is surgical resection of the underlying tumour; however, the accompanying hypercortisolaemia Conclusion In its severe form, Cushing's syndrome is a medical emergency that must be rapidly controlled. Etomidate is both safe and effective, and has shown promising results in the treatment of severe hypercortisolaemia. We believe that these patients should be admitted to the Anaesthesia Intensive Care Unit during etomidate therapy in order to monitor their level of consciousness, lung function, and haemodynamics, and to closely monitor cortisol and electrolyte levels. Ethical considerations Informed consent was obtained for the use of patient information for teaching and research purposes in accordance with our hospital protocol. Conflict of interests None. Funding The authors have not received any funding for this manuscript. References (8) A. Ferriere et al. Cushing’s syndrome: Treatment and new therapeutic approaches Best Pract Res Clin Endocrinol Metab (2020) Juszczak A, Morris D, Grossman A. Cushing's Syndrome [Internet]. South Dartmouth (MA): MDText.com, Inc; 2000 [revised... T.B. Carroll et al. Continuous Etomidate Infusion for the Management of Severe Cushing Syndrome: Validation of a Standard Protocol J Endocr Soc (2018) V.A. Preda et al. Etomidate in the management of hypercortisolaemia in Cushing’s syndrome: a review Eur J Endocrinol (2012) There are more references available in the full text version of this article. 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Abstract Cushing’s syndrome with concurrent primary aldosteronism (PA) is a rare presentation, and establishing an early diagnosis is imperative to preventing morbidity and long-term sequelae. The diagnosis is established by sequential lab work, showing an elevated cortisol and aldosterone level. Taking the above into consideration, it is evident that repeatedly negative results on all three tests can present an extremely challenging case. In this report, we discuss a female who presented with an adrenal incidentaloma and features suggestive of primary hyperaldosteronism as well as Cushing’s syndrome but no elevations in serum, urine, or salivary cortisol. In this study, we present a 37-year-old female with resistant hypertension and tachycardia. She had several features suggestive of Cushing’s syndrome including resistant hypertension, proximal muscle weakness, weight gain, easy bruising, hair loss, and a history of tachycardia and chest pain. Examination revealed an obese female with thin silvery abdominal striae. The patient’s labs revealed normal serum cortisol, urine-free cortisol (UFC), late-night salivary cortisol, and a normal dexamethasone suppression test. An abdominal computed tomography (CT) scan revealed a right adrenal mass measuring 2.1 x 1.5 x 2.5 cm. Due to a high index of suspicion, adrenal venous sampling was performed, which revealed high levels of cortisol and aldosterone in the right vein, confirming the diagnosis. The patient subsequently underwent a right adrenalectomy. She developed hypotension post-op, leading to the diagnosis of glucocorticoid-remediable aldosteronism. Introduction Primary aldosteronism (PA) is the excess production of aldosterone by the adrenal glands, despite a low serum renin level. The presentation of hyperaldosteronism can be vague and include symptoms such as muscle weakness, fatigue, headaches, numbness, and cramps. More specific findings include resistant hypertension, low serum potassium, and metabolic alkalosis. The etiologies are variable and can include an adrenal adenoma (Conn syndrome) or bilateral adrenal hyperplasia [1]. Cushing’s syndrome is also caused by excess hormone secretion by the adrenal glands. The etiologies include a primary adrenal adenoma, hyperplasia, carcinoma, or exogenous corticosteroid use. It can also be caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma or as a result of paraneoplastic ACTH secretion. The clinical presentation is highly variable and leads to difficulties in establishing a diagnosis. The concurrent existence of primary hyperaldosteronism and Cushing’s syndrome creates additional hindrances in diagnosis, yet further obscured in a patient with a repeatedly negative workup for both conditions. Case Presentation A 37-year-old female presented to her primary care physician with complaints of proximal muscle weakness, tachycardia, and chest pain. Repeated blood pressure readings revealed that she was hypertensive, and she was started on amlodipine and benazepril, which elevated her blood pressure further. A computed tomography (CT) scan (Figure 1) of the abdomen was performed due to resistant hypertension, which revealed an adrenal incidentaloma (right adrenal gland measuring 2.1 x 1.5 x 2.5 cm). Precontract density was 5 Hounsfield units, and a 15-minute delayed washout showed 11 Hounsfield units for a 72% washout. She was thus referred to endocrinology. Figure 1: Abdominal CT scan showing a nodule in the right adrenal gland measuring 2.1 x 1.5 x 2.5 cm She presented to the endocrinology clinic on March 12, 2021. A thorough physical examination was performed, which revealed a well-appearing obese female (BMI of 38.86 kg/m2) with no acute distress. Her blood pressure was 144/108 mmHg, her pulse was 95, and she was afebrile. Thin silvery striations were present on the abdomen, and alopecia was present on the crown. A review of all other systems was unremarkable. A detailed family history revealed early-onset hypertension in her brother (age: 35 years) and her mother (age: 30 years). Personal history included elevated anxiety, weight gain, headaches (frontal band distribution), increased thirst, easy bruising as well as delayed clearance of bruises, and proximal muscle weakness presenting as difficulty in climbing stairs and inability to lift heavy objects. She reported no change in menstrual cycles. There was no history of exogenous corticosteroid use. Serum biochemistries were sent (Table 1), which showed normal levels of thyroid stimulating hormone (TSH), creatinine, liver function tests, and serum electrolytes. However, mildly elevated aldosterone (23 ng/dl), mild hypokalemia (3.3 mEq/L), and suppressed ACTH and dehydroepiandrosterone (DHEA) sulfate were discovered. The aldosterone to renin ratio was also elevated at 59.9 on spironolactone and was 71.4 three months later when spironolactone was discontinued. These findings lead to a preliminary diagnosis of primary hyperaldosteronism. Test Result Calcium 9.1 mmol/L Sodium 137 mmol/L Potassium 4.1 mmol/L Chloride 106 mmol/L CO2 27 BUN 15 mmol/L Glucose 95 mmol/L Creatinine 1.1 μmol/L AST 24 U/L ALT 20 U/L Albumin 4.4 g/L Total protein 7.0 g/L Total bilirubin 0.4 μmol/L Alkaline phosphatase 40 U/L Renin 0.44 Table 1: Patient serum biochemistries BUN: Blood urea nitrogen; AST: Aspartate transaminase; ALT: Alanine transaminase. A workup for elevated cortisol was also performed as the patient was phenotypically Cushingoid, and the following biochemistries were sent sequentially: serum cortisol, 24-hour urine-free cortisol (UFC), salivary cortisol, and a low-dose dexamethasone suppression test (Table 2). The bloodwork was hence nonconfirmatory. Endocrine workup Serum cortisol 4.5 mcg/dL Urine-free cortisol 1.57 g/24 h Salivary cortisol <0.03 μg/dL Dexamethasone suppression test 1.5 mcg/dL Aldosterone <4.0 Table 2: Patient follow-up bloodwork Despite a repeatedly negative workup for Cushing's syndrome, adrenal venous sampling was performed due to a high index of suspicion. The results revealed an inferior vena cava (IVC) cortisol of 20, left adrenal venous (LAV) cortisol of 81, and right adrenal vein (RAV) cortisol of 1280. The results of the IVC aldosterone were 24, LAV aldosterone was 660 and RAV aldosterone was 1500. The elevated levels of cortisol in the RAV were in complete contradiction to the aforementioned workup. A diagnosis of Cushing’s syndrome and concurrent PA was determined. Adrenal veinous sampling was instrumental in establishing the diagnosis but was equivocal and did not lateralize aldosterone and cortisol excess. However, the amount of aldosterone and cortisol were both significantly higher on the right side. After a panel discussion with doctors from several disciplines, a laparoscopic adrenalectomy was planned. The procedure was successful, and the patient was initially showing clinical improvement. The specimen was sent for pathological evaluation and revealed an adrenal cortical adenoma. After initial improvement, the patient developed hypotension, which was likely due to adrenal insufficiency. The patient was supplemented with 1-mg dexamethasone tablets, which stabilized her condition, and a diagnosis of glucocorticoid-remediable-aldosteronism was made. Based on a strong family history of early onset-resistant hypertension, a genetic component was suspected. Several genes associated with PA with autosomal dominant inheritance have been identified [2], such as CYP11B2, CLCN2, KCNJ5, CACNA1D, and CACNA1H. The patient was offered genetic testing but was unable to follow through due to financial reasons. Discussion This patient presented as an extremely rare example of PA and Cushing’s syndrome, with negative serum cortisol, 24-hour UFC, late-night salivary cortisol, and a dexamethasone suppression test. Despite repeatedly negative lab results, the patient presented with a markedly elevated cortisol on adrenal venous sampling. In our literature search, we found an instance of a patient with several negative UFCs [3]; however, to the best of our knowledge, there have been no reported instances of a completely negative workup in a patient who is positive for Cushing’s syndrome. In fact, in the practice guidelines published by the Journal of Clinical Endocrinology & Metabolism [4], it is recommended that patients with a suspected diagnosis of Cushing’s syndrome or an adrenal incidentaloma and two concordant negative test results need not undergo further investigations. One proposed mechanism for the misleading workup could be assay interference. Interference occurs when a substance or process falsely alters an assay result [5]. This can lead to incorrect diagnosis and subsequent treatment and poses a threat to the patient. Another suggested mechanism causing false negative test results could be the hook effect [6]. The hook effect is described as a phenomenon that leads to falsely low results due to the presence of excessive analyte. In a study by Friedman et al. [7], it was noted that patients with “episodic Cushing’s syndrome” or those with mild symptoms had a negative workup. The study recommended serial monitoring for the disease. The interesting fact is that our patient had several features suggestive of active Cushing’s syndrome, and the hypotension seen postoperatively was a testament to the fact that there was in fact a cortisol excess, which led to adrenal insufficiency. In light of the above, a consistently negative workup is perplexing. Zhang et al. suggested performing a low-dose dexamethasone suppression test in individuals presenting with PA, prior to adrenal vein sampling (AVS) and surgery due to the high prevalence of Cushing’s syndrome in patients with PA [8]. A positive test result can lead to a straightforward diagnosis; however, in this rare case where the patient had severe negative tests, it can present as a challenge in diagnosis and treatment. Conclusions The presence of PA and concurrent Cushing’s syndrome can present as a diagnostic challenge. It is recommended to follow up on the signs of Cushing's syndrome with preliminary tests and to presume its absence if two concordant tests are negative. Our patient, however, was an exceptional case. This case highlighted the importance of maintaining a high index of suspicion for patients presenting with several signs and symptoms of the disease and a negative workup. More attention should be paid to the patient's history, and a thorough physical examination should be conducted. In those with an uncertain diagnosis, adrenal venous sampling can provide a clearer picture and lead to a more accurate understanding of the case. References Reincke M, Bancos I, Mulatero P, Scholl UI, Stowasser M, Williams TA: Diagnosis and treatment of primary aldosteronism. Lancet Diabetes Endocrinol. 2021, 9:876-92. 10.1016/S2213-8587(21)00210-2 Dutta RK, Söderkvist P, Gimm O: Genetics of primary hyperaldosteronism. Endocr Relat Cancer. 2016, 23:R437-54. 10.1530/ERC-16-0055 Moloney KJ, Mercado JU, Ludlam WH, Broyles FE: Diagnosis of Cushing's disease in a patient with consistently normal urinary free cortisol levels: a case report. Clin Case Rep. 2016, 4:1181-3. 10.1002/ccr3.647 Nieman LK, Biller BM, Findling JW, Newell-Price J, Savage MO, Stewart PM, Montori VM: The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008, 93:1526-40. 10.1210/jc.2008-0125 Dimeski G: Interference testing. Clin Biochem Rev. 2008, 29:S43-8. The hook effect. (2014). Accessed: June 19, 2023: https://www.aacc.org/science-and-research/clinical-chemistry-trainee-council/trainee-council-in-english/pearls-of-lab.... Friedman TC, Ghods DE, Shahinian HK, et al.: High prevalence of normal tests assessing hypercortisolism in subjects with mild and episodic Cushing's syndrome suggests that the paradigm for diagnosis and exclusion of Cushing's syndrome requires multiple testing. Horm Metab Res. 2010, 42:874-81. 10.1055/s-0030-1263128 Zhang Y, Tan J, Yang Q, et al.: Primary aldosteronism concurrent with subclinical Cushing's syndrome: a case report and review of the literature. J Med Case Rep. 2020, 14:32. 10.1186/s13256-020-2353-8 From https://www.cureus.com/articles/170896-rare-challenges-in-diagnosing-cushings-syndrome-and-primary-aldosteronism-a-case-report-of-a-female-with-a-negative-workup#!/

Abstract Background: Cushing syndrome (CS) is a rare disease caused by excess cortisol levels with high cardiovascular morbidity and mortality. Hypertension in CS promotes hypercortisolism-associated cardiovascular events. Adipose tissue is a highly plastic tissue with most cell types strongly affected by the excess cortisol exposure. We hypothesized that the molecular and cellular changes of periadrenal adipose tissue in response to cortisol excess impact systemic blood pressure levels in patients with CS. Methods: We investigated gene expression signatures in periadrenal adipose tissue from patients with adrenal CS collected during adrenal surgery. Results: During active CS we observed a downregulation of gene programs associated with inflammation in periadrenal adipose tissue. In addition, we observed a clustering of the patients based on tissue gene expression profiles into 2 groups according to blood pressure levels (CS low blood pressure and CS high blood pressure). The 2 clusters showed significant differences in gene expression pattens of the renin-angiotensin-aldosterone-system. Renin was the strongest regulated gene compared with control patients and its expression correlated with increased blood pressure observed in our patients with CS. In the CS high blood pressure group, systemic renin plasma levels were suppressed indicative of an abnormal blood pressure associated with periadrenal adipose tissue renin-angiotensin-aldosterone-system activation. Conclusions: Here, we show for the first time a relevant association of the local renin-angiotensin-aldosterone-system and systemic blood pressure levels in patients with CS. Patients from the CS high blood pressure group still had increased blood pressure levels after 6 months in remission, highlighting the importance of local tissue effects on long-term systemic effects observed in CS. Footnotes *U. Stifel and F. Vogel contributed equally. For Sources of Funding and Disclosures, see page xxx. Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/HYPERTENSIONAHA.123.21185. Correspondence to: Martin Reincke, Department of Medicine IV, University Hospital, LMU Munich, GermanyEmail martin.reincke@med.uni-muenchen.de Jan Tuckermann, Institute of Comparative Molecular Endocrinology (CME), Ulm University, GermanyEmail jan.tuckermann@uni-ulm.de eLetters eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate. Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page. From https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.123.21185

Objective: To evaluate the long-term efficacy and safety of osilodrostat in patients with Cushing’s disease. Methods: The multicenter, 48-week, Phase III LINC 4 clinical trial had an optional extension period that was initially intended to continue to week 96. Patients could continue in the extension until a managed-access program or alternative treatment became available locally, or until a protocol amendment was approved at their site that specified that patients should come for an end-of-treatment visit within 4 weeks or by week 96, whichever occurred first. Study outcomes assessed in the extension included: mean urinary free cortisol (mUFC) response rates; changes in mUFC, serum cortisol and late-night salivary cortisol (LNSC); changes in cardiovascular and metabolic-related parameters; blood pressure, waist circumference and weight; changes in physical manifestations of Cushing’s disease; changes in patient-reported outcomes for health-related quality of life; changes in tumor volume; and adverse events. Results were analyzed descriptively; no formal statistical testing was performed. Results: Of 60 patients who entered, 53 completed the extension, with 29 patients receiving osilodrostat for more than 96 weeks (median osilodrostat duration: 87.1 weeks). The proportion of patients with normalized mUFC observed in the core period was maintained throughout the extension. At their end-of-trial visit, 72.4% of patients had achieved normal mUFC. Substantial reductions in serum cortisol and LNSC were also observed. Improvements in most cardiovascular and metabolic-related parameters, as well as physical manifestations of Cushing’s disease, observed in the core period were maintained or continued to improve in the extension. Osilodrostat was generally well tolerated; the safety profile was consistent with previous reports. Conclusion: Osilodrostat provided long-term control of cortisol secretion that was associated with sustained improvements in clinical signs and physical manifestations of hypercortisolism. Osilodrostat is an effective long-term treatment for patients with Cushing’s disease. Clinical trial registration: ClinicalTrials.gov, identifier NCT02180217 Introduction Cushing’s disease is a rare but serious disorder resulting from an adrenocorticotropic hormone (ACTH)-producing pituitary adenoma that, in turn, promotes excess adrenal cortisol (1). Chronic exposure to excess cortisol is associated with numerous comorbidities, including hypertension, muscle weakness, hirsutism, central obesity, hypercoagulability and diabetes mellitus, all of which lead to an increased risk of mortality and poor health-related quality of life (HRQoL) (1–3). The longer the exposure to excess cortisol, the lower the chance of reversing morbidity (2). Although transsphenoidal surgery is the recommended first-line treatment, approximately one-third of patients experience persistent or recurrent disease following surgery (4), and some patients are ineligible for or refuse surgery (4–6). Steroidogenesis inhibitors are usually the first choice for medical treatment (6). The effect of medical treatment can be easily monitored by measurement of serum and urine cortisol. Owing to the unremitting nature of Cushing’s disease, patients often require continued medical therapy to maintain long-term control of cortisol excretion. To date, long-term efficacy and safety data for steroidogenesis inhibitors from prospective clinical trials are limited (7, 8). Osilodrostat is a potent oral inhibitor of 11β-hydroxylase and is approved for the treatment of adult patients with Cushing’s disease (USA) or endogenous Cushing’s syndrome (EU and Japan) who are eligible for medical therapy (9–12). The LINC 4 study was a multicenter, 48-week, Phase III clinical trial in patients with Cushing’s disease that included an upfront 12-week randomized, double-blind, placebo-controlled period. Osilodrostat led to rapid normalization of mean urinary free cortisol (mUFC) excretion and was significantly superior to placebo at week 12; normal mUFC excretion was sustained in most patients throughout the 48-week core period (13). Following the 48-week core period, patients could enter an optional open-label extension period intended to run for an additional 48 weeks. Here, we report the long-term efficacy and safety data from the extension of LINC 4. These data augment the existing efficacy and safety profile of osilodrostat (7, 8, 13, 14). Methods Patients Eligibility criteria have been described previously (13). Briefly, the study enrolled adult patients with a confirmed diagnosis of persistent or recurrent Cushing’s disease after pituitary surgery and/or irradiation, or de novo Cushing’s disease (if not surgical candidates), with mUFC >1.3 times the upper limit of normal (ULN; 138 nmol/24 h or 50 μg/24 h; calculated from three samples collected on three consecutive days, with ≥2 values >1.3 x ULN). Patients who continued to receive clinical benefit from osilodrostat, as assessed by the study investigator, could enter the extension phase. The study was conducted in accordance with the Declaration of Helsinki, with an independent ethics committee/institutional review board at each site approving the study protocol; patients provided written informed consent to participate and consented again at week 48 to taking part in the extension phase. The trial is registered at ClinicalTrials.gov (NCT02180217). Study design Data from the 48-week core period of this Phase III study, consisting of a 12-week randomized, placebo-controlled, double-blind period followed by a 36-week open-label treatment period, have been published previously (13). The optional open-label extension phase was initially planned to run for an additional 48 weeks (to week 96 for the last patient enrolled). However, patients could continue in the extension only until a managed-access program or alternative treatment became available locally, or until a protocol amendment was approved at their site that specified that patients enrolled in the optional extension phase should come for an end-of-treatment (EOT) visit within 4 weeks or by week 96, whichever occurred first. Patients still receiving clinical benefit from osilodrostat at their EOT visit were eligible to join a separate long-term safety follow-up study (NCT03606408). Consequently, the extension phase ended when all patients had transitioned to the long-term safety follow-up study, if eligible, or had discontinued from the study. Patients continued to receive open-label osilodrostat at the established effective dose from the core phase (dose adjustments were permitted based on efficacy and tolerability; the maximum dose was 30 mg twice daily [bid]). Outcomes Study outcomes assessed during the extension phase were as follows: complete (mUFC ≤ULN), partial (mUFC decrease ≥50% from baseline and >ULN) and mUFC response rate at weeks 60, 72, 84, 96 and 108, then every 24 weeks until the extension EOT visit; change in mUFC, serum cortisol and late-night salivary cortisol (LNSC) at weeks 60, 72, 84, 96 and 108, then every 24 weeks until the extension EOT visit; time to loss of mUFC control, defined as the time (in weeks) from the first collection of post-baseline normal mUFC (≤ULN) to the first mUFC >1.3 x ULN on two consecutive scheduled visits on the highest tolerated dose of osilodrostat and not related to a dose interruption or reduction for safety reasons after week 26; change in cardiovascular/metabolic-related parameters associated with Cushing’s disease (fasting plasma glucose [FPG] and glycated hemoglobin [HbA1c]) at weeks 60, 72, 84, 96 and 108, then every 24 weeks until the extension EOT visit; blood pressure, waist circumference and weight every 4 weeks until week 72, then every 12 weeks until week 108, then every 24 weeks until the extension EOT visit; change from baseline in physical manifestations of hypercortisolism at weeks 72, 96 and 108, then every 24 weeks until the extension EOT visit; changes in HRQoL (determined by Cushing’s Quality of Life Questionnaire [CushingQoL] and Beck Depression Inventory II [BDI-II]) at weeks 72 and 96 and the extension EOT visit; and proportion of patients with ≥20% decrease or increase in tumor volume. mUFC (mean of two or three 24-hour urine samples), serum cortisol (measured between 08:00 and 10:00) and LNSC (measured from two samples collected between 22:00 and 23:00) were evaluated using liquid chromatography-tandem mass spectrometry and assessed centrally. Pituitary magnetic resonance imaging with and without gadolinium enhancement was performed locally at weeks 72 and 96 and the extension EOT visit; images were assessed centrally for change in tumor size. Safety was continually assessed from core study baseline throughout the extension for all enrolled patients by monitoring for adverse events (AEs); all AEs from first patient first visit to last patient last visit are reported. AEs of special interest (AESIs) included events related to hypocortisolism, accumulation of adrenal hormone precursors, arrhythmogenic potential and QT prolongation, and enlargement of the pituitary tumor. Statistical methods Analyses presented here are based on cumulative data generated for the full analysis set (all patients enrolled at core study start who received at least one dose of osilodrostat) up to last patient last visit. Safety analyses included all enrolled patients who received at least one dose of osilodrostat and had at least one valid post-baseline safety assessment. All analyses excluded data for patients in the placebo arm collected during the placebo-controlled period. Results were analyzed descriptively, and no formal statistical testing was performed. Correlations were evaluated using the Pearson’s correlation coefficient; extreme outliers were defined as >(Q3 + 3 x IQR) or <(Q1 − 3 x IQR), where Q1 and Q3 are the first and third quartiles and IQR is the interquartile range (Q3 − Q1). Results Patient disposition and baseline characteristics LINC 4 was conducted from October 3, 2016 to December 31, 2020. Of the 73 patients who were enrolled and received treatment in the core phase, 65 completed the core phase and 60 (82.2%) opted to enter the extension; 53 (72.6%) patients completed the extension (Figure 1). At core study baseline, most patients had undergone previous pituitary surgery (87.7%) or received prior medical therapy (61.6%; Table 1). Patients had a variety of comorbidities at core study baseline, most commonly hypertension (61.6%); physical manifestations of hypercortisolism were common (Table 1). Figure 1 Figure 1 Patient disposition. *Patient was randomly allocated to osilodrostat but did not receive any study treatment because of a serious AE (grade 4 pituitary apoplexy that required hospitalization prior to receiving any study drug) that was not considered related to treatment. Table 1 Table 1 Core study patient baseline characteristics. Exposure to osilodrostat From core baseline to study end, median (range) osilodrostat exposure was 87.1 (2.0–126.6) weeks; 29 (39.7%) patients were exposed to osilodrostat for more than 96 weeks. The median (25th–75th percentiles) average osilodrostat dose received during the overall study period was 4.6 (3.7–9.2) mg/day; during the core study, median (25th–75th percentiles) average dose was 5.0 (3.8–9.2) mg/day (13). The osilodrostat dose being taken for the longest duration was most frequently 4.0 mg/day (27.4%). Following titration, daily osilodrostat dose remained stable during long-term treatment (Figure 2). Figure 2 Figure 2 (A) Mean and (B) median osilodrostat dose over time. Shaded areas indicate the randomized, double-blind period and the open-label period of the core phase. According to the study protocol, all patients restarted the open-label period on osilodrostat 2 mg bid unless they were on a lower dose at week 12. All patients on <2 mg bid osilodrostat (or matched placebo) at week 12 continued to receive the same dose, regardless of initial treatment allocation. n is the number of patients who contributed to the mean/median. Long-term efficacy of osilodrostat treatment Of patients who had received at least one dose of osilodrostat, 68.5% (n=50/73) had mUFC ≤ULN at the end of the core period, and 54.8% (n=40/73) had mUFC ≤ULN at week 72. Of patients who opted to enter the extension, 66.7% had mUFC ≤ULN (n=40/60) and 8.3% (n=5/60) had mUFC decreased by ≥50% from baseline and >ULN at week 72 (Figure 3A). Of patients with an assessment at their extension EOT visit, 72.4% (n=42/58) had mUFC ≤ULN and 8.6% (n=5/58) had mUFC decreased by ≥50% from baseline and >ULN. Figure 3 Figure 3 (A) Proportion of patients with mUFC response over time, (B) mean mUFC over time, and (C) individual patient changes in mUFC. (A) Patients with missing mUFC at any visit, including those who had discontinued treatment, were counted as non-responders. Shaded area represents the 48-week core phase; excludes data in placebo arm collected during placebo-control period. *The proportion of patients with mUFC ≤ULN at week 48 was calculated using the full analysis set (patients who had discontinued treatment were classified as non-responders). †Discontinued, n=12; missing because of the COVID-19 pandemic, n=4; mUFC not meeting response criteria, n=3; missing (any other reason), n=1. ‡mUFC not meeting response criteria, n=8; missing because of the COVID-19 pandemic, n=2; missing (any other reason), n=1. (B) Shaded areas indicate the randomized, double-blind period and the open-label period of the core phase. n is the number of patients who contributed to the mean. Analysis includes scheduled visits only. (B, C) Dashed line is the ULN for UFC (138 nmol/24 h). Mean mUFC excretion for the 48-week core period of the study has been reported previously (13); mUFC excretion normalized in patients who received osilodrostat, either during the 12-week randomized period (osilodrostat arm) or during the subsequent 36-week open-label period (all patients) (13). Mean mUFC excretion was maintained within the normal range in the extension period (week 72 (n=48), 90.5 [SD 122.6] nmol/24 h; 0.7 [0.9] x ULN; Figure 3B). Median (range) mUFC excretion is shown in Supplementary Figure 1A. Individual patient changes in mUFC from core study baseline to their last observed visit are shown in Figure 3C. There were no escape-from-response events during the extension phase following the primary analysis cut-off (February 25, 2020) (13). During the core period, mean (SD) serum cortisol levels decreased from 538.1 (182.3) nmol/L (0.9 [0.3] x ULN) at baseline to 353.9 (124.9) nmol/L (0.6 [0.2] x ULN) at week 48. Serum cortisol levels then remained stable throughout the extension period (week 72: 319.1 [129.8] nmol/L, 0.6 [0.2] x ULN; Figure 4A). LNSC also decreased and then remained stable, although >ULN, throughout the study (baseline: 10.8 [23.5] nmol/L, 4.3 [9.4] x ULN; week 48: 3.7 [2.6] nmol/L, 1.5 [1.0] x ULN; week 72: 3.8 [3.0] nmol/L, 1.5 [1.2] x ULN; Figure 4B). Median serum cortisol and LNSC are shown in Supplementary Figures 1B, C. Of patients with baseline and last observed value (LOV) measurements, 25.0% had normal LNSC at baseline (n=6/24) and 47.8% had normal LNSC at their last visit (n=11/23). Interpretation of this result is limited by the high degree of missing data (baseline: 67.1%, n=49/73; LOV: 68.5%, n=50/73). Figure 4 Figure 4 (A) Mean serum cortisol and (B) mean LNSC from baseline to the end of treatment. Shaded areas indicate the randomized, double-blind period and the open-label period of the core phase. n is the number of patients who contributed to the mean. Dashed line in (A) indicates reference serum cortisol range for males and females ≥18 years old (127–567 nmol/L). Dashed line in (B) indicates reference LNSC (22:00–23:00) range for males and females ≥18 years old (≤2.5 nmol/L). Changes in cardiovascular and metabolic parameters, physical manifestations of Cushing’s disease and patient-reported outcomes As previously reported, improvements from baseline occurred in most cardiovascular and metabolic-related parameters in the core period following osilodrostat treatment (9). This trend continued during the extension phase and included a reduction in FPG, HbA1c, cholesterol, systolic and diastolic blood pressure, waist circumference, and weight (Figure 5). Similarly, the improvements from baseline in physical features of hypercortisolism observed by week 48 were maintained for most parameters throughout the extension (Figure 6A), with either no change or improvement observed from baseline in ≥90% patients for all parameters at week 72. Facial rubor, supraclavicular fat pad, dorsal fat pad and central obesity had a favorable shift from baseline in ≥40% of patients at week 72. Few patients reported worsening from baseline of specific manifestations (Figure 6A). Figure 5 Figure 5 Changes in cardiovascular-related metabolic parameters. Shaded area indicates the core phase. n is the number of patients who contributed to the mean. Error bars indicate standard deviation. DBP, diastolic blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein; SBP, systolic blood pressure. Figure 6 Figure 6 Changes in (A) physical manifestations of Cushing’s disease and (B) patient-reported outcomes. Shaded area indicates the core phase. n is the number of patients who contributed to the mean. Improvements were also observed in scores for patient quality of life (QoL). Both standardized CushingQoL and BDI-II scores improved steadily during the core phase. QoL scores continued to improve further during the extension. At week 72 and EOT, mean (SD) standardized CushingQoL score was 66.4 (19.6) and 69.0 (20.9), and mean (SD) BDI-II score was 6.5 (7.0) and 6.2 (7.1), representing a mean (SD) change from baseline of 15.2 (19.0) and 17.1 (17.1) and −4.1 (9.3) and −4.5 (7.9), respectively (Figure 6B). Adverse events AEs that occurred in >20% of patients, irrespective of study-drug relationship, during the entire study period (median [range] osilodrostat exposure for all patients: 87.1 [2.0–126.6] weeks; excluding data collected in the placebo arm during the placebo-controlled period) are shown in Table 2. The most common AEs were decreased appetite (46.6%), arthralgia (45.2%) and fatigue (39.7%). Most AEs were mild or moderate; 60.3% were reported as grade 1/2 (Table 2). Table 2 Table 2 Summary of adverse events during LINC 4 core and extension periods. Overall, 10 AEs (adrenal insufficiency, n=3; hyperbilirubinemia, hypokalemia, headache, arthralgia, pituitary tumor, benign pituitary tumor, and depression, n=1 each) in nine patients (12.3%; one patient experienced both arthralgia and headache) led to treatment discontinuation. For two patients (2.7%), those AEs were reported as grade 3 (hyperbilirubinemia and hypokalemia). One patient discontinued following the primary analysis cut-off date (February 25, 2020). The most common AESIs in both the core and extension periods were those related to adrenal hormone precursors. However, the proportion of patients reporting these AESIs was lower in the extension than in the core period (Figure 7). AESIs related to hypocortisolism were most frequent during the core period but did occur throughout the remainder of the study, albeit at lower frequency (Figure 7). Hypocortisolism-related AEs were most frequently managed with temporary osilodrostat interruption (n=20) or dose adjustment (n=6), and with concomitant glucocorticoids (n=15). There were no new occurrences of AESIs related to arrhythmogenic potential and QT prolongation, or to pituitary tumor enlargement, in the extension (Figure 7). During the entire study period from core baseline to the end of the extension, AESIs led to osilodrostat discontinuation in six (8.2%) patients (n=1, related to accumulation of adrenal hormone precursors [hypokalemia]; n=3, related to hypocortisolism [all adrenal insufficiency]; n=2, related to pituitary tumor enlargement [pituitary tumor and pituitary tumor benign]). Figure 7 Figure 7 Occurrence of AESIs by time interval. The denominator for each time period only included patients who had at least one scheduled visit, or at least one observed AE, during that period. From baseline to week 12, the denominator only included patients randomized to osilodrostat. A patient with multiple occurrences of an AE within the same period is counted only once in that period. However, if an AE ends and occurs again in a different period, it is then counted in both periods. Shaded areas indicate the randomized, double-blind period and the open-label period of the core phase. *Maximum duration of follow-up was 127 weeks. Following an increase in 11-deoxycortisol and 11-deoxycorticosterone during the core study, levels tended to decrease during longer-term treatment (Figure 8). From baseline to LOV, the proportion of patients with elevated 11-deoxycorticosterone and 11-deoxycortisol levels increased from 10.0% (n=1/10) to 90.0% (n=9/10) and from 57.9% (n=33/57) to 86.7% (n=5 and 2/60), respectively. In female patients, mean (SD) testosterone levels increased from 1.1 (0.6) nmol/L at baseline to 2.5 (2.6) nmol/L at the end of the core phase, then decreased to within the normal range (0.7−2.6 nmol/L for females) by the extension phase end-of-treatment visit (1.9 [1.7] nmol/L; Figure 8). The proportion of females with an elevated testosterone level increased from 15.0% (n=9/61) at baseline to 63.2% (n=24/61) at week 72 and then reduced to 41.7% (n=25/61) at LOV. In males, testosterone levels increased and remained within the normal range throughout osilodrostat treatment (Figure 8). The proportion of male patients with testosterone levels below the lower limit of normal decreased from 58.3% (n=7/12) at baseline to 33.3% (n=4/12) at LOV. The proportion of patients experiencing AEs potentially related to increased testosterone (increased blood testosterone, acne and hirsutism) was lower during the extension than during the core study (Supplementary Figure 2). Mean serum potassium levels remained stable and within the normal range (3.5–5.3 mmol/L) throughout osilodrostat treatment (Figure 8). The proportion of patients with a normal potassium level was similar between baseline (98.6%, n=72/73) and LOV (94.4%, n=68/72). Figure 8 Figure 8 Mean (± SD) levels up to the end-of-treatment visit in the extension phase for 11-deoxycortisol, 11-deoxycorticosterone, potassium and testosterone (in males and females). Shaded area indicates the core phase. n is the number of patients who contributed to the mean. Reference ranges: 11-deoxycortisol ULN, 3.92 nmol/L in males and 3.1 nmol/L in females, or lower depending on age; 11-deoxycorticosterone ULN, 455 pmol/L in males and 696 pmol/L in females (mid-cycle); potassium, 3.5–5.3 mmol/L; testosterone, 8.4–28.7 nmol/L in males and 0.7–2.6 nmol/L in females. At baseline, median (range) tumor volume was 82.0 (12.0–2861.0) mm3; 28.8% (n=21/73) of patients had a macroadenoma (≥10 mm) and 68.5% (n=51/73) had a microadenoma (<10 mm). At week 72, median (range) tumor volume was 68.0 (10.0–3638.0) mm3 (Figure 9A). Of the 27 patients with measurements at both baseline and week 72, 29.6% (n=8/27) had a ≥20% decrease in tumor volume and 37.0% (n=10/27) had a ≥20% increase (Figure 9B). Notably, mean (SD) plasma ACTH increased steadily between baseline (17.1 [32.1] pmol/L, n=73) and week 72 (65.0 [96.9] pmol/L, n=45; Figure 9C); mean ACTH levels appeared to stabilize after week 72. All patients experienced an increase in ACTH levels from baseline to week 72 (n=45) and LOV (n=73); of these, 34/45 (75.6%) and 47/73 (64.4%) experienced an increase in ACTH of ≥2 × baseline levels to week 72 and to LOV, respectively. There was no correlation between change in tumor volume and change in ACTH from baseline to week 72 (r=0.1; calculated without two extreme outliers). Figure 9 Figure 9 (A) Mean and median tumor volume over time, (B) number of patients with a change in tumor volume from baseline, and (C) mean ACTH over time. Shaded areas indicate the core phase. n is the number of patients who contributed to the mean. Dashed lines in (C) indicate reference morning (07:00–10:00) plasma ACTH ranges for males and females ≥18 years old (1.3–11.1 pmol/L). Discussion Following transsphenoidal surgery, approximately one-third of patients experience persistence or recurrence of disease and subsequently require further treatment to control excess cortisol secretion (4). It is therefore essential that clinical studies evaluating the long-term safety and efficacy of potential new treatments, such as osilodrostat, are performed. The data presented here from the LINC 4 extension reinforce previous reports demonstrating that osilodrostat is effective and well tolerated during long-term treatment of Cushing’s disease (7, 8, 13, 14). The normalization of mUFC excretion, observed from as early as week 2 in some patients (13), was sustained to the end of the optional open-label extension phase. Overall, the response rate was durable and remained ≥60% throughout the study, with 72.4% of patients maintaining mUFC ≤ULN at their extension EOT visit. Considering the range in baseline mUFC values (21.4–2607.3 nmol/24 h), this indicates that patients can benefit from osilodrostat treatment regardless of their baseline mUFC level. This also suggests that baseline mUFC is not an indicator of whether a patient will respond to osilodrostat treatment. Notably, there were no escape events during the extension period. Additionally, the improvements in most cardiovascular and metabolic parameters, physical manifestations and QoL previously reported during the 48-week core phase were maintained or further improved with long-term treatment (13). Collectively, these results demonstrate the ability of osilodrostat to reduce the burden of disease and comorbidities frequently experienced by patients with Cushing’s disease. mUFC excretion is commonly assessed in clinical trials and during routine clinical practice to evaluate response to treatment. It is also important to monitor the recovery of the circadian cortisol rhythm in response to treatment by measuring serum cortisol and LNSC (6, 15–17). Elevated LNSC levels have been linked to dysregulation in glucose tolerance, insulin sensitivity and insulin secretion (18). As such, one potential explanation for persistent comorbidities in some patients with normalized mUFC excretion is that LNSC, although reduced, remains just above the ULN. Assessment of LNSC during treatment with other medical therapies has been reported, although differences in treatment duration and patient population type and size limit meaningful comparisons between therapies (15–17). In LINC 4, mean serum cortisol levels remained within the normal range. Mean LNSC improved considerably from baseline but remained above the ULN throughout the study; 47.8% (n=11/23) of patients achieved normalized LNSC at their LOV visit. A numerically large decrease in LNSC, but with mean levels remaining above the ULN, is consistent with previous reports during long-term osilodrostat treatment (8); the mechanism underlying this observation is currently unknown. In real-life clinical practice, the osilodrostat label allows flexible dosing (9, 11), which may help achieve normalization of LNSC. Furthermore, the number of patients with available LNSC assessments was limited, particularly during the extension; therefore, the data should be interpreted with caution. Future studies should examine whether patients with normalization of both UFC and LNSC have better outcomes than patients with only normalized UFC. Overall, the safety findings reported here for the extension period were consistent with those reported in the primary analysis (13) and previous clinical trials (7, 8, 14). Osilodrostat was generally well tolerated throughout the study; most reported AEs were mild or moderate in severity and manageable. Only nine of 73 (12.3%) patients discontinued osilodrostat at any time because of an AE (3/73 [4.1%] prior to week 48; 6/60 [10.0%] after week 48). Given that osilodrostat is a potent inhibitor of 11β-hydroxylase, AEs related to hypocortisolism or increased levels of adrenal hormone precursors are expected. The frequency of these AEs was lower in the extension period than in the core period, although events did still occur, highlighting the importance of monitoring patients regularly throughout long-term osilodrostat use. AEs potentially related to arrhythmogenic potential and QT prolongation remained infrequent throughout the study. Furthermore, the clinical benefit and tolerability of osilodrostat is supported by the high proportion of patients who chose to continue into the extension period: 92.3% who completed the core phase continued into the optional extension phase, with 88.3% of those completing the extension. Although dose adjustments were allowed in the open-label phase, the dose of osilodrostat remained stable over long-term treatment, with 4 mg/day adequate for most patients to achieve and sustain control of mUFC excretion. Most AEs related to hypocortisolism occurred during the dose-escalation periods of both LINC 4 (27%) and LINC 3 (51%) (19); the lower occurrence in LINC 4 than LINC 3 may have been related to the more gradual dose-escalation schedule of LINC 4 (every 3 weeks) relative to that of LINC 3 (every 2 weeks) (13, 14, 19). As such, an increased dose-titration interval could be considered when there is a need to mitigate the potential for glucocorticoid withdrawal syndrome or hypocortisolism-related AEs following a rapid decrease in cortisol. Dose-increase decisions should be informed by regular cortisol assessments, the rate of decrease in cortisol, and the individual’s clinical response and tolerability to osilodrostat. Furthermore, as with all steroidogenesis inhibitors, patients should be educated on the expected effects of treatment and dose increases, with a particular focus on the symptoms of hypocortisolism and the advice to contact their physician if they occur. As expected, levels of 11-deoxycortisol, 11-deoxycorticosterone and, in women, testosterone increased during osilodrostat treatment. These then decreased during long-term treatment; notably, testosterone levels in women returned to within the normal range and to near baseline levels. These observations are consistent with the findings of LINC 3, which also demonstrated that these increases were reversible following discontinuation of osilodrostat (14). Compared with the primary analysis, there were no new AEs of increased testosterone in the extension phase of LINC 4; these findings are consistent with both LINC 2 and LINC 3 long-term analyses (7, 8). In general, osilodrostat did not adversely affect pituitary tumor volume, with similar proportions of patients reporting either a ≥20% decrease, ≥20% increase or stable tumor volume throughout the study. Although ACTH levels increased during osilodrostat treatment, there was no apparent correlation between the change in ACTH and the change in tumor volume after 72 weeks of treatment; however, longer-term data are needed to evaluate this further. As ACTH-producing pituitary adenomas are the underlying drivers of hypercortisolism, in turn responsible for the high morbidity and poor QoL associated with the disease, tumor stability is of great clinical importance in patients with Cushing’s disease, especially those for whom surgery has failed or is not a viable option. In addition to LINC 4, other studies have assessed the long-term efficacy and safety of other medical therapies (20–24); however, there is a paucity of prospective, long-term data. For metyrapone, an oral steroidogenesis inhibitor that is given three or four times daily (25), prospective data are currently only available for 36 weeks of treatment in the Phase III/IV PROMPT study (22, 23). Normalization of mUFC excretion was observed in 48.6% (n=17/35) of patients at week 36 (23), and gastrointestinal, fatigue and adrenal insufficiency AEs were the most commonly reported during the first 12 weeks of treatment (22). Current data for levoketoconazole, an oral steroidogenesis inhibitor that is a ketoconazole stereoisomer taken twice daily, are available for 12 months (median duration of exposure 15 months, n=60) following the extended open-label extension of the Phase III SONICS study (26). Of patients with data, 40.9% (n=18/44) had normal mUFC excretion at month 12 (26). During the extension, no patient experienced alanine aminotransferase or aspartate aminotransferase >3 x ULN, suggesting that the potentially clinically important events relating to liver toxicity may be more likely to occur early during treatment, although periodic monitoring during long-term treatment is advisable (26). Pasireotide is a second-generation somatostatin receptor ligand that is administered subcutaneously twice daily (27, 28) or intramuscularly once a month (29–31). In a 12-­month extension of a Phase III study evaluating the long-term efficacy of long-acting pasireotide, 53.1% of patients had normalized mUFC at study completion (median treatment duration 23.9 months), with the most common AEs being related to hyperglycemia (21). The differences in duration and design of these studies prevent a meaningful comparison of the long-term efficacy of medical treatments for Cushing’s disease. The extension period of LINC 4 was initially planned to run to week 96; however, in agreement with the FDA, a protocol amendment was approved that resulted in approximately half of the patients completing the extension phase between weeks 72 and 96. We also acknowledge the potential for selection bias for patients who experienced the greatest clinical benefit during the 48-week core study; however, over 80% of patients chose to continue osilodrostat treatment after consenting to take part in the extension. Conclusions During the LINC 4 extension period, osilodrostat provided long-term control of cortisol excretion, accompanied by sustained improvements in clinical symptoms, physical manifestations of hypercortisolism and QoL. The safety profile was favorable. These data provide further evidence of the durable clinical benefit of long-term osilodrostat treatment in patients with persistent, recurrent or de novo Cushing’s disease. Data availability statement The datasets generated and analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request. Recordati Rare Diseases will share the complete de-identified patient dataset, study protocol, statistical analysis plan, and informed consent form upon request, effective immediately following publication, with no end date. Ethics statement The studies involving human participants were reviewed and approved by an independent ethics committee/institutional review board at each study site. The patients/participants provided their written informed consent to participate in this study. Author contributions The study steering committee (PS, AH, RF, and RA), AP, and the funder designed the study. AH, MG, MB, PW, ZB, AT, and PS enrolled patients in the study. Data were collected by investigators of the LINC 4 Study Group using the funder’s data management systems. MP and the funder’s statistical team analyzed the data. A data-sharing and kick-off meeting was held with all authors and an outline prepared by a professional medical writer based on interpretation provided by the authors. Each new draft of the manuscript subsequently prepared by the medical writer was reviewed and revised in line with direction and feedback from all authors. All authors contributed to the article and approved the submitted version. Funding This study was funded by Novartis Pharma AG; however, on July 12, 2019, osilodrostat became an asset of Recordati. Financial support for medical editorial assistance was provided by Recordati. Acknowledgments We thank all the investigators, nurses, study coordinators and patients who participated in the trial. We thank Catherine Risebro, PhD of Mudskipper Business Ltd for medical editorial assistance with this manuscript. Conflict of interest Author MG has received speaker fees from Recordati, Ipsen, Crinetics Pharmaceuticals, and Novo Nordisk and attended advisory boards for Novo Nordisk, Recordati, Ipsen, and Crinetics Pharmaceuticals. Author PS reports consultancy for Teva Pharmaceuticals. Author PW reports receiving travel grants and speaker fees from Novartis, Ipsen, Recordati, Novo Nordisk, Strongbridge Biopharma now Xeris Pharmaceuticals, and Lilly. Author MB reports receiving travel grants from Novartis, Ipsen, and Pfizer and consultancy for Novartis. Author ZB has nothing to disclose. Author AT reports consultancy for CinCor and PhaseBio. Author RF reports consultancy for HRA Pharma and Recordati and a research grant from Corcept Therapeutics. Author AH reports speaker fees from Chiasma and Ipsen and has been an advisor to Strongbridge Biopharma now Xeris Pharmaceuticals, Novo Nordisk, and Lundbeck Pharma. Author MP is employed by the company Novartis Pharma AG. Author AP was employed by the company Recordati AG at the time of manuscript development. Author RA reports grants and personal fees from Xeris Pharmaceuticals, Spruce Biosciences, Neurocrine Biosciences, Corcept Therapeutics, Diurnal Ltd, Sparrow Pharmaceuticals, and Novartis and personal fees from Adrenas Therapeutics, Janssen Pharmaceuticals, Quest Diagnostics, Crinetics Pharmaceuticals, PhaseBio Pharmaceuticals, H Lundbeck A/S, Novo Nordisk, and Recordati Rare Diseases. 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Efficacy and safety of once-monthly pasireotide in Cushing's disease: a 12 month clinical trial. Lancet Diabetes Endocrinol (2018) 6:17–26. doi: 10.1016/S2213-8587(17)30326-1 PubMed Abstract | CrossRef Full Text | Google Scholar Keywords: Cushing’s disease, osilodrostat, hypercortisolism, 11β-hydroxylase, long-term treatment Citation: Gadelha M, Snyder PJ, Witek P, Bex M, Belaya Z, Turcu AF, Feelders RA, Heaney AP, Paul M, Pedroncelli AM and Auchus RJ (2023) Long-term efficacy and safety of osilodrostat in patients with Cushing’s disease: results from the LINC 4 study extension. Front. Endocrinol. 14:1236465. doi: 10.3389/fendo.2023.1236465 Received: 07 June 2023; Accepted: 28 July 2023; Published: 23 August 2023. Edited by: Fabienne Langlois, Centre Hospitalier Universitaire de Sherbrooke, Canada Reviewed by: Filippo Ceccato, University of Padua, Italy Kevin Choong Ji Yuen, Barrow Neurological Institute (BNI), United States Copyright © 2023 Gadelha, Snyder, Witek, Bex, Belaya, Turcu, Feelders, Heaney, Paul, Pedroncelli and Auchus. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Mônica Gadelha, mgadelha@hucff.ufrj.br †Present address: Alberto M. Pedroncelli, Camurus AB, Lund, Sweden Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. From https://www.frontiersin.org/articles/10.3389/fendo.2023.1236465/full

October 7 @ 9:00 am – 1:00 pm The annual Pituitary Patient Education Day is a free event that features presentations from Johns Hopkins pituitary experts. To RSVP, please email pituitaryday@jhmi.edu. Space is limited. One member per family is encouraged to attend. Presentations Pituitary lesions: acromegaly, Cushing, prolactinomas, non-functioning masses and hypophysitis (Roberto Salvatori, M.D.) How pituitary tumors can affect your vision (Amanda Henderson, M.D.) Medications for pituitary disease: what you should know (Amir Hamrahian, M.D.) The nose as the door to the pituitary gland (Masaru Ishii, M.D., Ph.D.) Surgery for small and large pituitary tumors: images from the Johns Hopkins operating room (Gary Gallia, M.D., Ph.D.) Radiation: when is it needed and how (Lawrence Kleinberg, M.D.) Chevy Chase Auditorium 1800 Orleans Street Baltimore, Maryland 21287+ Google Map More info at https://events.hopkinsmedicine.org/event/johns-hopkins-pituitary-patient-education-day/

Key takeaways: Cushing’s syndrome symptoms moderately impact quality of life for adults with the condition. Weight gain, muscle fatigue and menstrual changes decline in severity from diagnosis to follow-up. Adults with endogenous Cushing’s syndrome reported that the condition moderately affects their quality of life and causes them to have symptoms about 16 days in a given month, according to findings published in Pituitary. “Our study aimed to evaluate the ongoing burden of Cushing’s syndrome in order to identify areas of unmet need,” Eliza B. Geer, MD, medical director of the Multidisciplinary Pituitary and Skull Base Tumor Center and associate attending of endocrinology and neurosurgery at Memorial Sloan Kettering Cancer Center, told Healio. “We found that patients with treated Cushing’s continue to experience ongoing symptoms more than half of the days in a given month, miss about 25 workdays per year and need twice the average number of outpatient visits per year, indicating a significant impact on daily function and work productivity. Some of these symptoms, like fatigue and pain, have not been well studied in Cushing’s patients, and need more attention.” Geer and colleagues administered a cross-sectional survey to 55 adults aged 21 years and older who had been diagnosed with Cushing’s syndrome at least 6 months before the survey and were receiving at least one pharmacologic therapy for their disease (85% women; mean age, 43.4 years). The survey was conducted online from June to August 2021. Five patient-reported outcome scales were included. The CushingQoL was used to analyze quality of life, a visual analog scale was included to assess pain, the Brief Fatigue Inventory was used to measure fatigue, the Sleep Disturbance v1.0 scale assessed perceptions of sleep and the PROMIS Short Form Anxiety v1.0-8a scale was used to measure fear, anxious misery, hyperarousal and somatic symptoms related to arousal. Participants self-reported the impact of Cushing’s syndrome on daily life and their physician’s level of awareness of Cushing’s syndrome. Some symptoms decline in severity over time Of the study group, 81% had pituitary or adrenal tumors, and 20% had ectopic adrenocorticotropic hormone-producing tumors; 80% of participants underwent surgery to treat their Cushing’s syndrome. The frequency of reported symptoms did not change from Cushing’s syndrome diagnosis to the time of the survey. The most frequently reported symptoms were weight gain, muscle fatigue and weakness and anxiety. Participants reported a decline in symptom severity for weight gain, muscle fatigue and weakness and menstrual changes from diagnosis to the survey. Though symptom severity declined, none of the three symptoms were entirely eliminated. Adults did not report declines in severity for other symptoms. Hirsutism and anxiety were reported by few participants, but were consistently scored high in severity among those who reported it. There were no changes in patient satisfaction with medications from their first appointment to the time of the survey. “It was surprising that anxiety and pain did not improve with treatment,” Geer said. “A quarter of patients at baseline reported anxiety and this percentage was exactly the same after treatment. Same for pain — nearly a quarter of patients reported pain despite treatment. While the presence of anxiety has been well-documented in Cushing’s patients, pain has not, and needs further study.” Nearly half of primary care providers unable to diagnose Cushing’s syndrome All participants reported having at least one challenge with being diagnosed with Cushing’s syndrome. Of the respondents, 49% said their primary care provider was unable to diagnose their Cushing’s syndrome and 33% initially received the wrong diagnosis. Physicians referred 49% of participants to a specialist, and 39% of adults said their doctor lacked knowledge or understanding of their condition. The study group had a moderate level of quality of life impairment as assessed through the CushingQoL scale. The mean pain score was 3.6 of a possible 10, indicating low levels of pain. Moderate to severe levels of fatigue were reported by 69% of participants. Self-reported sleep and anxiety scores were similar to what is observed in the general population. Participants said sexual activity, self-confidence and life satisfaction were most impacted by a Cushing’s syndrome diagnosis. Adults experienced symptoms a mean 16 days in a typical month and saw their outpatient physician an average of six times per year. Those who were employed said they miss 2 days of work per month, or about 25 days per year, due to Cushing’s syndrome. “Longitudinal assessment of clinically relevant patient-reported outcomes based on validated measures and coupled with biochemical and treatment data is needed in a large cohort of Cushing’s patients,” Geer said. “This will allow us to identify clinically meaningful changes in symptom burden within each patient, as well as predictors of outcomes — which patients improve on which symptoms, and which patients do not feel better despite biochemical normalization. We need to improve our ability to help our patients feel better, not just achieve normal cortisol levels.” For more information: Eliza B. Geer, MD, can be reached at geere@mskcc.org. From https://www.healio.com/news/endocrinology/20230830/adults-with-cushings-syndrome-report-high-burden-of-illness-despite-ongoing-treatment

Introduction: The differential diagnosis between Cushing’s disease (CD) and ectopic ACTH syndrome (EAS) is complex, and bilateral inferior petrosal sinus sampling (BIPSS) is considered the gold-standard test. However, BIPSS with corticotropin-releasing hormone (CRH) stimulation is rarely available. Objective: This retrospective cohort study aimed to assess the accuracy of the inferior petrosal sinus to peripheral ACTH gradient (IPS:P) before and after desmopressin stimulation for the differential diagnosis of ACTH-dependent Cushing’s syndrome (CS), applying different cutoff values. Methods: A total of 50 patients (48 with CD and 2 with EAS) who underwent BIPSS were included in this study. The sensitivity and specificity of IPS:P in BIPSS before and after desmopressin stimulation were evaluated. Various cutoff values for IPS:P were examined to determine their diagnostic accuracy. Results: Using the traditional IPS:P cutoff, the sensitivity was 85.1% before stimulation, 89.6% after stimulation, and a combined sensitivity of 91.7%. Applying cutoff values of IPS:P >1.4 before and >2.8 after stimulation, the sensitivity was 87.2% and 89.6%, respectively, with a combined sensitivity of 91.7%. Receiver operating characteristic (ROC) curve analysis determined optimal cutoff values of 1.2 before stimulation and 1.57 after stimulation, resulting in a sensitivity of 93.6% and 93.8%, respectively, with a combined sensitivity of 97.9%. Specificity remained at 100% throughout all analyses. Among the 43 patients who responded positively to stimulation, 42 (97.7%) did so within the first three minutes, and all 43 (100%) did so within the first five minutes. None of the assessed clinical variables predicted the ACTH response to stimulation in BIPSS with statistical significance. Discussion: ACTH stimulation with desmopressin during BIPSS improves the accuracy of IPS:P, making it a valuable tool for investigating ACTH-dependent Cushing’s syndrome. Considering the low risk of complications, we recommend the use of desmopressin stimulation during BIPSS for the differential diagnosis of ACTH-dependent CS. Introduction Cushing Syndrome (CS) is a rare disease that results from chronic exposure to elevated cortisol levels. It can be caused by either endogenous or exogenous factors, and its incidence is estimated to be 0.7-3.2 cases per million per year (1, 2). The mortality rate for CS is elevated and may remain higher than the general population even after remission of hypercortisolism (3, 4). The causes of endogenous CS are traditionally classified into two categories: ACTH-dependent (about 80-85% of cases) and ACTH-independent (15-20% of cases) (5). The most common cause of ACTH-dependent CS (75-80% of cases) is Cushing Disease (CD), which is characterized by a corticotropic pituitary adenoma. The remaining cases (15-20%) of ACTH-dependent CS are caused by ectopic ACTH syndrome (EAS), which occurs when tumors of various sites, histological differentiation, and aggressiveness produce ACTH. There are also exceptionally rare cases (<1%) of ectopic CRH-producing tumors (5, 6). CS diagnosis is a complex and challenging pathway due to the variable pattern of hormonal findings, the non-specificity of clinical presentation, particularly in mild hypercortisolism states (7), and the technical limitations of diagnostic tests. Once CS is confirmed, it should be differentiated between ACTH-dependent or -independent cases (8). ACTH levels <10 pg/ml suggest an adrenal cause; ACTH levels >20 pg/ml suggest ACTH-dependent causes; and levels between 10-20 pg/ml are considered indeterminate, requiring additional tests to establish the etiology (5, 8). When ACTH-dependency is confirmed, the next diagnostic step is the differentiation between CD and EAS. In this step, non-invasive tests are initially recommended, such as the CRH test (CRH-t), the 8 mg dexamethasone suppression test (DST-8 mg), and a pituitary magnetic resonance imaging (MRI) (5, 8). These tests, however, presents heterogenous results, depend on the availability of CRH, restricted in many countries including Brazil, and present low discriminatory power (9, 10). An alternative to CRH-t is the use of desmopressin, which stimulates ACTH release in most patients harboring ACTH-secreting pituitary adenomas. The use of this stimulus for the differential diagnosis of CD vs EAS is controversial, since studies have demonstrated that EAS patients may present ACTH elevation following desmopressin administration (11–14). The DST-8 mg is widely available; however it also presents limitation due to the variability of criteria used; furthermore, it has shown insufficient discriminatory capacity in some studies (15, 16). Pituitary MRI fails to detect adenomas in CD patients in about 30-50% of cases even with modern technology equipment (17); moreover, it may also generate false-positive results since pituitary incidentalomas are common in the population, including macroadenomas (18). In cases of conflicting non-invasive test results and unavailability of other methods, bilateral inferior petrosal sinus sampling (BIPSS) should be performed to detect a central-to-peripheral ACTH gradient that allows the localization of the ACTH production (5). Some authors and guidelines recommend performing BIPSS in all patients with pituitary lesions < 6 mm demonstrated on MRI (5, 8, 19), whereas others suggest BIPSS should routinely be performed, especially to guide surgical therapy of CD (20–23). Thus, the procedure is considered the gold-standard in the differential diagnosis of ACTH-dependent CS, preferentially performed with CRH or, less frequently, with desmopressin. The use of CRH is a limiting factor since it is unavailable in many countries. On the other hand, although used in some medical centers, desmopressin as a stimulus for BIPSS is still poorly debated and assessed in the literature, and its utility in this setting remains uncertain since studies validating it in different populations and in larger series are still lacking (8, 24–26). A recent study evaluating desmopressin in a large cohort of patients proposed new diagnostic criteria, questioning the need of stimulus with the new cut-offs (27). Thus, the aim of this study is to assess the role of central-to-peripheral ACTH gradient after stimulus with desmopressin during BIPSS for the differential diagnosis of ACTH-dependent CS in a cohort of patients followed-up in a referral center for CS in Brazil. Patients and methods Patients Between 1998 and 2020, 107 patients with ACTH-dependent CS were retrospectively evaluated at the Neuroendocrinology clinic of a tertiary center in Southern Brazil for BIPSS under desmopressin stimulation during initial diagnostic evaluation or after recurrence. Of these, 58 patients underwent BIPSS with desmopressin, 50 of which for the initial diagnostic evaluation, 7 after recurrence and 1 after emergency adrenalectomy. Eight patients who underwent BIPSS were excluded for insufficient data regarding final etiologic diagnosis (lack of histopatological confirmation, lack of biochemical remission 6 months after surgery, or lack of remission after radiotherapy). Finally, 50 patients were included in the analysis. The present study was conducted in compliance with the principles laid down in the Declaration of Helsinki and was approved by the Hospital de Clínicas de Porto Alegre Ethics Committee. Diagnosis of CS and ACTH-dependency status After exhaustive screening for exogenous glucocorticoid administration, CS diagnosis was based on the presence of at least two of the following conditions: cortisol after low-dose dexamethasone suppression test (either 1 mg overnight or 0.5 mg 6/6 hours for 48h) > 1.8 µg/dL (DST-1mg); 24-h urinary free cortisol (UFC) or late night salivary cortisol consistently elevated in at least two samples (8). Additionally, late night serum cortisol > 7.5 µg/dL (8) and a desmopressin test (DES-t) with a peak ACTH > 71.8 pg/mL or an increase in ACTH ≥ 37 pg/mL from baseline (28) were also considered suggestive of CS. After clinical and biochemical diagnostic confirmation of CS, plasma ACTH measurement classified CS into ACTH-dependent (ACTH > 20 pg/dL) or ACTH-independent (ACTH < 10 pg/dL). Values between 10-20 pg/dL were considered indeterminate and new samples were obtained for correct classification (8). Next, patients diagnosed with ACTH-dependent CS underwent pituitary MRI for the identification of an adenoma. Due to the unavailability of CRH-t, it was rarely performed. The DES-t for the differential diagnosis of CD and EAS was considered predictive of CD when the increase was > 20% in cortisol or >35% in ACTH after stimulus. In virtue of its low accuracy, DST-8 mg was only performed in a few cases. Patients with inconclusive or negative imaging, those with adenomas < 6 mm or those with adenomas > 6 mm but discordant non-invasive tests were submitted to BIPSS with sampling of ACTH at baseline and after desmopressin stimulus. After investigation, patients with a suggestive diagnosis of CD underwent transsphenoidal surgery. Histological confirmation of a pituitary adenoma staining positive for ACTH was considered the gold-standard for diagnosis. Additionally, patients with inconclusive or absent histological specimen who exhibited clinical and biochemical remission 6 months after surgery or who remitted after pituitary radiotherapy were also considered diagnosed for CD. The EAS cases were confirmed based on surgical excision or biopsy of tumoral lesions confirming the presence of ACTH-staining neoplastic cells. Bilateral inferior petrosal sinus sampling The procedure was performed in the presence of documented hypercortisolism, in an angiography room, under sedation with fentanyl and midazolam, and by a qualified professional in interventional radiology. Initially, bilateral common femoral venipuncture was performed, maintained with 6 French (F) introducers. Then, ascending catheterization of the superior vena cava and internal jugular veins was performed with a 5F vertebral catheter and hydrophilic guidewire, with final positioning of the catheter tip at the level of the inferior petrosal sinuses. Angiographic confirmation was performed after injection of 10 ml of diluted nonionic contrast under digital subtraction, demonstrating bilateral sinus and sellar region opacification. In situations of fine-caliber inferior petrosal sinuses, a coaxial microcatheter was used for a better distal reach of the required topography. Heparinization was not usually necessary in this technique, only sequential washing of the catheters was performed between the sampling times with saline solution with 2 ml of heparin for each 1000 ml of solution. Samples were collected after washing the catheters at baseline. Then, 10 µg of desmopressin was administered intravenously and samples were collected after one, three, five, and 15 minutes. In some cases, the sampling times were slightly different, but always with one sampling at baseline and at least 3 samplings after stimulation. All samples were collected in ice-cold tubes, kept on ice and then centrifuged in a refrigerated centrifuge and frozen at -8°C until ACTH measurement, which occurred immediately after the end of the procedure. After the samplings, the catheters and introducers were removed, followed by manual compression of the inguinal region at the puncture site for 10 minutes, until complete hemostasis. After compression, a compressive dressing was placed at the puncture site and the patients remained at bed rest without flexing the thigh for 6 h. Our routine protocol in performing the BIPSS did not include the concomitant measurement of prolactin as suggested in some previous studies in the literature. Hormone assays Until April 2004, cortisol was measured using a commercially available radioimmunoassay (RIA) kit (Diagnostic Systems Laboratories, Webster, TX, USA). From May 2004 to March 2010, the method was modified to an electrochemiluminescence immunoassay (ECLIA) kit (Modular Analytics E 170; Roche, Mannheim, Germany). From March 2010 to February 2014, cortisol was measured by chemiluminescence immunoassay (ADVIA Centaur XP Immunoassay System, Tarrytown, NY, USA). From February 2014 to October 2019, the method was Competitive Electrochemiluminescence. (Roche e602 equipment line). From October 2019 until the end of the study, the method was Microparticle Chemiluminescent Immunoassay. (Abbott equipment line). ACTH measurements up to February 2000 were performed by commercially available RIA. From February 2000 to April 2015, the method was chemiluminescence with the Immulite 1000 equipment. From May 2015 to April 2018, the method was electrochemiluminescence with the Roche e602 equipment. From May 2018 to August 2019, the method was sandwich electrochemiluminescence using the Roche e602 equipment. From August 2019 until the end of the study, the method was chemiluminescent immunoassay in the Immulite 2000 equipment. These assay differences do not show a large variation from normal values and as samples collected from the same patient were always analyzed with the same assay, the calculations of different indexes of central versus peripheral samplings did not change as a result of the trials. Of the cases studied, ACTH was measured by RIA in 1 patient, by Immulite 1000 in 35 patients, by Roche e602 via electrochemiluminescence in 9 patients, by Roche e602 via sandwich electrochemiluminescence in 4 patients and by Immulite 2000 in 1 patient. The basal ACTH and UFC values, therefore, are presented according to the percentage above the ULN according to each methodology used at each moment. For the calculation of the ACTH inferior petrosal sinus to peripheral gradient (IPS:P), however, absolute values were used since the ratios are calculated for the same patient using the same assay. Statistical analysis The Kolmogorov-Smirnov test was used to assess the distribution of variables. Continuous variables with normal distribution are presented as mean ± standard deviation (SD). Continuous variables with asymmetric distribution are shown as median and interquartile range (IQR). Categorical variables were compared using Fischer’s exact test. The comparison of continuous variables was performed using the Mann-Whitney test. ROC curves were used to assess the ability of the IPS:P gradient to discriminate between CD and EAS, and the Youden index was used to define optimal cutoffs. Sensitivity and specificity were calculated for the different criteria analyzed. Statistical analyzes were performed using the SPSS 24.0 program (statistical package software, SPSS Incorporation, Chicago, IL, USA). Differences were considered significant when p<0.05. Results Patient characteristics are shown in Table 1. During the study period, 50 patients with a confirmed diagnosis of ACTH-dependent CS whose etiology could be confirmed through histopathological or biochemical data (remission after 6 months of surgery or after radiotherapy) who had undergone the BIPSS were included. The mean age (SD) at diagnosis was 38.22 (15.56) years, 39 patients (78%) were female, and 48 patients had CD and 2 EAS. Table 1 Table 1 Characteristics of studied patients. In the imaging results, 23 (46%) were microadenomas, among which 15 were < 0.6cm (65.2% of microadenomas), 8 were macroadenomas (16%), and 19 had negative or inconclusive imaging (38%). One of the patients with EAS had an image suggestive of a 0.4 cm microadenoma on MRI. Regarding macroadenomas, the indication for BIPSS was proposed based on the following situations: 3 presented with a clinical picture of EAS, including 2 with systemic lesions suspicious for neoplasia, 3 presented imaging characteristics that were somewhat atypical for adenomas, 1 was associated with a brainstem vascular lesion and one was a recurrent disease with postsurgical alteration and residual lesion. BIPSS was performed in 44 patients who had not yet undergone investigation or treatment and in 6 patients who had been previously treated for CD but had relapsed during follow-up. No complications were recorded in any of the cases submitted to BIPSS. There were no thromboembolism events related to the procedure. At baseline (before stimulation), 49 patients were evaluated (1 patient with CD had samples collected, but his results were not properly recorded). The median IPS:P gradient at baseline was 6.62 (IQR 2.46-11.36) in patients with CD and 1.14 (IQR 1.10-1.14) in patients with EAS (p=0.01). Using the IPS:P>2 gradient criteria, 40 of 47 patients with CD were positive and none of the 2 patients with EAS were positive, resulting in 85.1% sensitivity (95% confidence interval (CI) 71.1-93.3%) and 100% specificity. After stimulation with desmopressin, all 50 patients were evaluated. The median SPI:P gradient after stimulation was 29.46 (IQR 15.39-61.50) in patients with CD and 1.26 (min-max 1.25-1.28) in patients with EAS (p=0.01). In patients with EAS, the highest ACTH peak was 537 pg/mL (109.5% increase from baseline), while in patients with CD, the lowest increase from baseline was 19.48%. Using the IPS:P gradient criteria > 3, 43 of 48 patients with CD were positive, and none of the 2 patients with EAS were positive, resulting in 89.6% sensitivity (95%CI 76.5-96.1%) and 100% specificity. When evaluating patients who were positive at baseline and/or after stimulation in a combined manner, 44 of 48 CD patients were positive, whereas no EAS patients were positive. The overall sensitivity, therefore, was 91.7% (95%CI 79.1-97.3%), and the specificity was 100%. Of the 9 negative patients at baseline, 3 (33.33%) became positive after stimulation. Among the 43 patients who tested positive after the stimulus, 42 (97.7%) had already tested positive up to the third minute, and 100% of the patients were positive up to the fifth minute (Figure 1), totaling 86% of the total sample. Of the 3 patients whose stimulation was necessary, 2 had microadenomas and 1 had macroadenomas. In the two patients with EAS, the time of peak of ACTH was at 1 minute for patient 1 (31.1% increase from baseline) and at 3 minutes for patient 2 (109.5% increase from baseline). Figure 1 Figure 1 Time (minutes) until obtaining IPS:P gradient values of ACTH considered positive response of BIPSS after stimulation with desmopressin. When assessing only the 23 patients with microadenoma, 20 of 22 patients with CD were positive at baseline, and the patient with EAS and 0.4 cm microadenoma was negative, resulting in 90.9% sensitivity (95%CI 69.37-98.4%), while maintaining 100% specificity. After stimulation, all 22 patients with CD were positive and the only patient with EAS and microadenoma was negative, resulting in 100% sensitivity (95%CI 81.5-100%) while maintaining 100% specificity. When only microadenomas < 0.6 cm were evaluated, 12 of 14 CD patients were positive at baseline, and the patient with EAS and 0.4 cm microadenoma was negative, resulting in 85.7% sensitivity (95%CI 56.2-97.5), with 100% specificity. After stimulation, all 14 patients with CD were positive, and the patient with EAS and microadenoma was negative, resulting in a sensitivity of 100% (95%CI 73.2-100%) while maintaining 100% specificity. All eight patients with microadenomas >0.6cm were already positive at baseline and remained positive after stimulation (100% sensitivity and 100% specificity). Thus, only patients with microadenoma <0.6 cm improved sensitivity after stimulation. Among the 8 patients with macroadenoma, sensitivity was 75% at baseline and remained the same after stimulation. However, when assessed for need for stimulation, only one patient with macroadenoma benefited, but sensitivity did not increase because a patient who was positive at baseline became negative after stimulation. Assessing all patients with positive imaging on MRI (micro or macroadenomas, n = 31), 26 of 30 CD patients were positive at baseline, and the patient with EAS and microadenoma was negative, resulting in 86.7% sensitivity and 100% specificity. After stimulation, 28 of 30 CD patients were positive and the patient with EAS and microadenoma remained negative, resulting in 93.3% sensitivity and maintaining 100% specificity. The combined sensitivity (baseline or after stimulus) in this group of patients was 96.7%. Among the 19 patients with negative imaging, 18 had baseline results and were evaluated. Baseline sensitivity was 82.4%. After stimulation, data from 19 patients were evaluated and resulted in a sensitivity of 83.3%. When the patients with negative imaging (n=19) and those with microadenomas <0.6 cm (n=15) were analyzed together, which represent the most difficult cases in clinical practice, we observed that the IPS:P gradient >2 at baseline resulted in sensitivity of 83.9% and 100% specificity. After stimulation, the IPS:P >3 gradient had a sensitivity of 90.6% while maintaining 100% specificity. After assessing the traditionally proposed criteria, the analysis was performed using the criteria proposed by Chen et al. (27). Using the IPS:P gradient at baseline > 1.4, 41 of 47 CD patients were positive and none of the EAS patients were positive, resulting in 87.2% sensitivity (95%CI 73.5-94.7%) while maintaining 100% specificity. After stimulation, using the IPS:P>2.8 gradient criteria, 43 of 48 patients with CD were positive, resulting in 89.6% sensitivity (95%CI 76.5-96.1%), strictly the same as the traditional criteria maintaining 100% specificity. When evaluating patients who were positive at baseline and/or after stimulation, 44 of 48 patients with CD were positive, and no patient with EAS was positive, resulting in 91.7% overall sensitivity (95%CI 79.1-97.3%), the same as the traditional criteria. Finally, only 2 of 49 patients who were negative at baseline became positive after stimulation. To establish institution-specific cut-off points, a ROC curve was performed to assess the accuracy of the central/peripheral ACTH gradient in BIPSS in our cohort of patients. For the IPS:P gradient at baseline, the cut-off point with the highest accuracy was 1.2, whereas for the IPS:P gradient after stimulation, the cut-off point with the highest accuracy was 1.57 (Figure 2). Using these cut-off points, 44 of 47 CD patients were positive at baseline and no EAS patients were positive, resulting in 93.6% sensitivity (95%CI 81.4-98.3%), while maintaining 100% specificity. After stimulation, 45 of 48 CD patients were positive and no EAS patients were positive, resulting in 93.8% sensitivity (95%CI 81.8-98.4%), with 100% specificity (Figure 3). When evaluating patients who were positive at baseline and/or after stimulation, 47 of 48 CD patients were positive and no EAS patients were positive, resulting in an overall sensitivity of 97.9% (95%CI 87.5-99.9%) With 100% specificity. Finally, only 2 patients who were negative at baseline became positive after stimulation. Figure 2 Figure 2 ROC curve of baseline IPS:P values in BIPSS in the investigation of ACTH-dependent CS. Figure 3 Figure 3 ROC curve of IPS:P values after stimulation with desmopressin in BIPSS in the investigation of ACTH-dependent CS. In the comparison between the traditional criterion and our study criterion, the baseline sensitivity changed from 85.1 to 93.6%. After stimulation, baseline sensitivity changed from 89.6 to 93.8%, respectively. A summary of the sensitivity results with the different diagnostic criteria is presented in Table 2. Table 2 Table 2 Sensitivity of BIPSS with traditional criteria and with present study criteria. Technical difficulties or anatomical variations were found in 6 patients undergoing BIPSS. Among the 43 cases with a positive IPS:P gradient, 3 had anatomical variations and 1 had some technical difficulty. Of the 5 cases in which the IPS:P gradient did not occur (false-negatives), 1 presented anatomical variation and 1 presented some technical difficulty during the test. Among the 6 patients who underwent BIPSS after recurrence, all had a final diagnosis of CD, and only 1 was negative on BIPSS. Of the 50 patients evaluated, 43 had undergone DES-t as part of the diagnostic workup, of which 41 were later diagnosed with CD and 2 with EAS. Forty patients were considered responsive in DES-t, 38 patients with CD and 2 patients with EAS. Among the 40 responsive patients, 34 (85%) were also positive in BIPSS, all with a final diagnosis of CD. The 3 non-responsive patients in DES-t presented a positive response in BIPSS after desmopressin. Of the 6 patients who were positive in DES-t but negative in BIPSS, 2 were patients with EAS. Of the 4 patients with CD, 2 had normal petrosal sinus anatomy, 1 had a report of some anatomical variation, and 1 had a report of technical difficulties during BIPSS. Thus, DES-t was not able to predict response to desmopressin during BIPSS (p>0.9999). When comparing the ACTH values at baseline, 3, 5 and 10 minutes after stimulation in BIPSS, there was no significant difference between the group with positive versus negative DES-t, as well as no difference in the time to positivity between the groups, adenoma size, and number of patients with negative imaging. In addition, the clinical variables evaluated (ACTH, UFC, DST-1mg, baseline cortisol, adenoma size) were not able to significantly predict response to stimulus. Discussion In this study, the use of BIPSS with ACTH measurements at baseline and after stimulation with desmopressin in the differential diagnosis of the ACTH-producing source in a sample of 50 patients with ACTH-dependent CS and inconclusive non-invasive tests resulted in 85.1% baseline sensitivity, increasing to 89.6% after stimulation, maintaining 100% specificity when applying traditional IPS:P≥2 criteria at baseline and ≥3 after stimulation (29). When combined, the baseline and/or stimulated sensitivity results were 91.7%. Results of meta-analyses that combined studies performed with CRH stimulation and desmopressin indicate that the sensitivity of BIPSS ranges from 86-97% and the specificity from 89-100% (27, 30). Published studies with desmopressin are generally small, with a variable number of cases of EAS, different indications for BIPSS, and variable diagnostic criteria. In a study with a sample of 56 patients with ACTH-dependent CS and negative imaging, using the criterion of IPS:P≥2 at baseline and IPS:P≥3 after stimulation with desmopressin, the combined sensitivity was 92.1% and 100% specificity, similar to the findings of the present study (25). Smaller studies that also used desmopressin stimulation found similar (26, 31–33) or slightly higher sensitivities (34, 35). Studies performed exclusively in pediatric patients were less uniform, with one of them reporting similar results to studies that included adults (36) and another study demonstrating lower sensitivity in adult population (37). Our institution’s optimal cut-off points, determined by analyzing the ROC curve, were IPS:P≥1.2 at baseline and ≥1.57 after stimulation. This resulted in 93.6% baseline sensitivity (it was 85.1% with IPS:P≥2), and 93.8% after stimulation (was 89.6% with IPS:P≥3), and a combined sensitivity of 97.9% (it was 91.7%), maintaining specificity at 100%. Despite the increased sensitivity, these criteria should be used with caution, since the number of cases with EAS was small. The IPS:P gradient at baseline and after stimulation achieved in patients with EAS in some studies with desmopressin would exceed the cutoffs found by us (24, 25, 27), which would incorrectly classify these patients as CD. Before adopting the new values in our institution, therefore, more patients with EAS are necessary to validate these criteria. Also using the ROC curve, Castinetti et al. evaluated 43 patients with ACTH-dependent SC (36 DC and 7 EAS) and established the criteria of IPS:P>2 at baseline or after stimulation, obtaining a sensitivity of 86% at baseline and 97% after stimulation with desmopressin, not mentioning the combined sensitivity. The study, however, showed 85% specificity at baseline, given that a patient with EAS had a 3.33 gradient (24). In addition to applying the traditional criteria, Machado et al. also used ROC curve analysis to establish cut-off points, finding an IPS:P≥1.45 at baseline (88.2% sensitivity) and ≥ 2.04 after stimulation (92.2% sensitivity) as optimal, both with 100% specificity, although the authors did not recommend the use of these new values (25). The results of these studies using the ROC curve suggest that lower cutoff points, both at baseline and after stimulation, can improve sensitivity without compromising specificity. However, a study that performed a ROC curve in patients stimulated with CRH found an optimal 2.10 baseline cut-off, slightly higher than the traditional one of 2, although the post-stimulation cut-off point was 2.15, lower than the one usually used (38). A study with desmopressin, in turn, found values in the ROC curve of 1.76 at baseline, lower than the traditional one, but ≥3.9 after stimulation, higher than the gradient of three usually used, increasing baseline sensitivity but keeping the sensitivity after stimulation unchanged (32). The largest published study evaluating BIPSS with desmopressin stimulation evaluated 226 patients with CD and 24 with EAS (27). Applying the IPS:P>2 criteria at baseline and >3 after stimulation, the sensitivity was 87.2 and 94.2%, respectively, while maintaining 100% specificity. The combined sensitivity was 96.5%. In this series, 3 cases of EAS reached gradients greater than 2 after stimulation, which suggests that cut-off points equal to or lower than this may decrease specificity. The authors also performed an ROC curve, determining the cutoff point of >1.4 at baseline and >2.8 after stimulation. In this analysis, the sensitivity at baseline was 94.7% and 96% after stimulation, resulting in a combined 97.8% sensitivity, higher than that found with the traditional criteria. According to the authors, with these cut-off points, only 7 patients benefited from the stimulus. After this publication, no other studies have tested these new cutoffs. Our study was the first, therefore, to assess the new values. In our series, using the cutoff point of >1.4 at baseline and >2.8 after stimulation, the sensitivity was 87.2 and 89.3%, respectively, and the combined sensitivity was 91.7%, thus slightly improving the sensitivity at baseline with little change after stimulation. In an attempt to identify predictors of need for stimulation, Chen et al. found that patients requiring stimulation had adenomas < 0.6 cm or negative imaging. In addition, patients who required stimulation had lower IPS ACTH levels and did not lateralize. These data, however, are obtained only after performing the BIPSS, which makes their use in practice unfeasible (27). In our series, among patients with microadenomas, only those with lesions <0.6 cm benefited from the stimulus. Patients with negative imaging had a small increase in sensitivity. A patient with a macroadenoma also benefited from the stimulus, although the sensitivity of the cases with macroadenoma did not change, as a positive patient at baseline became negative after the stimulus. Despite current recommendations suggesting to perform BIPSS in patients with adenomas < 0.6 cm or with negative/inconclusive imaging results (8, 39), Chen et al. identified 2 patients with EAS and adenomas > 0.6 cm who would be misdiagnosed with CD if the 0.6 cm threshold were respected. Therefore, they suggest performing BIPSS in all patients with ACTH-dependent CS (27). Given the relevance of EAS cases in this study, a discussion about the current size criteria for indicating BIPSS should be undertaken. Of our 50 patients, 43 (41 CD and 2 EAS) underwent DES-t prior to BIPSS, and 40 were considered responsive, including the two cases of EAS. Among the responders, 34 patients also responded to the stimulus during the BIPSS, all of them with CD. The 3 patients who did not respond to the peripheral stimulus were, however, positive in the BIPSS. The lack of correlation between the DES-t results and the BIPSS may be related to the different sampling intervals in the two exams (short intervals in the BIPSS and long intervals in the peripheral test). Considering that the majority (86%) of our patients performed both tests, it is possible to conclude that the DES-t did not help in the prediction of response to the central stimulus, which makes the use of peripheral test results debatable for this purpose. Of the BIPSS studies with desmopressin, only one described the results of DES-t, although it did not perform any specific analysis of the relationship with BIPSS (36). The study differs from ours, also, as it only evaluated pediatric patients. Although BIPSS is still considered the gold standard in the differential diagnosis of ACTH-dependent CS, some authors have suggested that the procedure should be indicated only in cases in which t-CRH was negative (40, 41). Recent studies have evaluated non-invasive strategies combining t-CRH, DES-t, TSD-8mg, and imaging to reduce the need for BIPSS. Strategies that resulted in a positive predictive value of 100%, however, included t-CRH as part of the diagnostic process (42, 43), which makes adherence to this diagnostic modality inapplicable in many countries due to the unavailability of CRH. In one of these studies, the combination of TSD-8mg with DES-t, which would be possible in Brazil, was inferior to the combination of DES-t with t-CRH or t-CRH with TSD-8mg (43). The low number of patients undergoing TSD-8mg in our study did not allow the evaluation of this strategy. Although not recommended as a test in the differential diagnosis of the etiology of ACTH-dependent SC, DES-t seems promising as a marker of long-term postoperative outcome and as an early marker of recurrence (44), which encourages further studies in these circumstances. Despite there have been reports of thromboembolic events related to BIPSS that occurred heparin (45, 46), it is a very rare complication. The administration of desmopressin, which increases coagulation factor VIII and von Willebrand factor (47), has raised concerns about the potential for increased incidence of thromboembolic events during BIPSS. This is due to the fact that desmopressin is associated with the hypercoagulable state of CS (48) and may also interfere with VIII and von Willebrand factors. The study by Chen et al, the largest published with desmopressin to date, did not record any case of thromboembolism, even without routine anticoagulation during the procedure (27). In our study, performed without routine anticoagulation, there were also no thromboembolic events. The only desmopressin BIPSS study that recorded thromboembolic events routinely used heparin during the procedure (25). Thromboembolic events, therefore, do not appear to be an additional concern when using desmopressin, with or without the use of heparin during the procedure. The decision regarding the use or not of anticoagulants during BIPSS should be a decision of each institution and based on the usual anticoagulation recommendations. In our study, we did not perform the concomitant dosage of prolactin in samples collected from the inferior petrosal sinuses, a procedure that potentially reduces false negatives, as advised by some authors based on studies with CRH (49–51) and a study with desmopressin (31). These findings, however, were not confirmed by all groups, both with CRH (52) and with desmopressin (32), and their applicability depends on further studies to define its role. In our study, a total of 3 patients who were negative at baseline benefited from the stimulus, As they became positive, 2 of them with microadenomas and one with macroadenoma. The study by Chen et al. questions the use of routine stimulation in all patients to reduce the risks and the duration of the procedure, potentially reducing complications. The authors argue that, when using the IPS:P>1.4 criterion at baseline, the sensitivity was high enough to classify most patients, with the exception of 7 patients with adenoma <0.6 cm who needed stimulation (27). Our study, however, would have misclassified a case with CD and macroadenoma as EAS if the stimulus had not been performed. The assessment of the need for stimulation in cases of CS with macroadenoma is limited since most studies performed the BIPSS only in patients with lesions < 0.6 cm or negative imaging, preventing a more comprehensive assessment. Considering that BIPSS is currently still the gold standard in the differential diagnosis of ACTH-dependent CS, even small gains in sensitivity should be considered important since incorrect classification of patients can lead to inappropriate treatments and potentially fatal delays in the resolution of hypercortisolism. Considering that BIPSS is generally well tolerated and the rate of serious complications is low (53), other strategies to reduce the risks of the procedure that do not involve avoiding the stimulus seem necessary. In this context, it is important to evaluate the time interval between the infusion of the secretagogue and the positive test result. In our study, 97.7% of the patients who tested positive after stimulation were already positive in the third minute and 100% of the patients were positive until the fifth minute, demonstrating that there seems to be no benefit in prolonging the test beyond this period. All of the few studies on BIPSS with desmopressin have directly or indirectly reported a similar time to positivity and for peak ACTH (i.e., positive up to 3-5 minutes) (26, 33, 35, 37). Stimulating patients for a maximum time of 5 minutes considerably reduces the procedure time without neglecting the sensitivity gain resulting from the stimulation and may, therefore, be a strategy to potentially reduce the risk of complications. Our study evaluated a sample of patients whose BIPSS indication was more comprehensive since the unavailability of t-CRH and the low accuracy of TSD-8mg limited the use of non-invasive tests. The wide heterogeneity existing in the BIPSS studies regarding the characteristics of the evaluated patients (primary diagnosis or recurrence), the BIPSS technique (sampling times, anticoagulant use, material used, laboratory assays, cut-off points, type of secretagogue) makes direct comparisons difficult. Conducting multicenter prospective studies with a greater sample of EAS patients is necessary to improve our understanding of the best cut-off points and procedure duration. The present study has some limitations, as expected in the complexity of CS investigation. Our main limitation is that the low prevalence of EAS that underwent BIPSS, resulting from the rarity of this condition, may explain the high specificity when applying the cutoff points indicated by the ROC curve, and the application of these new gradients of IPS:P depends on validation in larger samples of EAS. Lower specificity may result from poor responsiveness to the secretagogue (desmopressin or CRH), cyclic CS during periods of normal cortisol secretion or due to anomalous venous drainage (54). Retrospective data collection and analysis prevented access to complete information for all patients. There were differences over time in terms of sampling times, although at least 3 different samplings were always performed throughout the study period. We highlight that, in this study, we did not discuss the data regarding the eventual lateralization of the basal ACTH values and after stimulation with desmopressin to guide the location of the pituitary adenoma in the transsphenoidal surgery. This utility of the BIPSS has been less and less recommended in the literature due to the imprecision of the results, especially due to the existence of venous communications between the cavernous sinuses and the instability and intensity of blood aspiration for sample collection. In conclusion, in BIPSS with ACTH dosage, the use of stimulation with desmopressin increases the sensitivity of the test from 85.1% to 89.6%, reaching 100% in the sub-analysis of microadenomas. In spite of being small, this increase is useful in the investigation of ACTH-dependent CS, a clinical situation in which gains in diagnostic sensitivity are very important. Additionally, considering the low risk of complications and the possibility to interrupt the test within 5 minutes, as demonstrated in our study, our data recommend the use of stimulation with desmopressin in the BIPSS in the differential diagnosis of ACTH-dependent CS. Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Ethics statement The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre Ethics Committee. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Author contributions TA, TR and MC conceived the study and designed the research. TA conducted the data collection and database management. TA performed the data analysis. LS, MF and FG performed the BIPSS procedures. TA, TR, FC and MC contributed to the interpretation of the results. TA and MC drafted the manuscript. FC critically revised the manuscript. All authors read and approved the final version of the manuscript. All authors contributed to the article and approved the submitted version. Funding This work was supported by the Research Incentive Fund (FIPE) of Hospital de Clínicas de Porto Alegre and the Postgraduate Program in Medical Sciences: Endocrinology (PPG ENDO) from Universidade Federal do Rio Grande do Sul. Acknowledgments The authors would like to acknowledge the contributions of Guilherme Alcides Flores Soares Rollin, Arthur Boschi, and Camila Viecceli to the data collection process. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Abbreviations BIPSS, bilateral inferior petrosal sinus sampling; CD, Cushing Disease; CRH-t, CRH test; CS, Cushing Syndrome; DES-t, desmopressin test; DST-1 mg, 1 mg dexamethasone suppression test; DST-8 mg, 8 mg dexamethasone suppression test; EAS, Ectopic ACTH Syndrome; ECLIA, electrochemiluminescence immunoassay; F, French; IPS:P, inferior petrosal sinus to peripheral gradient; IQR, interquartile range; MRI, magnetic resonance imaging; RIA, radioimmunoassay; SD, standard deviation; UFC, urinary free cortisol; ULN, upper limit of normal. References 1. Newell-Price J, Bertagna X, Grossman AB, Nieman LK. Cushing’s syndrome. 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Second-line tests in the diagnosis of adrenocorticotropic hormone-dependent hypercortisolism. Ann Lab Med (2021) 41(6):521–31. doi: 10.3343/alm.2021.41.6.521 PubMed Abstract | CrossRef Full Text | Google Scholar Keywords: Cushing’s syndrome, Cushing’s disease, ectopic ACTH syndrome, bilateral inferior petrosal sinus sampling, ACTH, desmopressin Citation: Almeida TSd, Rodrigues TdC, Costenaro F, Scaffaro LA, Farenzena M, Gastaldo F and Czepielewski MA (2023) Enhancing Cushing’s disease diagnosis: exploring the impact of desmopressin on ACTH gradient during BIPSS. Front. Endocrinol. 14:1224001. doi: 10.3389/fendo.2023.1224001 Received: 17 May 2023; Accepted: 11 July 2023; Published: 03 August 2023. Edited by: Fabienne Langlois, Centre Hospitalier Universitaire de Sherbrooke, Canada Reviewed by: Filippo Ceccato, University of Padua, Italy Matthieu St-Jean, Université de Sherbrooke, Canada Copyright © 2023 Almeida, Rodrigues, Costenaro, Scaffaro, Farenzena, Gastaldo and Czepielewski. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Tobias Skrebsky de Almeida, tsalmeid@gmail.com Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. From https://www.frontiersin.org/articles/10.3389/fendo.2023.1224001/full

Background: Café-au-lait skin macules, Cushing syndrome (CS), hyperthyroidism, and liver and cardiac dysfunction are presenting features of neonatal McCune–Albright syndrome (MAS), CS being the rarest endocrine feature. Although spontaneous resolution of hypercortisolism has been reported, outcome is usually unfavorable. While a unified approach to diagnosis, treatment, and follow-up is lacking, herein successful treatment and long-term follow-up of a rare case is presented. Clinical case: An 11-day-old girl born small for gestational age presented with deterioration of well-being and weight loss. Large hyperpigmented macules on the trunk, hypertension, hyponatremia, hyperglycemia, and elevated liver enzymes were noted. ACTH-independent CS due to MAS was diagnosed. Although metyrapone (300 mg/m2/day) was started on the 25th day, complete remission could not be achieved despite increasing the dose up to 1,850 mg/m2/day. At 9 months, right total and left three-quarters adrenalectomy was performed. Cortisol decreased substantially, ACTH remained suppressed, rapid tapering of hydrocortisone to physiological dose was not tolerated, and supraphysiological doses were required for 2 months. GNAS analysis from the adrenal tissue showed a pathogenic heterozygous mutation. During 34 months of follow-up, in addition to CS due to MAS, fibrous dysplasia, hypophosphatemic rickets, and peripheral precocious puberty were detected. She is still regularly screened for other endocrinopathies. Conclusion: Neonatal CS due to MAS is extremely rare. Although there is no specific guideline for diagnosis, treatment, or follow-up, addressing side effects and identifying treatment outcomes will improve quality of life and survival. Introduction McCune–Albright syndrome (MAS) is a rare mosaic disorder of remarkable complexity with an estimated prevalence of 1/100,000 and 1/1,000,000 (1). Timing of postzygotic missense gain of function mutation of GNAS encoding stimulatory Gαs determines the extent of tissue involvement, imposing a unique clinical phenotype. Although a combination of two or more classical features, such as fibrous dysplasia of bone (FD), café-au-lait skin macules, and hyperfunctioning endocrinopathies (gonadotropin-independent gonadal function, nonautoimmune hyperthyroidism, growth hormone excess, and neonatal hypercortisolism), are diagnostic, renal, hepatobiliary, and cardiac involvement have also been reported (2–4). Adrenocorticotropic hormone (ACTH)-independent adrenal Gαs activation results in the rarest endocrine feature of MAS, which almost invariably presents in the neonatal period: Cushing syndrome (CS). Due to greater burden of Gαs-mutation-bearing cells, the presence of CS is correlated with increased number of accompanying features of MAS and a poorer outcome. Although there is spontaneous resolution in 33% of cases with neonatal CS, mortality occurs with a high rate of 20% (4). A dilemma for the clinician is that most publications to date have been case reports, and there is as yet no guideline for diagnosis, treatment, or follow-up. Here, a rare case of severe CS due to MAS, underlining the unique clinical phenotype specific to the neonatal period, is presented. Our goal is to offer a practical approach based on 3 years of clinical experience of this rare disorder that will help navigate challenges during follow-up. Case presentation A baby girl, born small for gestational age with a birthweight of 2,340 g (−2.1 SDS) and a head circumference of 32.6 cm (−1.61 SDS) was admitted to the neonatal intensive care unit in the first day of life for respiratory distress. She was the second child of a healthy non-consanguineous Caucasian couple, born 38 weeks of gestation via cesarean section following an uneventful pregnancy. Alanine aminotransferase [ALT, 2,376 U/L (normal, 0–40)] and aspartate aminotransferase [AST, 875 U/L (normal, 0–40)] were elevated; gamma-glutamyl transferase and bilirubin were normal. Antibiotics were administered intravenously after a diagnosis of possible neonatal sepsis. Respiratory distress resolved, and liver enzymes decreased (ALT, 687 U/L; AST, 108 U/L). As soon as the antimicrobial treatment was completed, she was discharged in the seventh day of life. She was referred to our center, 4 days later, for failure to thrive (2,315 g), difficulty in feeding, and deterioration of general health. On physical examination, round facies, elongated philtrum and retro-micrognatia, hyperpigmented macules both at the front and back of the trunk and on labia majora, which do not cross midline, and hypertrichosis on the forehead and extremities were noted (Supplementary Figure S1). Newborn reflexes were hypoactive, blood pressure was 100/70 mmHg, and second-degree cardiac murmur was also detected. Systems were normal otherwise. Laboratory findings revealed hyponatremia, impaired renal and liver function tests, tubulopathy, and proteinuria, while blood count was normal (hemoglobin, 10.4 g/dl; leukocyte, 25.0 × 103/μl; platelet count, 449×103/μl) (Table 1). Hyponatremia resolved with fluid treatment, while liver enzymes, blood urea nitrogen, and creatinine remained elevated. Further endocrine evaluation revealed an elevated serum basal cortisol [225.68 g/dl (N, 6.7–22.6 µg/dL)] and 24-h urinary free cortisol [1,129 μg/day (N, 1.4–20 μg/day)]. Serum cortisol was not suppressed during overnight high-dose dexamethasone suppression test (Table 2) (5). Thyroid hormones were consistent with non-thyroidal illness. Table 1 Table 1 Laboratory investigations on admission, prior to medical treatment (19 days), after medical treatment (6 months), and post-adrenalectomy. Table 2 Table 2 Endocrine evaluation prior to medical treatment (19 days), after medical treatment (6 months), and post-adrenalectomy. ACTH-independent CS and café-au-lait spots suggested MAS. Hypercortisolism-related complications emerged. On the 11th day, hyperglycemia (blood glucose, 250 mg/dl) was seen, and it persisted after cessation of intravenous fluids in the exclusively breastfed neonate; thus, 0.5 U subcutaneous neutral protamine Hagedorn insulin (NPH) (three times a day) was initiated on the 16th day of life when blood glucose was 340 mg/dl, and serum insulin was 18.10 μIU/ml. Hypertension (110/90 mmHg) and hypokalemia were triggered by mineralocorticoid action of excessive cortisol on 20th day. Spironolactone (2 mg/kg/day) was started, and nifedipine (0.5 mg/kg/day) was added in order to control blood pressure (Supplementary Figure S2). Since immunosuppressive effects of excess cortisol may increase the risk for opportunistic infections, Pneumocystis jirovecii prophylaxis was started and live vaccines were postponed. Features of MAS and accompanying hyperfunctioning endocrinopathies were screened (Table 2). On ultrasonography, adrenal glands were hypertrophic; kidneys showed increased parenchymal echogenicity, loss of separation between the cortex and medulla, and enhanced medullary echogenicity; and size and echogenicity of the liver were normal. Magnetic resonance imaging of the abdomen confirmed that adrenal glands were hypertrophic (right and left adrenal gland were 24×22×18 mm and 18×19×20 mm in size, respectively) and lobulated. Echocardiogram revealed left ventricular hypertrophy. Bone survey verified generalized decrease in bone mass and revealed areas of irregular ossification and radiolucency in radius, ulna, and distal tibia, which were interpreted as osteoporosis due to hypercortisolism (Supplementary Figure S1). Medical treatment Metyrapone (300 mg/m2/day, per oral, in four doses) was started on the 25th day (Supplementary Figure S2) (6). Since liver function tests were impaired, metyrapone was preferred over ketoconazole. Soon after metyrapone was started, hyperglycemia and hypertension improved, enabling the discontinuation of insulin and nifedipine. Spironolactone was also gradually tapered and discontinued after 13 days of metyrapone treatment, and she was discharged. The dose of metyrapone was adjusted frequently, according to clinical findings and serum cortisol levels during regular visits. However, even after gradually increasing metyrapone dose to 1,850 mg/m2/day over the course of 6 months, total biochemical suppression of serum cortisol could not be achieved (Supplementary Figure S3A), and the patient had progressive loss of bone mineral density, persistent left ventricular hypertrophy, and a lack of catch-up growth. In addition to that, café-au-lait macules became darker, dehydroepiandrosterone sulfate (DHEA-S) gradually increased (Table 2), and previously non-existent marked clitoromegaly was noted as a side effect of high-dose metyrapone. She was also prescribed ursodeoxycholic acid (15 mg/kg/day); however, liver enzymes remained high (Table 1). Right total and left three-quarters adrenalectomy Right total and left three-quarters adrenalectomy was carried out at 9 months of age in light of the patient’s continued clinical findings of hypercortisolism, the existence of unfavorable prognostic markers (high cortisol levels upon admission and heart and liver problems), and the adverse effects of high-dose metyrapone. The patient was administered 100 mg/m2/day glucocorticoids (GC) perioperatively; however, she developed symptoms of adrenal insufficiency. The required GC dose to attain euglycemia, restore general well-being, and resolve adrenal insufficiency was 300 mg/m2/day. Fludrocortisone (0.05 mg/day) was also started. Following surgery, supraphysiological doses of GC were required, as she suffered frequent symptoms of adrenal insufficiency (hypoglycemia, malaise, and loss of appetite). GC dose could be tapered very slowly, and a daily dose of 15 mg/m2/day could be attained in 2 months. As liver function tests, serum cortisol levels and left ventricular hypertrophy all improved following adrenalectomy (Table 1). Bilateral nodular adrenal hyperplasia was observed in the pathological evaluation of surgical specimen, while the findings of liver wedge biopsy were non-specific (Supplementary Figure S4). Sequence analysis of GNAS from the surgical sample of adrenal gland revealed a heterozygous, previously described missense mutation in exon 8 (c.2530C>A, p.Arg844Ser), while the sequence analysis of the GNAS gene from peripheral blood sample was normal. Lymphocyte activation was normal 3 months post-adrenalectomy, and immunization schedule for live vaccines was established. Other findings of MAS She had breast development and vaginal bleeding that lasted 2 days when she was 7 months old, which repeated five more times after the adrenalectomy till 26 months of age. Breast development was Tanner stage 3, and bone age was markedly advanced (4 years and 2 months), despite severe hypercortisolism. On pelvic ultrasonography, uterus was enlarged to 34×22×24 mm; thus, letrozole (0.625 mg, per oral) was started at 26 months of age. She also developed marked hypophosphatemia at the age of 6 months (Table 1). Radiological investigations since birth demonstrated severe osteopenia and lytic lesions, which were attributed to severe hypercortisolism; however, overt lesions of FD were not confirmed. When she was 9 months old, FGF-23 was elevated [122 pg/ml (normal <52)], which suggested hypophosphatemic rickets associated with FD. Oral phosphate (8 mg/kg) and calcitriol (18 ng/kg) were started. At the age of 23 months, bone survey revealed sclerosis of the base of the skull and maxilla and FD in the lower extremities. She has been on oral phosphate (58.7 mg/kg/day), while calcitriol was ceased. She is now 34 months old with severe short stature [height, 81 cm (−3.5 SDS); weight, 9,580 g (−3.7SDS)] (Supplementary Figure S3B). She had been under regular clinic visits and has been on 15 mg/m2/day hydrocortisone and fludrocortisone 0.025 mg/day, letrozole (1×6.25 mg/day), phosphate (58 mg/kg), and ursodeoxycholic acid (100 mg/day) (Supplementary Figure S2). She has six words, cannot form two-word sentences, shows body parts, cannot stand up from supine position without support, and takes a few steps with support. Despite regular physiotherapy and ergotherapy, developmental delay is evident (Bayley Scales of Infant and Toddler Development III language scale, 13/79; motor scale, 2/46). Discussion ACTH-independent CS and café-au-lait macules suggested MAS in this case. Interestingly, this patient was admitted for hyponatremia and hyperglycemia requiring insulin treatment. Neonatal MAS and CS are rare conditions, and presentation of this case is quite unique (4). The earlier the timing of somatic mutation, the greater the burden of Gsα-mutation-bearing cells leading to widespread tissue involvement in MAS. In the current case, adrenal, hepatic, cardiac, renal, and bone tissue involvement were evident in first weeks of life, while precocious puberty and hypophosphatemic rickets were observed later. A lifetime risk of additional tissue involvement is being acknowledged. CS is the rarest endocrine manifestation of MAS, which appears in <5%–7.1%. It presents exclusively within the first year of life (median age, 3.1 months) where features may develop as early as in utero (2–4, 7). The fact that our case was SGA and had moon facies and hirsutism with impaired linear growth, weight gain, hyperglycemia, hypertension, and nephrocalcinosis detected in the neonatal period, suggested severe, in utero onset CS. Upon suspicion, both comorbidities (hyperthyroidism, excess growth hormone, FD, and cardiac and hepatobiliary function) of MAS and complications of GC excess (hypertension, hyperglycemia, hyperlipidemia, nephrocalcinosis, decreased bone mineral density, and muscle atrophy) were assessed (1, 3). Since the initial description of MAS, only 20 neonates with CS have been described with various initial basal serum cortisol ranging from 9.6 to 80.1 µg/dl, and data regarding long-term follow-up and outcome are still developing (1, 2, 8–11). Disease course is heterogenous, and spontaneous resolution of hypercortisolism has been reported (30%) since Gs-bearing cells are mostly located in the fetal adrenal zone, which normally undergoes apoptosis after birth. However, the outcome is mostly unfavorable in cases with extensive endocrine and extra-endocrine manifestations (1, 2, 8–15). Brown et al. reported poorer prognosis and a lower likelihood of spontaneous remission of adrenal disease in patients with cardiac (cardiomyopathy) and liver involvement (hepatocellular adenomas, inflammatory adenomas, choledochal cysts, neonatal cholestasis, and hepatoblastoma). It was hypothesized that these patients have a greater burden of Gsα mutation (3, 4). Treatment of neonatal CS is a long and challenging path where both cortisol excess and its complications should be targeted. Marked hypercortisolism that precipitate neonatal diabetes requiring insulin treatment like our patient is rare and was previously reported only in six patients with CS (4). Until hypercortisolism is managed, hyperglycemia should be treated with insulin. Hypertension is due to mineralocorticoid effect of excess cortisol; thus, blood pressure lowering agents of choice should be aldosterone antagonists (spironolactone) or potassium-sparing diuretics. The treatment strategy of hypercortisolism is determined by disease severity. In a mildly affected case, medical treatment with an expectation of spontaneous resolution (due to previously stated apoptosis of fetal adrenal zone) may be of choice (3, 4, 16–19). Metyrapone, ketoconazole, and mitotane are medical options for lowering cortisol (20–23). Since our patient had impaired liver function, metyrapone, a potent, rapid acting relatively selective inhibitor of 11-hydroxylase was preferred over ketoconazole for its low risk of hepatotoxicity. Reports reviewing adult data suggest an initial dose of 500–750 mg/day and achievement of biochemical control with 1,500 mg/day (23). However, the initial and maximum dose of metyrapone in neonates is unclear; some authors recommend 300 mg/m2/day in four equal doses (6). In our case, adequate biochemical and clinical suppression of cortisol with metyrapone was not achieved despite an increase in dose from 300 to 1,850 mg/m2/day. There are important issues to be considered while using a steroidogenesis inhibitor like metyrapone. Monitoring biochemical response is essential, not only for dose titration and management of cortisol excess but also for adrenal insufficiency due to possible overtreatment. Clinical signs of adrenal insufficiency should always be questioned and assessed. The 24-h urinary free cortisol is the commonly used method; however, it may be impractical due to difficulties in the collection of urine in infants. Alternative methods may be the measurement of early morning serum cortisol and ACTH (23). Low ACTH level may indicate hypercortisolism or may be a sign of suppression due to long-term exposure to hypercortisolism. However, there are deadlocks to be considered in the evaluation of these measurements. A high cortisol level measured by immunoassays does not always indicate an actual elevation. It should be kept in mind that cortisol immunoassays exhibit significant cross-reactivity with cortisol precursors that may be elevated in patients treated with a steroidogenesis inhibitor (especially with metyrapone, which is known to increase 11-deoxycortisol). Such cross-reactivity can be a cause for overestimation of cortisol and may lead to risk of overtreatment (24, 25). It has been suggested that the patients on metyrapone should be biochemically monitored via specific methods, such as mass spectrometry (24–26). Metyrapone is a relatively selective inhibitor of 11-hydroxylase and 18-hydroxylase. Recent in vitro studies indicate greater inhibitory action of metyrapone on aldosterone synthase, resulting in significant reversible reduction in both cortisol and aldosterone. The loss of negative feedback leads to an increase in ACTH, which causes an accumulation of cortisol and aldosterone precursors resulting in an increase in adrenal androgens (23). Although we could not serologically prove an increase in ACTH, hyperpigmentation and the increase in adrenal androgens confirm this mechanism. As far as we know, an increase in DHEA-S causing virilization was an unreported side effect of metyrapone. Clinical (clitoromegaly and hirsutism) and laboratory (DHEA-S) signs of hyperandrogenism should be monitored when higher doses of metyrapone are required. In the severely affected case with CS, where medical treatment is inadequate and the chance of spontaneous resolution is subsiding, adrenalectomy is indicated when medically feasible. Brown et al. suggested that the presence of comorbid cardiac and liver disease like in our case should prompt consideration for early adrenalectomy (4). Although a previous correlation with initial serum cortisol level and prognosis was not established, it may be speculated that excessively high serum cortisol level is associated with increased number of Gsα-mutation-bearing adrenal cells. Thus, we suggest that in neonatal CS due to MAS, initial very high serum cortisol levels, like our case, may be a negative prognostic factor both for spontaneous resolution and clinical response to medical treatment. In infants with severe CS, bilateral adrenalectomy is generally performed. Alternatives like unilateral adrenalectomy and one-side total, other-side three-quarters adrenalectomy may be considered to avoid the requirement for lifelong GC and mineralocorticoid replacement. Unilateral adrenalectomy was reported to successfully improve clinical symptoms and endocrinological status in adult studies; nevertheless, recurrence during follow-up was 23.1%, while 17.5% required contralateral adrenalectomy (27–29). Since the causes of CS in adult series are variable and different from pediatric CS due to MAS, it should be borne in mind that reproducibility of adult data is poor. In CS due to MAS, Gsα-mutation-bearing adrenal gland cells are heterogeneously distributed, and partial adrenalectomy may carry the risk of inadequate management and recurrence. Only a few pediatric case reports addressed this issue. Unilateral adrenalectomy of the larger gland was performed in two neonates with CS due to MAS; remission was achieved for 2 years (30, 31). Itonaga et al. reported a 6-month-old neonate with MAS-associated CS treated with right-sided total adrenalectomy and left-sided half adrenalectomy with remission for 2 years (32). Although these cases were less severe [basal serum cortisol: 16.9, 18.5, and 23.4 µg/dl, respectively (N: 6.2–18.0 µg/dL)], we preferred to perform partial adrenalectomy (right total and left three-quarters adrenalectomy) and succeeded. Our patient has been in remission for more than 2 years. In the largest case–control analysis of CS in patients with MAS, overall mortality was 20% (six cases) where four of them were deceased following bilateral adrenalectomy (66.7% of all deaths) (4). Anaphylaxis (or adrenal insufficiency), sudden cardiac arrest, sepsis, and sudden death were listed as causes of mortality in those four cases where GC dose and process of GC tapering were not clearly described. The fact that our patient required high-dose GC during peri- and postoperative period to restore well-being, tapering to maintenance dose was very slow, and she is still on maintenance dose GC, suggests that rapid tapering of GCs should be avoided and, although being speculative, may explain sudden death following adrenalectomy. Gross motor developmental delay may be caused by prenatal exposure to excess GCs. Prenatal GC treatment for possible congenital adrenal hyperplasia or risk of premature birth have been shown to result in cognitive deficits after birth. Furthermore, children who develop CS later in life may experience a decline in cognitive and school performance where the younger the age of onset, the greater the deterioration in IQ scores (3, 4, 33, 34). Since transgenic mice with Gsα mutation was shown to have short- and long-term memory deficits and impaired associative and spatial learning, it may also be speculated that Gsα mutation may also be present in the central nervous system (35, 36). The establishment of diagnosis of FD follows a characteristic and predictable time course. Although GNAS mutations are acquired early in embryogenesis, skeletal development appears to be relatively normal in utero, without frank clinical signs of FD at birth. Boyce et al. affirmed that FD lesions become apparent over the first several years of life and expand during childhood and adolescence, like our case. Previous case reports have also stated severe osteoporosis, rickets, polyostotic irregular lucencies, pathological fractures, and biopsy-proven FD during infancy (1, 2, 8–15). The exact pathophysiological mechanism is unclear, and Gsα activation in abnormally differentiated osteocytes is accused. FGF-23 overproduction is an inherent feature of FD, and most patients have elevated circulating levels of FGF-23, but frank hypophosphatemia is rare. The increase in FGF-23 is linked to substantial skeletal involvement. Although FGF-23 levels may wax and wane over time, an increase in FGF-23 usually occurs during periods of rapid growth like infancy and adolescence. Concurrent hyperfunctioning endocrinopathies like hyperthyroidism or CS may also adversely affect bone health. Peripheral precocious puberty (PP) is the most frequent presenting feature in female patients with MAS (85%) (6). To date, a safe, effective, and long-term treatment for PP in girls with MAS has not been established. The benefits of current interventions on the ultimate outcome of interest, adult height, have not been well-established due to the rarity of the condition and heterogeneous nature of the disease. Despite the small sample size, studies have concluded that letrozole resulted in a statistically significant decrease in the bone age/chronological age ratio, growth velocity, hence increasing predicted adult height (37). Growth outcome in MAS is not only dependent on timing of pubertal onset but on several other disease components (skeletal involvement and endocrinopathies) as well. Hyperthyroidism and growth hormone excess may accelerate growth, while CS may decelerate it (37, 38). Lack of consensus on both medical and surgical treatment strategies were major obstacles while navigating this case of severe neonatal MAS. The eminence of this report is that it presents current literature with clinical experience on this rare case of neonatal CS due to MAS. High index of suspicion for MAS in a neonate with extensive café-au-lait macules and symptoms of hypercortisolism is the key for early recognition and intervention. Initial excessive cortisol in neonatal CS may be a negative prognostic factor for spontaneous resolution and response to medical treatment, indicating early right total and left three-quarters adrenalectomy. Post-adrenalectomy survival may be related to close supervision during GC tapering. Data availability statement The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/Supplementary Material. Ethics statement Written informed consent was obtained from the individual(s), and minor(s)’ legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article. Author contributions YU collected and analyzed data, drafted the initial manuscript, and reviewed and revised the manuscript. OG collected data. İU, HH, BG, SE, and TK collected data and reviewed and revised the manuscript. ZO and EG analyzed data, conceptualized the work, and revised and critically reviewed the manuscript for important intellectual and medical content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Acknowledgments We thank our patient’s family for providing consent for publication of this work. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Supplementary material The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fendo.2023.1209189/full#supplementary-material Supplementary Figure 1 | (A) The findings of physical and radiologic examination. Notice cushingoid facies, hyperpigmented macules that does not cross the midline at the front of the trunk. (B) Anteroposterior radiographs reveal irregularities in radius, ulna and femur. Although generalized osteopenia improves at 34 months, FD lesions become prominent over months. Supplementary Figure 2 | Timeline of the course of symptoms in neonatal McCune Albright Syndrome noting adjustments made in treatment. Grey box denotes age in days for the first month of life then in months. NPH: Neutral Protamine Hagedorn insulin, CS: Cushing syndrome, PP: precocious puberty. Supplementary Figure 3 | (A) Change in serum cortisol with increased metyrapone (methyrapone was initiated on day 25). (B) Growth chart, the arrow represents right total and left three quarters adrenalectomy. Supplementary Figure 4 | Representative histological features of nodular adrenal hyperplasia. (A, show low-power while (C) Show high-power views. References 1. Lourenço R, Dias P, Gouveia R, Sousa AB, Oliveira G. Neonatal McCune-Albright syndrome with systemic involvement: a case report. J Med Case Rep (2015) 9:189. doi: 10.1186/s13256-015-0689-2 PubMed Abstract | CrossRef Full Text | Google Scholar 2. Corsi A, Cherman N, Donaldson DL, Robey PG, Collins MT, Riminucci M. Neonatal McCune-Albright syndrome: A unique syndromic profile with an unfavorable outcome. JBMR Plus (2019) 3:e10134. doi: 10.1002/jbm4.10134 PubMed Abstract | CrossRef Full Text | Google Scholar 3. Boyce AM, Collins MT. Fibrous dysplasia/McCune-Albright syndrome: A rare, mosaic disease of Gα s activation. 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(2018) 7(12):1424–31. doi: 10.1530/EC-18-0344 PubMed Abstract | CrossRef Full Text | Google Scholar Keywords: McCune Albright syndrome, neonatal Cushing syndrome, metyrapone, adrenalectomy, follow-up Citation: Unsal Y, Gozmen O, User İR, Hızarcıoglu H, Gulhan B, Ekinci S, Karagoz T, Ozon ZA and Gonc EN (2023) Case Report: Severe McCune–Albright syndrome presenting with neonatal Cushing syndrome: navigating through clinical obstacles. Front. Endocrinol. 14:1209189. doi: 10.3389/fendo.2023.1209189 Received: 20 April 2023; Accepted: 04 July 2023; Published: 25 July 2023. Edited by: Martin Oswald Savage, Queen Mary University of London, United Kingdom Reviewed by: Li Chan, Queen Mary University of London, United Kingdom Sasha R Howard, Queen Mary University of London, United Kingdom Tomoyo Itonaga, Oita University, Japan Copyright © 2023 Unsal, Gozmen, User, Hızarcıoglu, Gulhan, Ekinci, Karagoz, Ozon and Gonc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Yagmur Unsal, yagmurunsal@yahoo.com Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. From https://www.frontiersin.org/articles/10.3389/fendo.2023.1209189/full

Cushing's syndrome (CS) is a rare disease with multiple somatic signs and a high prevalence of co-occurring depression. However, the characteristics of depression secondary to CS and the differences from major depression have not been described in detail. In this case, we report a 17-year-old girl with treatment-resistant depression with a series of atypical features and acute psychotic episodes, which is a rare condition secondary to CS. This case showed a more detailed profile of depression secondary to CS and highlighted the differences with major depression in clinical features, and it will improve insight into the differential diagnosis especially when the symptoms are not typical. Introduction Depression is a chronic medical problem with typical features, including sadness, decreased interest and cognitive impairments. In clinical practice, depression can occur in other medical conditions, especially endocrinopathies, making it a more complex problem and exhibiting a challenge in diagnosis, especially in first-contact patients or when the clinical presentations are atypical. It is generally accepted that patients who failed to respond to two or more adequate trials of first-line antidepressants for treatment of major depressive episode are considered to have treatment-resistant depression (TRD) (1). For patients with TRD, a throughout evaluation should be performed to investigate the underlying organic causes. Cushing's syndrome is a rare but serious endocrine disease due to chronic exposure to excess circulating glucocorticoids with multisystem effects (2). The etiology of CS can be divided into adrenocorticotropic hormone (ACTH)-dependent and ACTH-independent. It is characterized by a series of clinical features suggesting hypercortisolism, for example, metabolic abnormalities, hypertension and bone damages (3). A variety of neuropsychiatric symptoms, such as mood disturbance, cognitive impairment and psychosis, also occur in more than 70% CS patients (4). CS is life-threating if not timely diagnosed and treated, however, correct diagnosis can be delayed due to the wide range of phenotypes, especially when they are not classical (5). Previous studies suggested that major depression was the most common co-morbid complication in CS patients, with a prevalence of 50–81% (6). Haskett's study confirmed that 80% of subjects meet the criteria for major depression with melancholic features (7). As reported in most recent investigations, depression in CS was not qualitatively different from non-endocrine major depression and the similarity was even striking (3, 8). However, some studies showed different conclusions and suggested a high prevalence of atypical depressive features other than melancholic features in CS (9). TRD and anxious depression has also been reported in CS patients (10, 11). All of the above conclusions suggest the complexity of depression with CS, and no distinct features have been found pertaining to hypercortisolism (12, 13). Although the intensity of depression secondary to CS is severe, suicidal depression is still an unusual condition (14). Psychosis is a rare manifestation of CS, and the literature is limited. Only a few cases have been reported so far, especially combined with depression episode. In this case report, we presented a girl with CS, who experienced suicidal depression with a series of atypical features and acute psychotic symptoms, which was rarely reported in previous studies. Case description A 17-year-old girl with major depression for 3 years was involuntarily admitted for severe depressed mood with suicide attempts (neck cutting; tranquilizer overdose) and paranoid state in the last 2 weeks without any precipitating factors. She experienced depressed and irritable mood in the last 3 years, and her condition had not improved although several adequate trials of antidepressants were used with satisfactory compliance (sertraline 200 mg/d; escitalopram oxalate 20 mg/d). Over the 2 weeks prior to admission, her depression continued to worsen with increasing irritability, she committed several suicide attempts, and once stated that she was unsafe at home. On admission, her heart rate was 116 bpm with blood pressure 139/81 mmHg and normal temperature; physical examination showed a cushingoid and virilising appearance (central obesity, swollen and hirsute face with acne, purple striae on the abdomen and bruises on the arms). No other abnormal signs were noted. She seemed drowsy but arousable, and she walked slowly, with bent shoulders and an inclined head. Mental state examination was hard to continue because she was passive and reluctant to answer our questions. Venlafaxine 150 mg/d has been used for more than 3 months with poor effects at that time. Besides, weight gain (25 kg), irregular menstrual cycles and numbness of the hands and feet in the last half year were reported by her parents. Otherwise, No episodes of elevated mood and hyperactivity were found during the history taking. She does not have remarkable family history of serious physical or psychiatric illness; she was healthy, had an extroverted personality and had never used substances. Her premorbid social function and academic performance were good. Several clinical characteristics found during the following mental state examinations were listed as follows: • Prominent cognitive impairment without clouding of consciousness: Forgetfulness was frequently noted; she easily forgot important personal information such as her school and grade; she could not recall the suicide attempt committed recently and perfunctorily ascribed it to a casual event; and it was hard for her to recall her medical history (as it is for other depressive patients). The serial seven subtraction task could not be finished, and the interpretation of the proverb was superficial. Difficulty was found in attention maintenance; an effective conversation was hard to perform because she was mind-wandering (we needed to call her name to get her immediate attention) and often interrupted our conversations by introducing irrelevant topics or leaving without apparent reasons. • Decreased language function that did not match her educational background: The patient could not find the proper words to articulate her feelings; instead, many simple, obscure and contradictory words were used, which made her response seem perfunctory. For example, she responded with “I do not know,” “I forgot,” or kept silent in response to our questions, which made the conversations hard to perform. • Psychotic outbursts: Once she left the psychological therapy group, ranted about being persecuted and shook in fearfulness, stated “call the police” repeatedly, negative of explanations and comforts from others, but she cannot give any explanation about her behavior when calmed down. Sometimes she worried about being killed by the doctors but the worries were transient and fleeting. • Depressed mood and negative thoughts (self-blame, worthlessness, and hopelessness) that were not persistent and profound: During most of her hospitalization, the patient seemed confused and apathetic, with intermittent anxiety, but she could not clearly express what made her anxious. Her crying and sadness happened suddenly, without obvious reasons, and she even denied low mood sometimes and said she had come to the hospital for cardiac disease treatment (she did not have any cardiac disease). Her description of her depressed mood was uncertain when specifically questioned, and she rarely reported her depressed feeling spontaneously as other depressed patients would. She did not even have the desire to get rid of her “depression”. Her suicidal ideation was transient and impulsive, and she could not provide a comprehensive explanation for her suicide attempts, such as emptiness, worthlessness or guilt. She was impatient and restless when interacting with others or when a more in-depth conversation was performed. She seemed apathetic, gave little response to emotional support from others and did not care about relevant important issues, such as hospital discharge or future plans. Elevated mood and motor activity were not found during the admission period. • Social withdrawal and inappropriate behaviors: The patient often walked or stayed alone for long periods of time before speaking to other patients suddenly, which seemed improper or even odd in normal social interactions. During most hospitalization periods, lethargy and withdrawal were obvious. Diagnostic assessment and therapeutic interventions Basic laboratory tests reported abnormal results (Table 1), and the circulating cortisol level was far beyond the upper limit of normal, with a loss of circadian rhythm (Table 2); 24-h urinary free cortisol : >2897 nmol/24 h↑(69–345 nmol/24 h); serum ACTH (8 AM, 4 PM, 12 PM): 1.2 pg/ml, 1.3 pg/ml, <1 pg/ml (normal range: 1–46 pg/ml); low-dose dexamethasone suppression test (1 mg) (cortisol value): 1010.1 nmol/l (not suppressed; normal range: <50 nmol/L); high dose dexamethasone inhibition test (cortisol value): 879.0 nmol/l (not suppressed); OGTT and glycosylated hemoglobin; both normal. Other results used to rule out hyperaldosteronism and pheochromocytoma, such as the aldosterone/renin rate (ARR) and the vanillylmandelic acid, dopamine, norepinephrine and epinephrine levels, were reported to be within normal limits; ECG suggested sinus tachycardia; dual-energy X-ray bone density screening values were lower than the normal range; B-mode ultrasound showed a right adrenal tumor and fatty liver. The abdominal CT scan showed a tumor in her right adrenal gland. Brain MRI showed no abnormalities. Psychometric tests including HAMD (Hamilton depression scale), MADRS (Montgomery-Asberg Depression Rating Scale), WAIS (Wechsler Intelligence Scale) and MMSE (Mini-mental State Examination) were hard to perform due to her poor attention and non-cooperation presentation. Table 1 Table 1. Abnormal lab results for the patient. Table 2 Table 2. Circulating cortisol level. The patient had little response to adequate antidepressants in our hospital, including fluoxetine 20–60 mg/d and aripiprazole 5–30 mg/d combined with 3 sessions of MECT (modified electroconvulsive therapy), which was stopped because of her poor cognitive function and poor response. Her last diagnosis was right adrenal adenoma and non-ACTH-dependent Cushing's syndrome. The adrenal adenoma was excised through laparoscopic resection in a general hospital. Hydrocortisone, amlodipine besylate, potassium chloride, metoprolol and escitalopram were used for treatment. Escitalopram 10 mg/d has been used until 2 weeks after her discharge. At the follow-up visit about 1 month after the surgery, her depressive mood had significantly improved, with no self-injury behaviors or psychiatric symptoms found. The patient was calm but still reacted slowly, and cognitive impairment was still found at the last visit. Discussion Previous studies have reported a close association between CS and depression (15). However, suicidal depression with atypical features and acute psychosis have rarely been reported, and the characteristics of depression secondary to CS and the differences from major depression have not been described in detail. This case did not show a full-blown presentation of major depression according to the DSM-5. She presented with a series of features that were not typical as major depression, however, it should be emphasized that the atypical features were not identical to those noted in DSM5, especially regarding increased appetite and hypersomnia. The features suggesting difference from major depression were listed as follows: (a) depressed mood is not constant, it does not exist in most of the day; it is episodic without regular cyclicity, can happen or exacerbate suddenly; (b) the ability to describe anhedonia is poor, she can't report her feeling voluntarily like other patients with major depression, which might be partially related with the decreased language function; (c) depressive thoughts such as self-accusation and feelings of guilt, the classical symptoms of major depression, were rarely found; (d) more exaggerated cognitive impairment and decrease language function; € partial or little useful effect of SSRIs (selective serotonin reuptake inhibitors). The above characteristics were similar to those reported in Starkman's research (13, 16, 17), in which increasing irritability was also regarded as one of the important features for depression in CS. The literature about depression combined with psychosis episode in CS is rare. This patient showed acute episodes of persecutory delusion with disturbed behaviors; her psychotic symptoms occurred suddenly and were fragmentary, with poor sensitivity to antipsychotics; the content was not constant (she never referred to and even denied the unsafe feeling at home before admission), it changed with the environment and was not consistent with the mood state. However, we cannot reach an effective conclusion because the evidence was small; thus, these findings should be evaluated in combination with other clinical presentations. Conclusion Most reviews have concluded that mood disturbances in CS indicate “major depression”, but the detailed description of clinical features are lack, making clinicians uncertain about the presentation and confused about the diagnosis, especially when the somatic signs are indiscriminate. The clinical presentation in this case highlighted the fact that there is a wide range of phenotypes of depression in CS, for some CS patients, the depressive features are not highly consistent with the criteria of major depression regardless of the melancholic or atypical features in the DSM-5. Thus, a thorough and periodic evaluation is necessary to detect the underlying organic and psychosocial causes if the clinical symptoms are not typical (10). Data availability statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author. Ethics statement Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article. Author contributions XY, SC, XJ, and XH were responsible for clinical care. XY did literature search and drafted the manuscript. XH revised the manuscript. All authors contributed to the article and have approved the final manuscript. Acknowledgments We want to thank Juping Fu, Ying Zhang, and all other medical staff who gave careful nursing to the patient. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. References 1. Kverno KS, Mangano E. Treatment-resistant depression: approaches to treatment. J Psychosoc Nurs Ment Health Serv. 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Abstract The most common cause of Cushing syndrome (CS) is exposure to exogenous glucocorticoids. There is an increasing incidence of adulterated over-the-counter (OTC) supplements containing steroids. We present a case of Artri King (AK)-induced CS in a 40-year-old woman who presented with an intertrochanteric fracture of her right femur. Laboratory testing revealed suppressed cortisol and adrenocorticotropic hormone, which was consistent with suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Following the cessation of the AK supplement, the patient’s HPA axis recovered, and the clinical manifestations of CS improved. This case emphasizes the need for better regulation of OTC supplements and the need for cautious use. Introduction Cushing syndrome (CS) is a condition that occurs because of high blood levels of glucocorticoids (GCs). These patients can present with a variety of systemic signs and symptoms, including truncal obesity, easy bruising of the skin, violaceous abdominal striae, resistant hypertension, dysglycemia, as well as osteoporosis. CS can occur because of adrenal etiologies such as adrenal adenoma, adrenal cancer, or adrenal hyperplasia or from an adrenocorticotropic hormone (ACTH)-producing pituitary adenoma or ectopic tumor. However, the most common cause of CS is the exogenous administration of GCs [1]. While exogenous GCs are often medically prescribed for the treatment of inflammatory conditions, some patients may be accidentally exposed to exogenous GCs from over-the-counter (OTC) supplements. We present a case of a young woman who developed exogenous CS and suffered a hip fracture as a result of taking an OTC supplement, Artri King (AK), adulterated with GCs. Case Presentation A 40-year-old obese woman presented to the hospital following a fall at home. She reported a snapping noise and sudden right hip pain while trying to stand up, and subsequently fell to the floor. She had noted right-sided hip pain for several days preceding her fall. She was evaluated in the emergency department where computed tomography (CT) imaging of the right lower extremity showed an intertrochanteric fracture of the right femur (Figure 1). The patient underwent open reduction and internal fixation of her right femur. The patient reported an unexplained weight gain of approximately 40 lbs in the preceding five months with a peak weight of 223 lbs (101 kg) and a body mass index (BMI) of 37 kg/m2. The patient denied taking any medications or supplements at the time of hospitalization. The endocrinology team was consulted to evaluate for causes of secondary osteoporosis in this young woman. Figure 1: A CT scan showing the right intertrochanteric fracture of the right femur (yellow arrows) Diagnostic assessment Her vital signs showed a blood pressure of 142/96 mmHg, heart rate of 68 beats per minute, temperature of 98.1°F (36.7°C), and 98% oxygenation on room air. Physical examination did not reveal abdominal striae or buffalo hump. She did have supraclavicular fat deposition and central obesity. No proximal muscle weakness was present. Laboratory tests were pertinent for decreased 25-hydroxy vitamin D, increased parathyroid hormone (PTH), and normal calcium (Table 1). These findings were consistent with secondary hyperparathyroidism due to vitamin D deficiency. Dual-energy X-ray absorptiometry (DEXA) scan revealed osteoporosis (Figures 2, 3 and Tables 2, 3). Further testing showed normal thyroid-stimulating hormone (TSH), estradiol, follicle-stimulating hormone (FSH), and luteinizing hormone (LH), thus ruling out hyperthyroidism and primary ovarian insufficiency as possible causes of reduced bone mineral density (Table 1). Random cortisol was checked as hypercortisolism was suspected but it was found to be decreased along with decreased ACTH as well (Table 4). A cosyntropin stimulation test was performed, which showed decreased baseline cortisol with inappropriately decreased cortisol levels at 30 minutes and 60 minutes (Table 5). Given the discordance between the patient’s presentation and the lab results, assay interference was suspected, and further evaluation of the adrenal function was performed. Repeat labs using liquid chromatography-mass spectrometry (LCMS) assay again confirmed persistently low cortisol (Table 4). A 24-hour free urine cortisol was too low to quantify per assay despite the adequate volume. Further evaluation showed overall low adrenal steroids, including deoxycorticosterone, 17-hydroxyprogesterone, androstenedione, 11-deoxycortisol, pregnenolone, dehydroepiandrosterone sulfate, corticosterone, and progesterone. Lab test Patient's value Reference range 25-hydroxy vitamin D 12.8 ng/ml 30-100 ng/ml Parathyroid hormone (PTH) 86.2 pg/ml 10-66 pg/ml Serum calcium 9.5 ng/dl 8.8-10.5 mg/dl Thyroid-stimulating hormone (TSH) 2.49 mIU/L 0.36-3.74 mIU/L Estradiol 57.1 pg/ml 19.8-144.2 pg/ml Follicle-stimulating hormone (FSH) 5.4 mIU/ml 2.5-10.4 mIU/ml Luteinizing hormone (LH) 6 mIU/ml 1.9-12.5 mIU/ml Table 1: Patient's lab values on admission Figure 2: Dual-energy X-ray absorptiometry (DEXA) scan of the femoral neck showing osteopenia Figure 3: Dual-energy X-ray absorptiometry (DEXA) scan of the lumbar spine showing osteoporosis Region Area (cm2) Bone mineral content (g) Bone mineral density (g/cm2) T-score Peak reference Z-score Age-matched Femoral neck 4.76 3.53 0.742 -1.0 87 -0.7 91 Total 33.39 26.14 0.783 -1.3 83 -1.1 85 Table 2: Summary of dual-energy X-ray absorptiometry (DEXA) scan results of the femoral neck Region Area (cm2) Bone mineral content (g) Bone mineral density (g/cm2) T-score Peak reference Z-score Age-matched L1 10.79 7.56 0.701 -2.6 71 -2.4 73 L2 11.79 9.06 0.768 -2.4 75 -2.1 77 L3 12.70 9.98 0.786 -2.7 73 -2.4 75 L4 15.57 11.42 0.733 -3.0 69 -2.7 71 Total 50.86 38.03 0.748 -2.7 71 -2.5 73 Table 3: Summary of dual-energy X-ray absorptiometry (DEXA) scan results of the lumbar spine Lab test Patient's values while on Artri King Patient's values four weeks off of Artri King Reference range Random cortisol (routine assay) <0.64 μg/dL 7.3 μg/dL 5-25 μg/dL Adrenocorticotropic hormone (ACTH) 1.5 pg/ml 12 pg/ml 7.2-63.3 pg/ml Random cortisol (using liquid chromatography-mass spectrometry (LCMS) assay) 0.526 μg/dL N/A 5-25 μg/dL Table 4: Patient's cortisol and adrenocorticotropic hormone levels before and after stopping Artri King Cosyntropin stimulation test Patient value Reference range Baseline cortisol 1.64 μg/dL 5-25 μg/dL Cortisol after 30 minutes 1.33 μg/dL >18 μg/dL Cortisol after 60 minutes 6.48 μg/dL >18 μg/dL Table 5: Results of cosyntropin test while on Artri King Treatment She was started on teriparatide as well as vitamin D and calcium supplementation for the treatment of osteoporosis. Based on the aforementioned testing and the apparent symptoms of hypercortisolism, the patient was questioned again about the potential intake of steroids. She then recalled that she had been taking AK, an OTC supplement promoted for joint pain and arthritis. She reported that she had been taking two tablets of the supplement three times a day intermittently for the past three years. The patient neglected to bring it to the medical team’s attention before because she was under the impression that it was a multivitamin and did not have implications on her diagnosis. She was asked to stop the supplement and was educated about potential adrenal insufficiency symptoms and GC withdrawal. Outcome and follow up Repeat labs after four weeks off AK showed improved cortisol and ACTH levels indicating recovery of her hypothalamic-pituitary-adrenal (HPA) axis (Table 4). She lost 25 lbs in this time span with lifestyle modification. She continues teriparatide for osteoporosis, and monitoring of her bone mineral density is planned. Discussion This patient initially presented with a pathological fracture of her right femoral head. Given her young age, causes of secondary osteoporosis, including CS, were explored. The prevalence of osteoporosis in CS patients is 50% [2]. The effects of GC on bone health have been well studied. The major mechanism by which GC affects bone mineral density is by impairment of bone formation. GCs increase osteoblast and osteocyte apoptosis and decrease osteoblast function through their catabolic effects, which result in a dramatic decrease in bone formation rate. A prolonged lifespan of osteoclasts is observed with GC. A decrease in bone formation markers such as P1NP and osteocalcin has been observed in patients treated with GC [3]. Long-term GC use is associated with increased risk for fractures with a reported global prevalence of fractures of 30-50%. The risk for vertebral fractures is even higher, particularly in the thoracic and lumbar vertebrae. Interestingly, the risk for fracture with GC use peaks early in the course of treatment, often as early as three months into treatment, and declines rapidly after GC discontinuation [4]. An increased fracture risk has been described even with relatively low doses of GC (2.5-7.5 mg of prednisone or other equivalently dosed GC) and even with short-term use of under 30 days [5]. Our patient’s initial labs confirmed adrenal suppression despite our initial suspicion of CS, given her ongoing weight gain, central obesity, and osteoporosis. However, no obvious source of exogenous GC was identified. In most cases, the source of exogenous GC is easily identified through medication reconciliation; however, in our case, the patient was inadvertently exposed to steroids from an unregulated supplement, AK. The supplement’s ingredients were listed as glucosamine, chondroitin, collagen, vitamin C, curcumin, methylsulfonylmethane, nettle, and omega-3 fatty acids, with no mention of any steroid components. In a letter to the editor of the Internal Medicine magazine, several doctors published their concerns about a recent increase in CS cases associated with the use of AK and other similarly unregulated products [6]. Based on our literature search, three similar cases were published [7,8]. The reported cases developed CS after taking Artri King for several months, but none of them presented with a fracture. A warning by the U.S. Food & Drug Administration (FDA) was issued on April 20, 2022, indicating that FDA laboratory testing of this supplement confirmed the presence of undeclared drug ingredients, including dexamethasone, methocarbamol, and diclofenac. The FDA, however, was unable to confirm the exact amount of dexamethasone that these supplements contained [9]. Adverse events, including liver toxicity and death, were reported by the FDA. One study revealed that between 2007 and 2016, the FDA had issued more than 700 warnings about the sale of dietary supplements that contained unlisted and potentially dangerous ingredients. The majority of these supplements included those marketed for sexual enhancement, weight loss, or muscle building [10]. This case highlights the risks of undisclosed ingredients in OTC supplements. Conclusions In conclusion, we recommend that a thorough reconciliation of medication and supplements be obtained for all patients with CS. Supplements should be stopped and HPA axis testing should be repeated in patients with suspected exogenous GC exposure, even if steroids are not declared in the ingredients. It is also important to monitor such patients for adrenal insufficiency due to GC withdrawal and consider GC tapering if necessary. Our patient showed improvement in cortisol levels with no overt symptoms of adrenal insufficiency without the need for GC therapy. This case demonstrates the first case of AK-induced CS resulting in a pathological fracture. Given the increased use and availability of OTC supplements, this case highlights on the importance of detailed history-taking and the role of supplements in causing CS. This case also stresses the need for further education and counseling of our patients as well as tighter control on the manufacturing and sale of these supplements. References Lacroix A, Feelders RA, Stratakis CA, Nieman LK: Cushing's syndrome. Lancet. 2015, 386:913-27. 10.1016/S0140-6736(14)61375-1 Mancini T, Doga M, Mazziotti G, Giustina A: Cushing's syndrome and bone. Pituitary. 2004, 7:249-52. 10.1007/s11102-005-1051-2 Briot K, Roux 😄 Glucocorticoid-induced osteoporosis. RMD Open. 2015, 1:e000014. 10.1136/rmdopen-2014-000014 Canalis E, Mazziotti G, Giustina A, Bilezikian JP: Glucocorticoid-induced osteoporosis: pathophysiology and therapy. Osteoporos Int. 2007, 18:1319-28. 10.1007/s00198-007-0394-0 Waljee AK, Rogers MA, Lin P, et al.: Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017, 357:j1415. 10.1136/bmj.j1415 Del Carpio-Orantes L, Quintín Barrat-Hernández A, Salas-González A: Iatrogenic Cushing syndrome due to fallacious herbal supplements. The case of Ortiga Ajo Rey and Artri King. Med Int Mex. 2021, 37:599-602. Patel R, Sherf S, Lai NB, Yu R: Exogenous Cushing syndrome caused by a "Herbal" supplement. AACE Clin Case Rep. 2022, 8:239-42. 10.1016/j.aace.2022.08.001 Mikhail N, Kurator K, Martey E, Gaitonde A, Cabrera C, Balingit P: Iatrogenic Cushing’s syndrome caused by adulteration of a health product with dexamethasone. JSM Clin Case Rep. 2022, 3: U.S. Food and Drug Administration. Public notification: Artri King contains hidden drug ingredients. (2022). Accessed: February 25, 2023: https://www.fda.gov/drugs/medication-health-fraud/public-notification-artri-king-contains-hidden-drug-ingredients. Tucker J, Fischer T, Upjohn L, Mazzera D, Kumar M: Unapproved pharmaceutical ingredients included in dietary supplements associated with US Food and Drug Administration warnings. JAMA Netw Open. 2018, 1:e183337. 10.1001/jamanetworkopen.2018.3337 From https://www.cureus.com/articles/153927-exogenous-cushing-syndrome-and-hip-fracture-due-to-over-the-counter-supplement-artri-king#!/

Abstract Context Cushing’s disease (CD) is rare condition burdened by several systemic complications correlated to higher mortality rates. The primary goal of clinicians is to achieve remission, but it is unclear if treatment can also increase life expectancy. Aim To assess the prevalence of cortisol-related complications and mortality in a large cohort of CD patients attending a single referral centre. Materials and methods The clinical charts of CD patients attending a referral hospital between 2001 and 2021 were reviewed. Results 126 CD patients (median age at diagnosis 39 years) were included. At the last examination, 78/126 (61.9%) of the patients were in remission regardless of previous treatment strategies. Patients in remission showed a significant improvement in all the cardiovascular (CV) comorbidities (p < 0.05). The CV events were more frequent in older patients (p = 0.003), smokers and persistent CD groups (p < 0.05). Most of the thromboembolic (TE) and infective events occurred during active stages of the disease. The CV events were the most frequent cause of death. The standardized mortality ratio (SMR) resulted increased in persistent cases at the last follow-up (SMR 4.99, 95%CI [2.15; 9.83], p < 0.001) whilst it was not higher in those in remission (SMR 1.66, 95%CI [0.34; 4.85], p = 0.543) regardless of the timing or number of treatments carried out. A younger age at diagnosis (p = 0.005), a microadenoma (p = 0.002), and remission status at the last follow-up (p = 0.027) all increased survival. Furthermore, an elevated number of comorbidities, in particular arterial hypertension, increased mortality rates. Conclusions Patients with active CD presented a poor survival outcome. Remission restored the patients’ life expectancy regardless of the timing or the types of treatments used to achieve it. Persistent CD-related comorbidities remained major risk factors. Introduction Cushing’s disease (CD) is the most common cause of endogenous glucocorticoid excess due to uncontrolled adrenocorticotropic hormone (ACTH) secretion from a pituitary adenoma, for the most part a microadenoma [1]. A rare condition with an estimated incidence of 0.6—2.6 cases per million per year, it is burdened by high morbidity and mortality, for the most part linked to cardiovascular (CV) events. This is particularly true for active CD which is characterized by hypertension, diabetes mellitus, obesity and dyslipidaemia. The severity of the clinical picture seems to depend more on the duration of the disease rather than on the degree of cortisol elevation, although other confounding factors may affect the clinical phenotype [2]. Prompt diagnosis and resolution of hypercortisolemia are paramount to revert cortisol-related comorbidities and to improve life expectancy. Although new individualized medical treatment options for CD continue to evolve, transsphenoidal surgery (TSS) remains the first line treatment for potentially operable patients as it is the only treatment that seems to provide a rapid, long-lasting remission. Persistent and recurrent cases are nevertheless major concerns, since up to 50% of cases might require other treatment modalities to achieve disease control and those patients are once again exposed to cortisol excess that can negatively impact their survival [3]. An increased mortality has been noted in patients with active CD, while patients in remission show a markedly lower one. It is still unclear if mortality in these patients is higher than that in the general population. Some studies report a normal life expectancy [4,5,6,7,8] while others describe a persistently higher mortality [9,10,11]. One study reported finding a higher mortality as long as 10 years after remission, and only patients cured by a single TSS showed a normal life expectancy [12]. In view of these considerations, this study was designed to assess the prevalence of cortisol-related comorbidities/complications and mortality in a large group of CD patients attending a tertiary referral centre over the past 20 years. Other study aims were to evaluate the predictors of long-term outcomes and the impact of different treatments on life expectancy in CD patients. Materials and Methods One hundred twenty-six CD patients diagnosed between December 2001 and December 2021 were eligible for this monocentric, retrospective, observational study. Hypercortisolism was suspected on the basis of the patient’s clinical features and it was confirmed by appropriate hormonal testing [low dose dexamethasone suppression test (LDDST), 24-h urinary free cortisol (UFC) and late-night salivary cortisol (LNSC)] after excluding the possibility of exogenous glucocorticoid intake from any route [13]. UFC and LNSC were assessed at least in two different samples as recommended [14, 15]. The diagnosis of ACTH-dependent syndrome was confirmed on the strength of detectable ACTH levels (> 10 ng/L) and appropriate responses to a high dose dexamethasone suppression test (HDDST), corticotrophin releasing hormone (CRH) and/or desmopressin (DDAVP) tests [16]. All the patients underwent a pituitary magnetic resonance imaging (MRI); they also underwent bilateral inferior petrosal sinus sampling (BIPSS) when the results of hormonal tests were ambiguous. The pituitary origin of ACTH secretion was confirmed by biochemical remission after TSS, histology and/or post-operative hypoadrenalism. The results of clinical, biochemical and radiological tests as well as the treatments performed to control cortisol secretion (surgery, radiotherapy and/or medical therapy), any comorbidities (i.e., arterial hypertension, impaired glucose homeostasis, dyslipidaemia, overweight), any hormone deficiencies, any complications (i.e., CD-related events such as infective, CV and thromboembolic events) and any deaths recorded in the medical charts were collected. The disease severity at baseline was defined on the basis of the patient’s UFC values as mild (up to two-fold the upper limit of normal – ULN), moderate (between 2 and 5 times the ULN) or severe (over five-fold the ULN). Patient’s classification on the basis of disease activity are indicated in Supplementary material and methods sections. The presence of hypertension, glucose metabolism impairment, obesity, dyslipidaemia and hypopituitarism were defined as by specific Guidelines, Supplementary [19,20,21,22,23,24]. The current study was designed in accordance with the principles of the Declaration of Helsinki and approved by the Ethical Committee of the province of Padova (protocol code 236n/AO/22, date of approval 29 April 2022). The types of CD complications characterizing the patient were classified into three categories: CV, thromboembolic (TE), or infective (IN) events. Depending on the timing of its presentation, an event was classified as occurring: “prior” to diagnosis, “during” active CD or “after” CD remission. Events requiring hospitalization or iv antibiotic administration were registered as IN events. The causes of death were classified under the following headings: CV, infections, cancer, psychiatric complications leading to suicide, TE events or other (the last when none of the previous causes was applicable). Statistical analysis Categorical variables were reported as counts or percentages, and quantitative variables as median and interquartile ranges [IQR]. The comparisons between groups were performed with a Mann–Whitney sum rank test for independent quantitative variables; a Wilcoxon signed-rank test was run for dependent quantitative variables. As far as categorical variables were concerned, the McNemar test or a chi-square test were used for paired and unpaired data, respectively. A Cox regression analysis was performed to evaluate possible predictors for events and mortality based on the assumption of constant hazards over time. As time-dependent variables (e.g., achieving remission) did not meet this assumption, their survival analysis was performed using Kaplan–Meier analysis. Regarding complications, as there is usually a delay in CD diagnosis [25], Kaplan Meier curves for event free probability were calculated beginning 24 months prior to the diagnosis in order to include “prior” events possibly related to cortisol excess in our analysis. Vice versa, survival analysis for mortality was calculated beginning with the CD diagnosis date. Standardized mortality ratio (SMR) was calculated based on indirect age standardization in order to compare the observed deaths in our CD population with the expected number of deaths in the general population [26, 27]. A Fisher exact test was carried out to assess significant differences with respect to the general population and calculating the 95% confidence interval (95% CI) for SMR. The threshold for statistical significance was set at p-value < 0.05. Statistical analyses were performed with R: R-4.2.0 for Windows 10 (32/64 bit) released in April 2022 and R studio desktop version 4.2.0 (2022-04-22) for Windows 10 64 bit (R Foundation for Statistical Computing, Vienna, Austria, URL https://www.R-project.org/). An open-source calculator was also used to perform the Fisher exact test (http://www.openepi.com). Results Baseline The data of 167 CD patients attending the Centre between December 2001 and December 2021 were collected. The information regarding 41 patients were not included in the analysis because of insufficient follow-up data (i.e. patients referred for second opinion or for diagnostic workup or those with follow-up < 1 year from first line treatment). The remaining 126 patients presented a median age at diagnosis of 39 [31–50 years]; the female: male ratio was 3:1. The median follow-up was 130.5 months [72.5–201.5]. The patients’ clinical features at the time of diagnosis are outlined in Table 1. Table 1 The patients’ clinical features at the time of diagnosis Full size table The median UFC levels were 3.2 times the ULN [2–5.6]. Almost half of the cohort presented moderate cortisol excess (45/98, 45.9%), with lower proportions of the patients presenting mild (26/98, 26.5%) and severe disease (22/98, 27.6%). Most of the patients (91/113, 80.5%) had a microadenoma, including 29/91(31.9%) with negative imaging. The remaining 22 patients (19.5%) had a macroadenoma. Treatments Most of the patients underwent TSS as the first line treatment (113/126), only one patient underwent craniotomy. Eight patients received primary medical treatment, three received first-line radiotherapy and one underwent BA soon after diagnosis. Overall, 115 patients underwent pituitary surgery (one patient with a previous unsuccessful pituitary irradiation) and the remission rate was 60.9%. Relapses were observed in 46.7% of the cases after a median time of 56 [29–83] months. The second surgery proved less successful with respect to the first one; the remission rate was 43.2% (16/37); of these, 25% developed recurrence during the follow-up period. The median time to relapse was 66.5 [36–120] months. Only two patients underwent a third surgery; in both cases it was not curative (Supplementary Fig. 1) [27]. A 4th and a 5th TSS were performed in one of these for debulking purposes due to an aggressive pituitary lesion. Surgical remission was not affected by pre-treatment with cortisol-lowering medications neither before the first (p = 1.0) nor the second TSS (p = 0.88). Moreover, hormone control did not improve the surgical outcomes, although a tendency towards a higher remission rate was observed in those patients who showed good disease control before undergoing the second surgery (Supplementary Fig. 2) [27]. Overall, 34 patients received radiotherapy, either the conventional (18.5%) or the stereotactic type (81.5%). Remission was noted in 36.7% (11/30) of the patients with at least a 12-month post-radiotherapy follow-up. As expected, the longer the follow-up, the higher the remission rate; it was 41.67% (10/24) and 46.7% (7/15) at 5 and 10 years, respectively. Thirteen patients underwent BA and achieved complete remission. Excluding the patients with less than 12 months of follow-up, 4 out of 11 (36.4%) of the patients developed CTP-BADX/NS over a mean follow-up period of 110 [106 -329] months. Three patients out of the 11 were previously irradiated at pituitary level to control cortisol secretion. Four CD patients underwent unilateral adrenalectomy due to a dominant adrenal lesion consistent with chronic ACTH stimulation. Two (50%), harbouring unilateral adenomas larger than 5 cm, achieved remission after surgery; both cases were previously irradiated at the pituitary level. All but one of the 48 patients with persistent hypercortisolism at the last follow-up were on cortisol lowering medications. The untreated patient had a residual mild cortisol excess after TSS and medical therapy was discontinued because of multiple drug intolerance. At the last follow-up 28 patients were receiving monotherapy, and 19 were receiving combination treatment; 25 patients were receiving steroidogenesis inhibitors, 9 pituitary-target drugs and 13 a combination of the two compounds (Supplementary Table 1) [27]. Most of our patients achieved UFC normalization (complete control in 67.4%, partial control in 22.7%, uncontrolled in 10.9%). Data pertaining to a single patient with renal function impairment who presented falsely low UFC were not included in this analysis. When available, LNSC was restored in 14/41 cases (34.2%). No differences in the patients’ outcomes linked to the type of treatment prescribed (monotherapy vs combination treatment) or its target (adrenal vs pituitary) were found (data not shown). We also evaluated the extent of cortisol excess throughout the active phase of CD both for the patients presenting persistence at the last available follow-up (n = 48) and for those in remission after multiple therapies (i.e., late remission) (n = 33). As described in the material and methods section, disease activity for each year of active disease was defined on the basis of patients’ UFC levels. A minimum of three UFC measurements were registered every year and the median value was calculated. When data were missing, the patients were considered uncontrolled during that period. The results are reported in Supplementary Table 2 [27]; both the persistence and late remission groups showed UFC levels < 2xULN over more than 50% of the time span evaluated (58.8% and 73.6%, respectively). There was a progressive increase in the proportion of controlled patients over the observation period (Fig. 1). Fig. 1 Percentage of patients controlled during active CD Full size image Comorbidities The principal CD features at baseline and at the last follow-up examination were evaluated, (Supplementary Table 2). At time of diagnosis, no differences were observed as regards comorbidities between patients who achieved remission and those with persistent disease at baseline, (Supplementary Table 3). The patients in remission at the last examination showed a significant improvement in all the parameters considered; those with persistent CD did not (Table 2). Table 2 A comparison of Cushing’s disease features at baseline and at the last follow-up examination Full size table As far as hormone deficiencies were concerned, 42/126 (33.3%) of the patients developed at least one deficit due to previous treatments (Supplementary table 4) [27], including hypocortisolism due to BA. Neither the second surgery nor radiotherapy led to an increase in hypopituitarism (Supplementary Fig. 3) [27]. Complications and mortality As far as CD complications were concerned, 18.3% of the patients had a TE event, 17.5% presented an IN event and 7.1% presented a CV one. Most of the events occurred during an active phase of CD (Table 3). Other concomitant thrombotic risk factors were present in 10/19 (52.6%) of the patients experiencing TE events. TE events were related to surgery (pituitary, adrenal or others) in 5 cases, to post-traumatic fractures in 2, to prolonged immobilization in 2, and to a symptomatic SARS CoV2 infection in one case. IN events affected the respiratory system in 9 cases, the gastro-intestinal tract in 5 cases, the soft tissues in three cases, the central nervous system in 2 cases, the musculoskeletal system in 2 cases and the genitourinary tract in one case. Table 3 Thromboembolic, infective, and cardiovascular events and their timing (see materials and methods) Full size table Overall, 11 deaths were recorded during the follow-up period (130.5 [72.5–201.5] months). The causes of death were classified as: cardiovascular events (n = 4), infections (n = 2), cancer (n = 2), suicide (n = 1), thromboembolic events (n = 0), others (n = 2; a cerebral haemorrhage in one case and an unknown cause in the other). Cox regression was performed to evaluate the predictors of events (CV, IN, TE) and mortality (Fig. 2). The older patients presented an increased risk of mortality (HR 9.41, 95%CI [1.97; 44.90], p = 0.005), of CV events (HR 4.84, 95%CI [1.13; 20.75], p = 0.003) and of TE events (HR 2.41, 95%CI [1.02; 5.65], p = 0.04). Similarly, the presence of a macroadenoma at the time of the first MRI was associated with reduced survival (HR 9.29, 95%CI [2.30; 37.53], p = 0.002). Smoking was correlated to CV events (HR 5.33, 95%CI [1.33; 21.37], p = 0.02). Hypercortisolism severity at baseline did not affect the risk of complications or survival. No gender related differences were observed, although a tendency toward more CV events was noted in the males (p = 0.08). Fig. 2 Cox regression analysis for predictors of mortality and cardiovascular, infective or thromboembolic events; only significant results are shown. HR: Hazard ratio; CI: confidence interval; n: number, CV: cardiovascular; TE: thromboembolic. *p < 0.05 Full size image Kaplan Meier curves were plotted for complications (CV, IN and TE) and mortality in order to assess time-dependent variables (i.e., the number of comorbidities and the disease status at the last follow-up, the timing of remission and the disease activity in the patients with persistent CD at the last follow-up). We found that persistent disease and multiple comorbidities (at least 3) at the last follow-up were associated with increased CV events (p = 0.044 and p = 0.013, respectively) and mortality (p = 0.027 and p = 0.0057, respectively) (Fig. 3). The timing of remission did not influence the mortality or the risk of complications (data not shown). With regard to the patients with persistence, those presenting total/partial control for more than half of the follow-up period considered tended to have fewer CV and IN events (p = 0.078 and p = 0.074, respectively) (Fig. 3). Similarly, among patients with persistent cortisol excess the impaired circadian rhythm of secretion was associate to TE events and a trend to higher mortality (Supplementary Fig. 4). Sub-analysis of each comorbidity revealed that hypertension played a pivotal role during the follow-up period for CV complications (p = 0.011) and mortality (p = 0.0039). Similarly, dyslipidaemia was related to CV events (p = 0.046) and prediabetes/diabetes were associated to TE events (p = 0.035). A tendency toward increased mortality in the patients with impaired glucose homeostasis at the last follow-up was also noted (p = 0.052) (Data not shown). Fig. 3 Kaplan Meier curves for cardiovascular events based on: A) comorbidities at the last follow-up examination; disease status at the last follow-up examination; C) control during active disease for patients presenting persistence at the last follow-up. Kaplan Meier curves for survival plotting: D) comorbidities at the last follow-up examination; E) disease status at the last follow-up examination. Kaplan Meier curves for infective events based on: F) hormone control during active disease of patients presenting persistence at the last follow-up examination. FU: follow-up; CV: cardiovascular; IN: infective. *p < 0.05 Full size image The entire CD cohort presented an increased mortality, with a SMR of 3.22 (95%CI [1.70; 5.60], p = 0.002). Mortality was significantly higher in the patients with persistent disease (SMR 4.99, 95%CI [2.15; 9.83], p < 0.001), but it was similar to that of the general population in the patients in remission (SMR 1.66, 95%CI [0.34; 4.85], p = 0.543). The finding was independent of the timing or the modality used to achieve cortisol control; for the early remission group the SMR was 2.15 (95%CI [0.36; 7.11], p = 0.477) and for the late remission group it was 1.14 (95%CI [< 0.01; 5.62], p = 1.0). The length of remission period was 82 [38–139] for the early remission group vs 85 [21–136] for the late remission one. Discussion Study findings have confirmed that CD patients have a higher mortality and, as previously observed, the most common cause of death in these patients was, first of all, CV events and, secondly, infections [9]. Although there were no fatal TE events in our cohort, that type of complication was the most frequent one. As expected, the patients with persistent CD presented significantly increased mortality with respect to the general population. At the last follow-up examination the CD patients in remission had a mortality rate that was comparable to that of the general population regardless of the number of treatments needed to achieve remission. The finding is in contrast with the results of a multicentre study examining patients with more than 10 years of remission that reported finding a normal life expectancy only in the patients who achieved an early remission following a single TSS [12]. The better life expectancy in our series may be explained by an extensive use of cortisol-lowering medications in our centre during active phases of CD. There was moreover at least a partial control in the late remission group during over 70% of the years assessed; this might have had a positive effect on the overall survival rate (data not shown). Furthermore, our study considered relatively recent years when significant improvement in timely diagnosis and available medical therapies have been made [9]. Lastly, being monocentric, our study showed a homogenous management of comorbidities that by contrast, is in highly unlikely in a retrospective international study. Since cardiovascular and metabolic risk factors related to cortisol-excess are major determinant of mortality in CD, the latter point is of the outmost importance. Survival was positively influenced in our cohort by a younger age at diagnosis, the presence of a microadenoma at baseline [9] and a remission status at the last follow-up examination. As expected, an elevated number of comorbidities increased mortality, and as has been previously reported, arterial hypertension, in particular, reduced survival [28]. A tendency toward increased mortality was also noted in connection to impaired glucose homeostasis, but data on this topic are still controversial [8, 10, 12, 28, 29]. Cortisol excess atherosclerotic risk leading to CV events are closely liked. Beyond cortisol’s direct action on the tissues, this association is probably related to a clustering of several metabolic complications such as insulin resistance, arterial hypertension, dyslipidaemia and overweight commonly present in CD patients [30, 31]. Indeed, the patients presenting multiple comorbidities, especially arterial hypertension and dyslipidaemia, showed more CV complications. CV events were also more frequent in the patients with persistent hypercortisolism, and, as observed in general population in the elderly and in the smokers [32]. Older age at the time of diagnosis and dis-glycemia at the last follow-up examination were found to be related to TE events. It was instead impossible to identify predictors of infective complications. Although most TE and IN events occurred during active disease, remission did not significantly reduce these complications. The finding is in line with the data of a recent study focusing on a Swedish population reporting that CD patients present a higher risk of sepsis and thromboembolism even during long term remission [33]. Moreover, it is worthy of note that most of the TE events (52.6%) were accompanied by a concomitant risk factor such as recent surgery. These data highlight the importance of adequate prophylaxis in CD patients facing prothrombotic conditions such as those linked to a perioperative period [3, 34]. Disease severity at the baseline did not affect the patients’ complications or survival; the finding is not entirely surprising as the degree of cortisol excess does not necessarily correlate with the severity of the clinical picture [2]. The patients who achieved remission in our cohort showed an overall improvement in all the cortisol-related comorbidities. Hypertension was the most prevalent complication at the time of diagnosis, while overweight, which persisted in approximately 50% of the cases after remission, became by far the most frequent comorbidity. Glucose homeostasis alterations were the least prevalent at the time of diagnosis, although an underestimation is probable, as only fasting glycaemia or glycosylated haemoglobin were evaluated in most cases and provocative testing for hypercortisolism was not carried out [35]. With regards to demographic features, for the most part our patients were diagnosed during their third/fourth decade of life and they were prevalently female, in line with previous reports [36]. Most cases were due to a pituitary microadenoma (80% of the cases in our patients), including non-visible lesions on the MRI. As far as treatment was concerned, the remission rate after the first TSS was quite low with respect to what would be expected at a tertiary centre; the finding can be explained by the fact that many of the patients studied had been referred to our unit after undergoing unsuccessful pituitary surgery elsewhere. However, the assessment of surgical performance in various centres goes beyond the aim of the present study. As expected, a second TSS was less successful than the first one, but the rate of success found in our patients was in line with literature data [37]. Although the immediate remission rate after a second TSS was comparable to the long term outcome of radiotherapy, a quarter of the patients experienced a relapse just as they did after the first surgery [17]. Regarding the risk of developing hypopituitarism was concerned, no significant difference was found between the two approaches. These data have confirmed that both re-intervention and radiation treatment can be considered valid second-tier options, and a case by case approach should be adopted. Pre-operative medical treatment with cortisol-lowering medications did not improve the surgical outcomes, regardless of its effectiveness in controlling cortisol excess, in line with data by the European Registry on Cushing’s Syndrome (ERCUSYN) [38]. At the last follow-up examination, no differences in disease control were found when the treatment targets (pituitary vs adrenal) of the patients were compared. A higher control rate of hypercortisolism during active CD was found over time, possibly reflecting better drug dose titration and the widening landscape of available drugs with over two thirds of the patients presented completely controlled UFC at last examination. The fact that only one third of our patients achieved circadian rhythm restoration confirmed the previously reported difficulty in normalizing this parameter [39,40,41]. Interestingly, TE were more frequent when LNSC was uncontrolled and the same tendency was observed for survival, confirming the better outcome of patients with rhythm restoration [8]. Although only the last available value of LNSC was assessed, this finding might potentially turn the spotlight on the importance of LNSC normalization during medical treatment [42], but further studies are required to confirm these data. In line with previous reports, more than one third of the patients who underwent BA developed CTP-BADX/NS [18]. Although BA seems to immediately control hypercortisolism, this benefit should be carefully weighed against the risk of permanent adrenal insufficiency and CTP-BADX/NS. The patients received minimal doses of glucocorticoid replacement treatments following BA to avoid both over- and under treatment that might negatively impact survival [43], and this might explain why BA was not associated to increased mortality as observed in other series [44]. Unilateral adrenalectomy was performed in selected cases when a large adrenal nodule, probably provoked by chronic ACTH stimulation [45], was found. Interestingly, two patients who had previously undergone radiation treatment of the pituitary achieved disease remission after this surgery. The “transition” from pituitary to adrenal hypercortisolism after long standing ACTH-stimulation on adrenal nodules in CD patients has already been described by other investigators, and it may explain our findings in the patients studied [46]. The study’s retrospective single-centre nature represents its primary limitation. Its other important limitation, the relatively low number of cases and deaths examined, is of course linked to the condition’s rarity. Being a monocentric study does, on the other hand, have its advantages as it ensures that the treatment strategies, comorbidities evaluation and management are homogeneous. Furthermore, data on comorbidities, disease activity, type of cortisol lowering medications and comorbidities are available for most of our cohort. Besides, a potential protective effect of tailored medical therapy to reduce cortisol levels seems to reduce some complications and, to a less extent, overall mortality, especially when circadian cortisol secretion is restored. Further studies are still required to confirmed these latter findings. 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Author information Authors and Affiliations Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy Alessandro Mondin, Filippo Ceccato, Giacomo Voltan, Pierluigi Mazzeo, Carla Scaroni & Mattia Barbot Neuroradiology Unit, University Hospital of Padova, Padua, Italy Renzo Manara Academic Neurosurgery, Department of Neurosciences, University of Padova, Padua, Italy Luca Denaro Contributions AM and MB wrote the main manuscript text, AM run statistics, AM prepared figures, GV and PM data collection and prepared tables, all authors were involved in patients’ management, CS and MB design the study, FC, CS and MB reviewed the manuscript. Corresponding author Correspondence to Mattia Barbot. Ethics declarations Competing interests Authors certify that they have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matters discussed in this manuscript. Ethical approval The current study was designed in accordance with the principles of the Declaration of Helsinki and approved by the Ethical Committee of the province of Padova (protocol code 236n/AO/22, date of approval 29 April 2022). Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Below is the link to the electronic supplementary material. Supplementary file1 (DOCX 327 KB) From https://link.springer.com/article/10.1007/s11102-023-01343-2

YOU’RE INVITED! A4M/Metabolic Medical Institute (MMI) Webinar on Updates on Treating Hypothyroidism Dr. Theodore Friedman (The Wiz) will giving a webinar on Updates on Treating Hypothyroidism Topics to be discussed include: New articles showing patients prefer desiccated thyroid Moving away from a TSH-centered approach New thyroid hormone preparations, including Adthyza •Does biotin affect thyroid tests? •Hypothyroidism diet? What is the difference between desiccated thyroid and synthetic thyroid hormones? Is rT3 important? Wednesday • August 2, 2023 • 4 PM PDT register at https://us02web.zoom.us/webinar/register/WN_kRyqZFlrSgKj54CuK7OQqQ Slides will be available on the day of the talk here. There will be plenty of time for questions using the chat button. For more information, email us at mail@goodhormonehealth.com

The most common procedure to remove pituitary tumors is transsphenoidal adenomectomy. It allows the removal of the tumor with minimal damage to the surrounding structures. The surgical team accesses the pituitary gland through the sphenoid sinus — a hollow space behind the nasal passages and below the pituitary gland. If performed in specialized centers and by an experienced pituitary surgeon, this type of surgery is reported to result in an overall cure rate, or full remission, of Cushing’s disease for 80% to 90% of patients. A higher success rate is seen with smaller tumors. However, reported remission rates vary considerably, mainly due to differences in the criteria used to define disease remission. In some cases, a second transsphenoidal adenomectomy is required to fully remove tumor tissue; in others, the initial surgical procedure is paired with a second form of treatment, such as radiation therapy or certain medications. Given the complexity of the procedure, the guidelines recommend patients undergo surgery in specialized Pituitary Tumor Centers of Excellence. Patients also are advised to have the surgery performed by an experienced pituitary neurosurgeon. Follow-up for all patients should be conducted by a multidisciplinary team, including a pituitary endocrinologist. Lifelong monitoring for disease recurrence is required.

Abstract Purpose. Few related factors of low bone mass in Cushing’s disease (CD) have been identified so far, and relevant sufficient powered studies in CD patients are rare. On account of the scarcity of data, we performed a well-powered study to identify related factors associated with low bone mass in young CD patients. Methods. This retrospective study included 153 CD patients (33 males and 120 females, under the age of 50 for men and premenopausal women). Bone mineral density (BMD) of the left hip and lumbar spine was measured by dual energy X-ray absorptiometry (DEXA). In this study, low bone mass was defined when the Z score was −2.0 or lower. Results. Among those CD patients, low bone mass occurred in 74 patients (48.37%). Compared to patients with normal BMD, those patients with low bone mass had a higher level of serum cortisol at midnight (22.31 (17.95-29.62) vs. 17.80 (13.75-22.77), ), testosterone in women (2.10 (1.33–2.89) vs. 1.54 (0.97–2.05), ), higher portion of male (32.43% vs. 11.54%, ) as well as hypertension (76.12% vs. 51.67%, ), and lower IGF-1 index (0.59 (0.43–0.76) vs. 0.79 (0.60–1.02), ). The Z score was positively associated with the IGF-1 index in both the lumbar spine (r = 0.35153, ) and the femoral neck (r = 0.24418, ). The Z score in the femoral neck was negatively associated with osteocalcin (r = −0.22744, ). Compared to the lowest tertile of the IGF-1 index (<0.5563), the patients with the highest tertile of the IGF-1 index (≥0.7993) had a lower prevalence of low bone mass (95% CI 0.02 (0.001–0.50), ), even after adjusting for confounders such as age, gender, duration, BMI, hypertension, serum cortisol at midnight, PTH, and osteocalcin. Conclusions. The higher IGF-1 index was independently associated with lower prevalence of low bone mass in young CD patients, and IGF-1 might play an important role in the pathogenesis of CD-caused low bone mass. 1. Introduction Cushing’s disease (CD), caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary tumor, is a rare disease with approximately 1.2 to 2.4 new cases per million people each year [1]. Osteoporosis has been recognized as a serious consequence of endogenous hypercortisolism since the first description in 1932 [2]. The prevalence of osteoporosis is around 38–50%, and the rate of atraumatic compression fractures is 15.8% in CD patients [3]. After cortisol normalization and appropriate treatment, recovery of the bone impairment occurs slowly (6–9 years) and partially [4, 5]. Hypercortisolemia impairs bone quality through multiple mechanisms [6]. Growth hormone (GH) and insulin-like growth factor 1 (IGF-1) play a crucial role in bone growth and development [7]. IGF-1 is considered essential for the longitudinal growth of bone, skeletal maturity, and bone mass acquisition not only during growth but also in the maintenance of bone in adults [8]. Previous research studies revealed that low serum IGF-1 levels were associated with a 40% increased risk of fractures [9, 10], and serum IGF-1 levels could be clinically useful for evaluating the risk of spinal fractures [11]. In Marl Hotta’s research, extremely low or no response of plasma GH to recombinant human growth hormone (hGRH) injection was noted in CD patients. This result suggested that the diminished hGRH-induced GH secretion in patients with Cushing’s syndrome might be caused by the prolonged period of hypercortisolemia [12]. Other surveys indicated that glucocorticoids, suppressing GH–IGF-1 and the hypothalamic-pituitary-gonadal axes, lead to decreased number and dysfunction of osteoblast [13]. However, the exact mechanism is still unclear, and few risk factors for osteoporosis in CD have been identified so far. Until now, relevant and sufficiently powered studies in CD patients have been rare [14, 15]. Early recognition of the changes in bone mass in CD patients contributes to early diagnosis of bone mass loss and prompt treatment, which could help minimize the incidence of adverse events such as fractures. On account of the scarcity of data and pressing open questions concerning risk evaluation and management of osteoporosis, we performed a well-powered study to identify the related factors associated with low bone mass in young CD patients at the time of diagnosis. 2. Materials and Methods 2.1. Subjects This retrospective study enrolled 153 CD patients (33 males and 120 females) from the Department of Endocrinology and Metabolism of Huashan Hospital between January 2010 and February 2021. All subjects were evaluated by the same group of endocrinologists for detailed clinical evaluation. This study, which was in complete adherence to the Declaration of Helsinki, was approved by the Human Investigation Ethics Committee at Huashan Hospital, Fudan University (No. 2017M011). We collected data on demographic characteristics, laboratory tests, and bone mineral density. Inclusion criteria included the following: (1) willingness to participate in the study; (2) premenopausal women ≥18 years old, men ≥18 years old but younger than 50 years old, and young women (<50 years old) with menstrual abnormalities who were associated with CD after excluding menstrual abnormalities caused by other causes; (3) diagnosis of CD according to the updated diagnostic criteria [16]; and (4) pathological confirmation after transsphenoidal surgery (positive immunochemistry staining with ACTH). Exclusion criteria included Cushing’s syndrome other than pituitary origin. 2.2. Clinical and Biochemical Methods IGF-1 was measured using the Immulite 2000 enzyme-labeled chemiluminescent assay (Siemens Healthcare Diagnostic, Surrey, UK). Other endocrine hormones, including cortisol (F), 24-hour urinary free cortisol (24hUFC), adrenocorticotropic hormone (ACTH), prolactin (PRL), luteinizing hormone (LH), follicle stimulating hormone (FSH), estrogen (E2), progesterone (P), testosterone (T), thyroid stimulating hormone (TSH), and free thyroxine (FT4), were carried out by the chemiluminescence assay (Advia Centaur CP). Intra-assay and interassay coefficients of variation were less than 8 and 10%, respectively, for the estimation of all hormones. Bone metabolism markers included osteocalcin (OC), type I procollagen amino-terminal peptide (P1NP), parathyroid hormone (PTH), and 25-hydroxyvitamin D (25(OH)VD), measured in a Roche Cobas e411 analyzer using immunometric assays (Roche Diagnostics, Indianapolis, IN, USA). The IGF-1 index was defined as the ratio of the measured value to the respective upper limit of the reference range for age and sex. Body mass index (BMI) was calculated using the following formula: weight (kg)/height2 (m2). The bone mineral density (BMD) measuring instrument was Discovery type W dual energy X-ray absorptiometry from the American HOLOGIC company. Quality control tests were conducted every working day. Before examination, the date of birth, height, weight, and menopause date of the examiner were accurately recorded, and then BMD (g/cm2) of the left hip and lumbar spine were measured by DEXA. Z value was used for premenopausal women and men younger than 50 years old, and Z-value = (measured value − mean bone mineral density of peers)/standard deviation of BMD of peers [17, 18]. In this study, low bone mass was defined as a Z-value of −2.0 or lower. 2.3. Statistical Analysis The baseline characteristics were compared between CD patients with and without low bone mass by using the Student’s t-test for continuous variables and the χ2 test for category variables. Bone turnover markers, alanine aminotransferase (ALT), triglyceride (TG), IGF-1 index, thyroid stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4), testosterone (T), 24 hours of urine cortisol (24 h UFC), and serum cortisol at 8 a.m. (F8 am) and at midnight (F24 pm) were not in normal distribution, so variables mentioned above were Log10-transformed, which could be used as continuous variables during statistical analysis. Participants were categorized into three groups according to tertiles of the IGF-1 index: <0.5986, 0.5986–0.8380, and >0.8380. The linear trend across IGF-1 index tertiles was tested using linear regression analysis for continuous variables and the Cochran–Armitage test for categorical variables. We used a multivariate logistic regression model to identify related factors that are independently associated with the risk of low bone mass. Variables included in the multivariate logistic regression model were selected based on the Spearman rank correlation analysis and established traditional low bone mass risk factors as priors. The results were presented as odds ratios (OR) and the corresponding 95% confidence intervals (CI). Significance tests were two-tailed, with value <0.05 considered statistically significant for all analyses. Statistical analysis was performed using SAS version 9.3 (SAS Institute Inc, Cary, NC, USA). 3. Results 3.1. The Prevalence of Low Bone Mass in Young Cushing’s Disease Patients From the inpatient system of Huashan hospital, a total of 153 CD patients under the age of 50 for men and premenopausal women (some with menstrual abnormalities were associated with CD) were included, aged from 13 to 49 years, with an average age of 34.25 ± 8.39 years. There were 33 males (21.57%) and 120 females (78.43%). These CD patients included newly diagnosed CD, recurrences of CD, and CD without remission after treatment. There were no differences in the prevalence of different statuses of CD between the two groups (Table 1). Table 1 Clinical and biochemical preoperative characteristics of young Cushing’s disease patients according to status of bone mineral density at diagnosis. Among these CD patients, low bone mass occurred in 74 patients (48.37%), including 24 men and 50 women. The prevalence of low bone mass was 41.67% and 72.73% in female and male CD patients, respectively, and 42 (56.76%) patients suffered from low bone mass in the lumbar spine only, while 10 (13.51%) patients had low bone mass in the femoral neck only, and 22 (29.73%) patients had low bone mass in both parts. In female patients with low bone mass, 27 (54%) had low bone mass in the lumbar region only, 9 (18%) in the femoral neck only, and 14 (28%) had low bone mass in both parts. For male patients with low bone mass, 16 (66.67%) patients had low bone mass only in the lumbar region, and the rest (8, 33.33%) had low bone mass in both parts. Ten patients had a history of fragility fractures (6 ribs, 3 vertebrae, 1 femoral neck, and ribs), and all of them achieved low bone mass in BMD. 3.2. Baseline Characteristics of Cushing’s Disease Patients with and without Low Bone Mass These CD patients were divided into two groups with and without low bone mass (Table 1). Compared to patients without low bone mass, those low bone mass patients had a higher level of diastolic blood pressure (DBP) (97.07 ± 13.69 vs. 89.76 ± 13.43, ), serum creatinine (66.15 ± 24.33 vs. 55.90 ± 13.35, ), uric acid (0.36 ± 0.10 vs. 0.32 ± 0.10, ), cholesterol (5.57 ± 1.30 vs. 5.06 ± 1.47, ), testosterone in women (2.10 (1.33–2.89) vs. 1.54 (0.97–2.05), ), F24 pm (22.31 (17.95–29.62) vs. 17.80 (13.75–22.77), ), and higher portion of male (32.43% vs. 11.54%, ), as well as hypertension (76.12% vs. 51.67%, ). The low bone mass group had a lower IGF-1 index (0.59 (0.43–0.76) vs. 0.79 (0.60–1.02), ) and FT3 level (3.54 (3.16–4.04) vs. 3.98 (3.47–4.45), ) than those without low bone mass. CD patients without low bone mass were more likely to have serum IGF-1 above the upper limit of the normal reference range (ULN) with age-adjusted (18, 26.87% vs. 3, 4.84%, ). No differences of bone turnover makers were found between the two groups. 3.3. Association between Baseline Characteristics and BMD Spearman’s rank correlation analysis was used to explore the related factors of low bone mass in young CD patients (Table 2). The results indicated that the Z score in the lumbar spine was positively associated with age at diagnosis (r = 0.18801, ), IGF-1 index (r = 0.35153, ), FT3 level (r = 0.24117, ), estradiol in women (r = 0.2361, ), and occurrence of normal menstruation in females (r = 0.2267, ). Meanwhile, SBP (r = −0.21575, ), DBP (r = −0.32538, ), ALT (r = −0.17477, ), serum creatinine (r = −0.36072, ), cholesterol (r = −0.20205, ), testosterone in women (r = −0.2700, ), F8 am (r = −0.18998, ), and serum cortisol at midnight (r = −0.27273, ) were negatively associated with the Z-score in the lumbar spine. The results also illustrated that the Z-score in the femoral neck was positively associated with BMI (r = 0.33926, ), IGF-1 index (r = 0.24418, ), FT3 level (r = 0.20487, ), and occurrence of normal menstruation in females (r = 0.2393, ). Serum creatinine (r = −0.1932, ), osteocalcin (r = −0.22744, ), and testosterone in women (r = −0.2363, ) were negatively associated with the Z-score in the femoral neck. Table 2 Spearman rank correlation of BMD and various variables in Cushing’s disease patients. 3.4. IGF-1 Index and Low Bone Mass Participants were categorized into the following three groups according to tertiles of the preoperative IGF-1 index: <0.5986 (tertiles 1), 0.5986–0.8380 (tertiles 2), and >0.8380 (tertiles 3). With the IGF-1 index increasing, the level of PTH decreased (54.85 (38.35–66.2), 38.9 (26.6–66.9), 36 (25.5–47.05), and ), while other bone metabolism makers, including PINP, osteocalcin, and 25 (OH) VD, showed no differences among the three groups (Figures 1(a)–1(d)). With the increase in the IGF-1 index level, the Z-score of both vertebra lumbalis (tertiles 1: −2.4 (−3.3∼−1.5); tertiles 2: −1.9 (−2.3∼−1.0); tertiles 3: −1.15 (−1.9∼−0.4), ) and the neck of femur (tertiles 1: −1.7 (−2.3∼−0.95); tertiles 2: −1.2 (−1.9∼−0.5); tertiles 3: −1.0 (−1.5∼−0.5), ) increased gradually (Figures 2(a) and 2(b)). Meanwhile, prevalence of low bone mass decreased (68.29%, 53.33%, 23.81%, ) (Figure 3(a)) both in the vertebra lumbalis (63.41%, 48.89%, 16.67%, ) and the neck of femur (32.5%, 11.11%, 11.19%, ), with the increasing of the IGF-1 index level (Figures 3(b) and 3(c)). (d) (a) (b) (c) (d) (a) (b) (c) (d) (a) (b) (c) (d) Figure 1 Bone turnover makers in three groups according to tertiles of the preoperative IGF-1 index. Tertiles 1: <0.5986, tertiles 2: 0.5986–0.8380, and tertiles 3 >0.8380. a for PINP; b for osteocalcin; c for PTH; d for VD-OH25. (a) p for trend = 0.2601. (b) p for trend = 0.1310. (c) p for trend = 0.008. (d) p for trend = 0.7956. (b) (a) (b) (a) (b) (a) (b) Figure 2 Z-score of both the neck of femur and the vertebra lumbalis in three tertiles of the IGF-1 index. a for the neck of femur; b for the vertebra lumbalis. Tertiles 1: <0.5986, tertiles 2: 0.5986–0.8380, and tertiles 3 >0.8380. (a) p for trend = 0.0148. (b) p for trend < 0.0001. (c) (a) (b) (c) (a) (b) (c) (a) (b) (c) Figure 3 Prevalence of low bone mass according to tertiles of the preoperative IGF-1 index. With increment of the IGF-1 index level, prevalence of low bone mass decreased, both in the vertebra lumbalis and neck of femur. Tertiles 1: <0.5986, tertiles 2: 0.5986–0.8380, and tertiles 3 >0.8380. (a) p for trend = 0.0002. (b) p for trend = 0.0169. (c) p for trend < 0.0001. In the logistic regression analysis of the related factors of low bone mass, most of the potentially relevant factors were put into this model; only the IGF-1 index was still significantly negatively associated with the prevalence of low bone mass after adjusting for covariables. The results indicated that compared to the patients in the lowest tertile of the IGF-1 index (<0.5563), those with the highest tertile of the IGF-1 index (≥0.7993) had a lower prevalence of low bone mass (95% CI 0.16 (0.06–0.41), ). After adjusting for age, gender, and BMI, the patients in the highest tertile of the IGF-1 index still conferred a lower prevalence of low bone mass (95% CI 0.15 (0.06–0.42), ). The association between the IGF-1 index and low bone mass still existed (95% CI 0.02 (0.001–0.5), ) even after adjusting for age, gender, CD duration, BMI, hypertension, dyslipidemia, diabetes, ALT, Scr, FT3, F24 pm, PTH, and osteocalcin (Table 3). In comparison to the reference population, the participants in the middle tertile of the IGF-1 index (0.5563–0.7993) had no different risk of low bone mass. Table 3 Association between the preoperative IGF-1 index and the risk of low bone mass. 4. Discussion Our results revealed that low bone mass occurred in around half of young CD patients, affecting more males than females, and mostly in the lumbar spine. The CD patients in our study had a high prevalence (48.37%) of low bone mass at the baseline. This was in accordance with the findings of previous research, and the reported prevalence of osteoporosis due to excess endogenous cortisol ranges from 22% to 59% [19–25]. In this study, CD patients’ lumbar vertebrae were more severely affected than the neck of the femur. It is reported that lumbar vertebrae, containing more trabecular bone than femur neck, were more vulnerable to endogenous cortisol [26]. Our results also indicated that men were more prone to low bone mass than women in CD, which was in accordance with several other studies [23, 27, 28]; possibly, the deleterious effect of cortisol excess on BMD might overrule the protective effects of sex hormones, and men were more often hypogonadal compared with women in CD patients. In our study, patients with low bone mass had a significantly higher level of F24 pm. Both cortisol levels in the morning and at midnight, were negatively associated with the Z-score of BMD in the lumbar spine at diagnosis. But these results were not seen in the femoral neck at diagnosis. This further indicated that lumbar vertebrae were more vulnerable to endogenous cortisol. BMI was considered to be associated with bone mass [29]. In our study, higher BMI was associated with higher BMD at diagnosis in the femur neck but not in the lumbar vertebrae, consistent with other studies [30]. Interestingly, besides the above known related factors, we also found that a higher level of the IGF-1 index was strongly associated with a lower prevalence of low bone mass, both in the vertebra lumbalis and the neck of the femur, independently of age, gender, duration, BMI, hypertension, dyslipidemia, diabetes, level of ALT, creatinine, FT3, and F24 pm. The IGF-1 index was also positively associated with the BMD Z-score, both in the lumbar spine and the femoral neck. So far, there have been few studies concerning the association between IGF-1 and low bone mass in Cushing’s disease patients. As we know, GH [31, 32] and IGF-1 [33] have been demonstrated to increase both bone formation (e.g., collagen synthesis) and bone resorption. However, in CD patients, glucocorticoids resulted in decreased number and dysfunction of osteoblasts by inhibiting GH-IGF-1 axes [34, 35]. In vitro studies suggested that at high concentrations of glucocorticoids, a decreased release of GHRH had been reported [36–38]; therefore, GH-IGF-1 axes were inhibited. IGF-1 possessed anabolic mitogenic actions in osteoblasts while reducing the anabolic actions of TGF-β [39]. The decrease in IGF-1 might be a risk factor for low bone mass in CD patients. In vitro studies had also indicated that the suppressive effects of glucocorticoids on osteoblast function can be partially reversed by GH or IGF treatment [8]. In recent years, some studies have also shown that patients with untreated Cushing’s disease may have elevated IGF-1, and mildly elevated IGF-1 in Cushing’s disease does not imply pathological growth hormone excess. Higher IGF-1 levels could predict better outcomes in CD [40, 41]. Possible mechanisms were not clear, which might involve changes in IGF binding proteins (IGFBPs), interference in IGFBP fragments, IGF-1 synthesis or clearance, and/or the effects of hyperinsulinism induced by excess glucocorticoids. In our study, the results also showed that IGF-1 was an independent protective factor for low bone mass in CD patients. Our study was one of the few well-powered research studies on the association of IGF-1 levels with low bone mass in young CD patients. These represented important strengths of our study, especially given the rarity of CD. The main limitation of this study was its retrospective nature. This could not prove causality. A prospective study should be conducted to explore the causality between IGF-1 and osteoporosis in CD patients. In addition, this study lacked morphometric data for spinal fractures in all patients, which may underestimate the incidence of fractures and osteoporosis. However, our study indicated that a lower IGF-1 index level was significantly associated with low bone mass in young CD patients, which might provide a new aspect to understand the possible risk factors and mechanism of osteoporosis in CD patients. In conclusion, our study found that a higher IGF-1 index was independently and significantly associated with decreased prevalence of low bone mass in young CD patients, drawing attention to the role of IGF-1 in the pathogenesis of CD-caused low bone mass and may support the exploration of this pathway in therapeutic agent development in antiosteoporosis in CD. Data Availability The data used to support the findings of the study are available on request from the authors. Additional Points Through a retrospective study of a large sample of Cushing’s disease (CD) patients from a single center, we found that a higher IGF-1 index was independently associated with a lower prevalence of low bone mass in young CD patients and IGF-1 might play an important role in the pathogenesis of CD-caused low bone mass. Disclosure Wanwan Sun and Quanya Sun were the co-first authors. Conflicts of Interest The authors declare that they have no conflicts of interest. Authors’ Contributions Wanwan Sun analyzed the data and wrote the manuscript. Quanya Sun collected the data. Hongying Ye and Shuo Zhang conducted the study design and quality control. All authors read and approved the final manuscript. Wanwan Sun and Quanya Sun contributed equally to this work. Acknowledgments The present study was supported by grants from the initial funding of the Huashan Hospital (2021QD023). 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Abstract Objectives To assess the diagnostic performance of high-resolution contrast-enhanced MRI (hrMRI) with three-dimensional (3D) fast spin echo (FSE) sequence by comparison with conventional contrast-enhanced MRI (cMRI) and dynamic contrast-enhanced MRI (dMRI) with 2D FSE sequence for identifying pituitary microadenomas. Methods This single-institutional retrospective study included 69 consecutive patients with Cushing’s syndrome who underwent preoperative pituitary MRI, including cMRI, dMRI, and hrMRI, between January 2016 to December 2020. Reference standards were established by using all available imaging, clinical, surgical, and pathological resources. The diagnostic performance of cMRI, dMRI, and hrMRI for identifying pituitary microadenomas was independently evaluated by two experienced neuroradiologists. The area under the receiver operating characteristics curves (AUCs) were compared between protocols for each reader by using the DeLong test to assess the diagnostic performance for identifying pituitary microadenomas. The inter-observer agreement was assessed by using the κ analysis. Results The diagnostic performance of hrMRI (AUC, 0.95–0.97) was higher than cMRI (AUC, 0.74–0.75; p ≤ .002) and dMRI (AUC, 0.59–0.68; p ≤ .001) for identifying pituitary microadenomas. The sensitivity and specificity of hrMRI were 90–93% and 100%, respectively. There were 78% (18/23) to 82% (14/17) of the patients, who were misdiagnosed on cMRI and dMRI and correctly diagnosed on hrMRI. The inter-observer agreement for identifying pituitary microadenomas was moderate on cMRI (κ = 0.50), moderate on dMRI (κ = 0.57), and almost perfect on hrMRI (κ = 0.91), respectively. Conclusions The hrMRI showed higher diagnostic performance than cMRI and dMRI for identifying pituitary microadenomas in patients with Cushing’s syndrome. Key Points • The diagnostic performance of hrMRI was higher than cMRI and dMRI for identifying pituitary microadenomas in Cushing’s syndrome. • About 80% of patients, who were misdiagnosed on cMRI and dMRI, were correctly diagnosed on hrMRI. • The inter-observer agreement for identifying pituitary microadenomas was almost perfect on hrMRI. Introduction Cushing’s syndrome, caused by excessive exposure to glucocorticoids, is associated with considerable morbidity and increased mortality [1]. Cushing’s syndrome has diverse manifestations, including central obesity, moon facies, purple striae, and hypertension [2]. Cushing’s disease, due to adrenocorticotropic hormone (ACTH) hypersecretion from pituitary adenomas, is the most common etiology of ACTH-dependent Cushing’s syndrome [1, 2]. According to the Endocrine Society Clinical Practice Guideline, transsphenoidal surgery is the first-line treatment for Cushing’s disease [3]. The identification of pituitary adenomas on preoperative MRI can significantly increase the postoperative remission rate from 50 to 98% [4]. Therefore, it is critical to identify pituitary adenomas on MRI before surgery. However, there are considerable challenges in identifying ACTH-secreting pituitary adenomas. This is because about 90% of the tumors are microadenomas (less than 10 mm in size) and the median diameter at surgery is about 5 mm [5, 6]. Conventional contrast-enhanced MRI (cMRI) using a two-dimensional (2D) fast spin echo (FSE) sequence has been routinely used to acquire images with 2- to 3-mm slice thickness, but some microadenomas are difficult to be identified on cMRI, resulting in false negatives reported in up to 50% of patients with Cushing’s disease [7]. Dynamic contrast-enhanced MRI (dMRI) increases the sensitivity of identifying pituitary adenomas to 66% [8], but it also increases false positives at the same time [9, 10]. The 3D spoiled gradient recalled (SPGR) sequence has been introduced in high-resolution contrast-enhanced MRI (hrMRI) to acquire images with 1- to 1.2-mm slice thickness. It is reported that the 3D SPGR sequence is superior to the 2D FSE sequence in the identification of pituitary adenomas with a sensitivity of up to 80% [11,12,13], but it cannot satisfy the clinical needs that about 20% of the lesions are still missed. Therefore, techniques are needed that can help better identify pituitary adenomas, particularly microadenomas. Previously, the 3D FSE sequence was recommended in patients with hyperprolactinemia [14]. Recently, the 3D FSE sequence has developed rapidly and can provide superior image quality with diminished artifacts [15]. Sartoretti et al demonstrated in a very effective fashion that the 3D FSE sequence is a reliable alternative for pituitary imaging in terms of image quality [16]. However, to our knowledge, few studies have investigated the diagnostic performance of 3D FSE sequences for identifying ACTH-secreting pituitary adenomas, particularly microadenomas. The aim of our study was to assess the diagnostic performance of hrMRI with 3D FSE sequence by comparison with cMRI and dMRI with 2D FSE sequence for identifying ACTH-secreting pituitary microadenomas in patients with Cushing’s syndrome. Materials and methods This single-institutional retrospective study was approved by the Institutional Review Board of our hospital. The study was conducted in accordance with the Helsinki Declaration. The informed consent was waived due to the retrospective nature of the study. Study participants We retrospectively reviewed the medical records and imaging studies of 186 consecutive patients with ACTH-dependent Cushing’s syndrome, who underwent a combined protocol of cMRI, dMRI, and hrMRI from January 2016 to December 2020. Postoperative patients with Cushing’s disease (n = 97), patients with ectopic ACTH syndrome who underwent pituitary exploration (n = 2), and patients with macroadenomas (n = 5) or lack of pathology (n = 13) were excluded from the study. Finally, 69 patients with ACTH-dependent Cushing’s syndrome were included in the current study (Fig. 1) and the patients included were all surgically confirmed. Fig. 1 Flowchart of patient inclusion/exclusion process and image analysis. ACTH adrenocorticotropic hormone, CD Cushing’s disease, EAS ectopic ACTH syndrome, T1WI T1-weighted imaging, T2WI T2-weighted imaging Full size image MRI protocol All the patients were imaged on a 3.0 Tesla MR scanner (Discovery MR750w, GE Healthcare) using an 8-channel head coil. The MRI protocol included coronal T2-weighted imaging, coronal T1-weighted imaging, and sagittal T1-weighted imaging before contrast injection. After contrast injection of gadopentetate dimeglumine (Gd-DTPA) at 0.05 mmol/kg (0.1 mL/kg) with a flow rate of 2 mL/s followed by a 10-mL saline solution flush, dMRI and cMRI with 2D FSE sequence were obtained first, and hrMRI with 3D FSE sequence using variable flip angle technique was performed immediately afterward. Detailed acquisition parameters are presented in Table S1. Image analysis: diagnostic performance Image interpretation was independently conducted by two experienced neuroradiologists (F.F. and H.Y. with 25 and 16 years of experience in neuroradiology, respectively), who were blinded to patient information. The evaluation order of cMRI, dMRI, and hrMRI sequences was randomized. The identification of pituitary microadenomas on images was scored based on a three-point scale (0 = poor; 1 = fair; 2 = excellent). Scores of 1 or 2 represented the identification of the lesion. Reference standards were established by using all available imaging, clinical, surgical, and pathological resources, with a multidisciplinary team approach. Image analysis: image quality Two readers (Z.L. and B.H. with 4 years of experience in radiology, respectively) were asked to assess the image quality of cMRI, dMRI, and hrMRI. Before exposure to images used in the current study, these readers underwent a training session to make sure that they were comparable to the experienced neuroradiologists in terms of image quality assessment. Images were presented in a random order. Image quality was assessed by using a 5-point Likert scale [17], including overall image quality (1 = non-diagnostic; 2 = poor; 3 = fair; 4 = good; 5 = excellent), sharpness (1 = non-diagnostic; 2 = not sharp; 3 = a little sharp; 4 = moderately sharp; 5 = satisfyingly sharp), and structural conspicuity (1 = non-diagnostic; 2 = poor; 3 = fair; 4 = good; 5 = excellent). An example of image quality assessment is shown in Table S2. Final decision was made through a consensus agreement. The mean signal intensity of pituitary microadenomas, pituitary gland, and noise on cMRI, dMRI, and hrMRI was measured using an operator-defined region of interest. For noise, a 10-mm2 region of interest was placed in the background, and noise was defined as the standard deviation of the signal intensity of the background [17]. For pituitary microadenomas and pituitary gland, the region of interest should include a representative portion of the structure. The mean signal intensity of the pituitary microadenoma was replaced with that of the pituitary gland when no microadenoma was identified. A signal-to-noise ratio (SNR) was defined as the mean signal intensity of the pituitary microadenoma divided by noise. A contrast-to-noise ratio (CNR) was defined as the absolute difference of the mean signal intensity between the normal pituitary gland and pituitary microadenomas divided by noise [17]. Supplementary Fig. 1 shows how to measure the SNR and CNR with the region of interest in a contrast-enhanced pituitary MRI. Supplementary Fig. 2 shows the selection of images for the SNR and CNR calculation. Statistical analysis The κ analysis was conducted to assess the inter-observer agreement for identifying pituitary microadenomas. The κ value was interpreted as follows: below 0.20, slight agreement; 0.21–0.40, fair agreement; 0.41–0.60, moderate agreement; 0.61–0.80, substantial agreement; greater than 0.80, almost perfect agreement. To assess the diagnostic performance of cMRI, dMRI, and hrMRI for identifying pituitary microadenomas, the receiver operating characteristic curves were plotted and the area under curves (AUCs) were compared between MR protocols for each reader by using the DeLong test. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. The Mann–Whitney U test was used to evaluate the difference in image quality scores and the Wilcoxon signed-rank test was used to evaluate SNR and CNR measurements between MR protocols. A p value of less than 0.05 was considered statistically significant. Statistical analysis was performed using MedCalc Statistical Software (version 20.0.15; MedCalc Software) and SPSS Statistics (version 22.0; IBM). Results Clinical characteristics A total of 69 patients (median age, 39 years; interquartile range [IQR], 29–54 years; 38 women [55%]) with ACTH-dependent Cushing’s syndrome were included in the study and their clinical characteristics are shown in Table 1. Among the 69 patients, 60 (87%) patients were diagnosed with Cushing’s disease and 9 (13%) were ectopic ACTH syndrome. The median disease course was 36 months (IQR, 12–78 months). The median serum cortisol, ACTH, and 24-h urine free cortisol level before surgery were 33.0 μg/dL (IQR, 25.1–40.1 μg/dL; normal range 4.0–22.3 μg/dL), 77.2 ng/L (IQR, 55.0–124.0 ng/L; normal range 0–46 ng/L), and 422.0 μg (IQR, 325.8–984.6 μg; normal range 12.3–103.5 μg), respectively. The median serum cortisol and 24-h urine free cortisol level after surgery were 3.0 μg/dL (IQR, 1.8–18.4 μg/dL) and 195.6 μg (IQR, 63.5–1240.3 μg), respectively. The median diameter of pituitary microadenomas was 5 mm (IQR, 4–5 mm), ranging from 3 to 9 mm. Table 1 Clinical characteristics of the patients Full size table Diagnostic performance of cMRI, dMRI, and hrMRI for identifying pituitary microadenomas The inter-observer agreement for identifying pituitary microadenomas by κ statistic between two readers was moderate on cMRI (κ = 0.50), moderate on dMRI (κ = 0.57), and almost perfect on hrMRI (κ = 0.91), respectively. The diagnostic performance for identifying pituitary microadenomas on cMRI, dMRI, hrMRI, and combined cMRI and dMRI is summarized in Table 2. For reader 1, the diagnostic performance of hrMRI (AUC, 0.95; 95%CI: 0.87, 0.99) was higher than that of cMRI (AUC, 0.75; 95%CI: 0.63, 0.85; p = 0.002), dMRI (AUC, 0.59; 95%CI: 0.47, 0.71; p < 0.001), and combined cMRI and dMRI (AUC, 0.65; 95%CI: 0.53, 0.76; p = 0.001). For reader 2, the diagnostic performance of hrMRI (AUC, 0.97; 95%CI: 0.89, 1.00) was higher than that of cMRI (AUC, 0.74; 95%CI: 0.63, 0.84; p = 0.001), dMRI (AUC, 0.68; 95%CI: 0.56, 0.79; p = 0.001), and combined cMRI and dMRI (AUC, 0.70; 95%CI: 0.58, 0.80; p = 0.003). Table 2 Diagnostic performance of cMRI, dMRI, and hrMRI for identifying pituitary microadenomas Full size table For reader 1, 23 of the 69 patients (33%) were misdiagnosed on both cMRI and dMRI, but 18 of the 23 misdiagnosed patients (78%) were correctly diagnosed on hrMRI. For reader 2, 17 of the 69 patients (25%) were misdiagnosed on both cMRI and dMRI, but 14 of the 17 misdiagnosed patients (82%) were correctly diagnosed on hrMRI. Figure 2 shows that a 5-mm pituitary microadenoma was identified on preoperative pituitary MRI. The margin of the lesion was fully delineated on hrMRI, but not on cMRI and dMRI. Figure 3 shows that a 3-mm pituitary microadenoma was missed on cMRI, but identified on dMRI and hrMRI. Figure 4 shows that a 5-mm pituitary microadenoma was correctly diagnosed on hrMRI, but missed on cMRI or dMRI. Figure 5 shows that a 4-mm pituitary microadenoma was evident on coronal images as well as reconstructed axial and reconstructed sagittal images on hrMRI. Fig. 2 Images in a 56-year-old man with Cushing’s disease. The 5-mm pituitary microadenoma (arrow) can be identified on (a) coronal contrast-enhanced T1-weighted image and (b) coronal dynamic contrast-enhanced T1-weighted image obtained with two-dimensional (2D) fast spin echo (FSE) sequence, but the margin is not fully delineated. The lesion (arrow) is well delineated on (c) coronal contrast-enhanced T1-weighted image on high-resolution MRI obtained with 3D FSE sequence. d Intraoperative endoscopic photograph during transsphenoidal surgery after exposure of the sellar floor shows a round pituitary microadenoma (arrow) Full size image Fig. 3 Images in a 34-year-old woman with Cushing’s disease. No tumor is identified on (a) coronal contrast-enhanced T1-weighted image obtained with two-dimensional (2D) fast spin echo (FSE) sequence. The 3-mm pituitary microadenoma (arrow) with delayed enhancement is identified on the left side of the pituitary gland on (b) coronal dynamic contrast-enhanced T1-weighted image obtained with 2D FSE sequence and (c) coronal contrast-enhanced T1-weighted image on high-resolution MRI obtained with 3D FSE sequence. d Intraoperative endoscopic photograph during transsphenoidal surgery shows a 3-mm pituitary microadenoma (arrow) Full size image Fig. 4 Images in a 43-year-old man with Cushing’s disease. The lesion is missed on (a) coronal contrast-enhanced T1-weighted image and (b) coronal dynamic contrast-enhanced T1-weighted image obtained with two-dimensional (2D) fast spin echo (FSE) sequence. c Coronal contrast-enhanced T1-weighted image on high-resolution MRI obtained with 3D FSE sequence shows a round pituitary microadenoma (arrow) measuring approximately 5 mm with delayed enhancement on the left side of the pituitary gland. d Intraoperative endoscopic photograph for microsurgical resection of the 5-mm pituitary microadenoma (arrow) Full size image Fig. 5 Images in a 48-year-old woman with Cushing’s disease. Preoperative high-resolution contrast-enhanced MRI using three-dimensional fast spin echo sequence shows a 4-mm pituitary microadenoma (arrow) with delayed enhancement is well delineated on the left side of the pituitary gland on (a) coronal, (b) reconstructed axial, and (c) reconstructed sagittal contrast-enhanced T1-weighted images. d Intraoperative endoscopic photograph during transsphenoidal surgery after exposure of the sellar floor shows a round pituitary microadenoma (arrow) Full size image Image quality of cMRI, dMRI, and hrMRI Image quality scores of cMRI, dMRI, and hrMRI are presented in Table 3. Scores for overall image quality, sharpness, and structural conspicuity on hrMRI (overall image quality, 5.0 [IQR, 5.0–5.0]; sharpness, 5.0 [IQR, 4.5–5.0]; structural conspicuity, 5.0 [IQR, 5.0–5.0]) were higher than those on cMRI (overall image quality, 4.0 [IQR, 3.5–4.0]; sharpness, 4.0 [IQR, 3.0–4.0]; structural conspicuity, 4.0 [IQR, 4.0–4.0]; p < 0.001 for all) and dMRI (overall image quality, 4.0 [IQR, 4.0–4.0]; sharpness, 4.0 [IQR, 4.0–4.0]; structural conspicuity, 4.0 [IQR, 4.0–4.5]; p < 0.001 for all). Table 3 Image quality scores on cMRI, dMRI, and hrMRI Full size table The SNR and CNR measurements are shown in Table 4. The SNR of the pituitary microadenomas on hrMRI (67.5 [IQR, 51.2–92.1]) was lower than that on cMRI (82.3 [IQR, 61.8–127.2], p < 0.001), but higher than that on dMRI (53.9 [IQR, 35.2–72.6], p = 0.001). The CNR on hrMRI (26.2 [IQR, 15.1–41.0]) was higher than that on cMRI (10.6 [IQR, 0–42.6], p = 0.023) and dMRI (11.2 [IQR, 0–29.8], p < 0.001). Table 4 SNR and CNR on cMRI, dMRI, and hrMRI Full size table Discussion The identification of pituitary microadenomas is considerably challenging but critical in patients with ACTH-dependent Cushing’s syndrome. Our study demonstrated that hrMRI with 3D FSE sequence had higher diagnostic performance (AUC, 0.95–0.97) than cMRI (AUC, 0.74–0.75; p ≤ 0.002) and dMRI (AUC, 0.59–0.68; p ≤ 0.001) for identifying pituitary microadenomas. To our knowledge, there are no previous studies specifically evaluating the identification of pituitary microadenomas on hrMRI with 3D FSE sequence by comparison with cMRI and dMRI in patients with ACTH-dependent Cushing’s syndrome, and this is the largest study conducted in ACTH-secreting microadenomas with a sensitivity of more than 90%. Recently, techniques for pituitary evaluation have developed rapidly. Because of false negatives and false positives on cMRI and dMRI using 2D FSE sequence [7, 9, 10], a 3D SPGR sequence was introduced for identifying pituitary adenomas. Previous studies demonstrated that the 3D SPGR sequence performed better than the 2D FSE sequence in the identification of pituitary adenomas with a sensitivity of up to 80% [11,12,13]. In patients with hyperprolactinemia, the 3D FSE sequence was recommended [14] and the 3D FSE sequence has rapidly developed recently with superior image quality [15, 16], suggesting that the 3D FSE sequence may be a reliable alternative for identifying pituitary adenomas. However, to our knowledge, few studies have investigated the diagnostic performance of the 3D FSE sequence for identifying ACTH-secreting pituitary adenomas. To fill the gaps, we conducted the current study and revealed that images obtained with the 3D FSE sequence had higher sensitivity (90–93%) in identifying pituitary microadenomas, than that in previous studies using the 3D SPGR sequence [8, 11,12,13]. There is a trade-off between spatial resolution and image noise. The reduced slice thickness can overcome the partial volume averaging effect, but it is associated with increased image noise [17]. Strikingly, our study showed that hrMRI had higher image quality scores than cMRI and dMRI, in terms of overall image quality, sharpness, and structural conspicuity. The SNR of the pituitary microadenomas on cMRI was slightly higher than that on hrMRI in our study. This is because the SNR was calculated as the mean signal intensity of the pituitary gland (instead of the pituitary microadenoma) divided by noise when no microadenoma was identified, and the mean signal intensity of the pituitary gland is higher than that of the pituitary microadenoma. About 40% of pituitary microadenomas were missed on cMRI, whereas less than 10% of pituitary microadenomas were missed on hrMRI. Given the situation mentioned above, the SNR on hrMRI was lower than that on cMRI. However, the CNR on hrMRI was significantly higher than that on cMRI and dMRI. Therefore, hrMRI in our study can dramatically improve the spatial resolution with high CNR, enabling the better identification of pituitary microadenomas. The identification of pituitary adenomas on preoperative MRI in patients with ACTH-dependent Cushing’s syndrome could help the differential diagnosis of Cushing’s syndrome and aids surgical resection of lesions. It should be noted that most of the pituitary adenomas in patients with Cushing’s disease are microadenomas [5, 6]. In our study, all the tumors are microadenomas with a median diameter of 5 mm (IQR, 4–5 mm), making the diagnosis more challenging. The sensitivity of identifying pituitary adenomas decreased from 80 to 72% after excluding macroadenomas in a previous study [12], whereas the sensitivity of identifying pituitary microadenomas in our study was 90–93% on hrMRI. In the current study, hrMRI performed better than cMRI, dMRI, and combined cMRI and dMRI, with high AUC (0.95–0.97), high sensitivity (90–93%), and high specificity (100%), superior to previous studies [8, 11,12,13]. The high sensitivity of hrMRI for identifying pituitary adenomas will help surgeons improve the postoperative remission rate [4]. The high specificity of hrMRI will assist clinicians to consider ectopic ACTH syndrome, and then perform imaging to identify ectopic tumors. Besides, the inter-observer agreement for identifying pituitary microadenomas was almost perfect on hrMRI (κ = 0.91), which was moderate on cMRI (κ = 0.50) and dMRI (κ = 0.57). Therefore, hrMRI using the 3D FSE sequence is a potential alternative that can significantly improve the identification of pituitary microadenomas. Limitations of the study included its retrospective nature and the relatively small sample size in patients with ectopic ACTH syndrome as negative controls. The bias may be introduced in the patient inclusion process. Only those patients who underwent all the cMRI, dMRI, and hrMRI scans were included. In fact, some patients will bypass hrMRI when obvious pituitary adenomas were detected on cMRI and dMRI. These patients were not included in the current study because of lack of hrMRI findings. Given the situation, the sensitivity of identifying pituitary adenomas will be higher with the enrollment of these patients. Besides, the timing of the sequence acquisition after contrast injection is essential [16] and bias may be introduced due to the postcontrast enhancement curve of both the pituitary gland and the microadenoma [14]. In the future, a prospective study with different sequence acquisition orders is needed to minimize possible interference caused by the postcontrast enhancement curve. Moreover, a larger sample size is also needed to verify the diagnostic performance of hrMRI using 3D FSE sequence for identifying pituitary microadenomas and to determine whether it can replace 2D FSE or 3D SPGR sequences for routinely evaluating the pituitary gland. In conclusion, hrMRI with 3D FSE sequence showed higher diagnostic performance than cMRI and dMRI for identifying pituitary microadenomas in patients with Cushing’s syndrome. Abbreviations ACTH: Adrenocorticotropic hormone AUC: Area under the receiver operating characteristics curve cMRI: Conventional contrast-enhanced MRI CNR: Contrast-to-noise ratio dMRI: Dynamic contrast-enhanced MRI FSE: Fast spin echo hrMRI: High-resolution contrast-enhanced MRI IQR: Interquartile range SNR: Signal-to-noise ratio SPGR: Spoiled gradient re called References Lacroix A, Feelders RA, Stratakis CA, Nieman LK (2015) Cushing’s syndrome. Lancet 386:913–927 Article CAS PubMed Google Scholar Loriaux DL (2017) Diagnosis and differential diagnosis of Cushing’s syndrome. N Engl J Med 376:1451–1459 Article CAS PubMed Google Scholar Nieman LK, Biller BM, Findling JW et al (2015) Treatment of Cushing’s syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 100:2807–2831 Article CAS PubMed PubMed Central Google Scholar Yamada S, Fukuhara N, Nishioka H et al (2012) Surgical management and outcomes in patients with Cushing disease with negative pituitary magnetic resonance imaging. World Neurosurg 77:525–532 Article PubMed Google Scholar Vitale G, Tortora F, Baldelli R et al (2017) Pituitary magnetic resonance imaging in Cushing’s disease. Endocrine 55:691–696 Article CAS PubMed Google Scholar Jagannathan J, Smith R, DeVroom HL et al (2009) Outcome of using the histological pseudocapsule as a surgical capsule in Cushing disease. J Neurosurg 111:531–539 Article PubMed PubMed Central Google Scholar Boscaro M, Arnaldi G (2009) Approach to the patient with possible Cushing’s syndrome. J Clin Endocrinol Metab 94:3121–3131 Article CAS PubMed Google Scholar Kasaliwal R, Sankhe SS, Lila AR et al (2013) Volume interpolated 3D-spoiled gradient echo sequence is better than dynamic contrast spin echo sequence for MRI detection of corticotropin secreting pituitary microadenomas. Clin Endocrinol (Oxf) 78:825–830 Article CAS PubMed Google Scholar Lonser RR, Nieman L, Oldfield EH (2017) Cushing’s disease: pathobiology, diagnosis, and management. J Neurosurg 126:404–417 Article PubMed Google Scholar Potts MB, Shah JK, Molinaro AM et al (2014) Cavernous and inferior petrosal sinus sampling and dynamic magnetic resonance imaging in the preoperative evaluation of Cushing’s disease. J Neurooncol 116:593–600 Article PubMed Google Scholar Grober Y, Grober H, Wintermark M, Jane JA, Oldfield EH (2018) Comparison of MRI techniques for detecting microadenomas in Cushing’s disease. J Neurosurg 128:1051–1057 Article PubMed Google Scholar Fukuhara N, Inoshita N, Yamaguchi-Okada M et al (2019) Outcomes of three-Tesla magnetic resonance imaging for the identification of pituitary adenoma in patients with Cushing’s disease. Endocr J 66:259–264 Article PubMed Google Scholar Patronas N, Bulakbasi N, Stratakis CA et al (2003) Spoiled gradient recalled acquisition in the steady state technique is superior to conventional postcontrast spin echo technique for magnetic resonance imaging detection of adrenocorticotropin-secreting pituitary tumors. J Clin Endocrinol Metab 88:1565–1569 Article CAS PubMed Google Scholar Magnaldi S, Frezza F, Longo R, Ukmar M, Razavi IS, Pozzi-Mucelli RS (1997) Assessment of pituitary microadenomas: comparison between 2D and 3D MR sequences. Magn Reson Imaging 15:21–27 Article CAS PubMed Google Scholar Lien RJ, Corcuera-Solano I, Pawha PS, Naidich TP, Tanenbaum LN (2015) Three-Tesla imaging of the pituitary and parasellar region: T1-weighted 3-dimensional fast spin echo cube outperforms conventional 2-dimensional magnetic resonance imaging. J Comput Assist Tomogr 39:329–333 PubMed Google Scholar Sartoretti T, Sartoretti E, Wyss M et al (2019) Compressed SENSE accelerated 3D T1w black blood turbo spin echo versus 2D T1w turbo spin echo sequence in pituitary magnetic resonance imaging. Eur J Radiol 120:108667 Article PubMed Google Scholar Kim M, Kim HS, Kim HJ et al (2021) Thin-slice pituitary MRI with deep learning-based reconstruction: diagnostic performance in a postoperative setting. Radiology 298:114–122 Article PubMed Google Scholar Download references Acknowledgements We thank Dr. Kai Sun, Medical Research Center, Peking Union Medical College Hospital, for his guidance on the statistical analysis in this study. Funding This study has received funding from the National Natural Science Foundation of China (grant 82071899), the National Key Research and Development Program of China (grants 2016YFC1305901, 2020YFA0804500), the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (grants 2017-I2M-3–008, 2021-I2M-1–025), the Beijing Natural Science Foundation (grant L182067) and National High Level Hospital Clinical Research Funding (2022-PUMCH-B-067, 2022-PUMCH-B-114). Author information Author notes Zeyu Liu and Bo Hou contributed equally to this work and share first authorship Hui You and Feng Feng contributed equally to this work and share corresponding authorship Authors and Affiliations Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China Zeyu Liu, Bo Hou, Hui You, Mingli Li & Feng Feng Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China Lin Lu, Lian Duan & Huijuan Zhu Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China Kan Deng & Yong Yao State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng Distinct, Beijing, 100730, China Yong Yao, Huijuan Zhu & Feng Feng Corresponding authors Correspondence to Hui You or Feng Feng. Ethics declarations Guarantor The scientific guarantor of this publication is Feng Feng. Conflict of interest The authors of this manuscript declare no conflict of interest. Statistics and biometry No complex statistical methods were necessary for this paper. Informed consent Written informed consent was waived by the Institutional Review Board. Ethical approval Institutional Review Board approval was obtained. Methodology • retrospective • diagnostic or prognostic study • performed at one institution Additional information Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Below is the link to the electronic supplementary material. Supplementary file1 (PDF 242 kb) Rights and permissions Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Reprints and Permissions From https://link.springer.com/article/10.1007/s00330-023-09585-1

From Janice: A devastating horrific disease that doctors won’t believe we have. Feeling like we will collapse with each step. Carrying an empty plastic bag seems too heavy to manage. And no one will believe us. They think we are lazy, fat and crazy. What is your experience?

Abstract Importance Cushing syndrome is defined as a prolonged increase in plasma cortisol levels that is not due to a physiological etiology. Although the most frequent cause of Cushing syndrome is exogenous steroid use, the estimated incidence of Cushing syndrome due to endogenous overproduction of cortisol ranges from 2 to 8 per million people annually. Cushing syndrome is associated with hyperglycemia, protein catabolism, immunosuppression, hypertension, weight gain, neurocognitive changes, and mood disorders. Observations Cushing syndrome characteristically presents with skin changes such as facial plethora, easy bruising, and purple striae and with metabolic manifestations such as hyperglycemia, hypertension, and excess fat deposition in the face, back of the neck, and visceral organs. Cushing disease, in which corticotropin excess is produced by a benign pituitary tumor, occurs in approximately 60% to 70% of patients with Cushing syndrome due to endogenous cortisol production. Evaluation of patients with possible Cushing syndrome begins with ruling out exogenous steroid use. Screening for elevated cortisol is performed with a 24-hour urinary free cortisol test or late-night salivary cortisol test or by evaluating whether cortisol is suppressed the morning after an evening dexamethasone dose. Plasma corticotropin levels can help distinguish between adrenal causes of hypercortisolism (suppressed corticotropin) and corticotropin-dependent forms of hypercortisolism (midnormal to elevated corticotropin levels). Pituitary magnetic resonance imaging, bilateral inferior petrosal sinus sampling, and adrenal or whole-body imaging can help identify tumor sources of hypercortisolism. Management of Cushing syndrome begins with surgery to remove the source of excess endogenous cortisol production followed by medication that includes adrenal steroidogenesis inhibitors, pituitary-targeted drugs, or glucocorticoid receptor blockers. For patients not responsive to surgery and medication, radiation therapy and bilateral adrenalectomy may be appropriate. Conclusions and Relevance The incidence of Cushing syndrome due to endogenous overproduction of cortisol is 2 to 8 people per million annually. First-line therapy for Cushing syndrome due to endogenous overproduction of cortisol is surgery to remove the causative tumor. Many patients will require additional treatment with medications, radiation, or bilateral adrenalectomy. From https://jamanetwork.com/journals/jama/article-abstract/2807073

In this application note, Tecan presents a method for diagnosing Cushing's syndrome efficiently and accurately. The approach involves simultaneous the measurement of cortisol and dexamethasone levels using LC-MS/MS, which reduces false positives in dexamethasone suppression test (DSTs). The described LC-MS/MS method enables the tracking of multiple analytes, including cortisol, cortisone, and dexamethasone, in serum or plasma. Implementing this analytical approach offers clinical laboratories a straightforward means of performing DSTs, and the availability of a commercially available kit ensures reliable and reproducible results. Download this Article Download PDF >> From https://www.selectscience.net/application-articles/minimizing-the-number-of-false-positives-in-dexamethasone-suppression-testing-for-the-diagnosis-of-cushings-syndrome?artID=59632

Abstract Rationale: Ectopic ACTH-producing pituitary adenoma (EAPA) of the clivus region is extraordinarily infrequent condition and merely a few reports have been reported to date. Patient concerns: The patient was a 53-year-old woman who presented with Cushing-like appearances and a soft tissue mass in the clivus region. Diagnoses: The final diagnosis of clivus region EAPA was established by clinical, radiological and histopathological findings. Interventions: The patient underwent gross total clivus tumor resection via transsphenoidal endoscopy. Outcomes: Half a year after surgery, the patient Cushing-like clinical manifestations improved significantly, and urinary free cortisol and serum adrenocorticotropin (ACTH) returned to normal. Lessons: Given the extreme scarcity of these tumors and their unique clinical presentations, it may be possible to misdiagnose and delayed treatment. Accordingly, it is especially crucial to summarize such lesions through our present case and review the literature for their precise diagnosis and the selection of optimal treatment strategies. 1. Introduction Pituitary adenoma arises from the anterior pituitary cells and is the commonest tumor of the sellar region.[1] It makes up approximately 10% to 15% of all intracranial tumors.[2] Ectopic pituitary adenoma (EPA) is defined as a pituitary adenoma that occurs outside the sellar area and has no direct connection to normal pituitary tissue.[3] The most frequent sites of EPA are the sphenoid sinus and suprasellar region, and much less frequent sites including the clivus region, cavernous sinus, and nasopharynx.[4] Hypercortisolism and the series of symptoms it leads to is termed Cushing syndrome (CS).[5] CS is classified into adrenocorticotropin (ACTH)-dependent and ACTH-independent CS depending on the cause, accounting for 80% to 85% and 15% to 20% of cases, respectively.[6] Pituitary adenoma accounts for ACTH-dependent CS 75% to 80%, while ectopic ACTH secretion accounts for the remaining 15% to 20%.[7] Ectopic CS is a very rare disorder of CS caused by an ACTH-secreting tumor outside the pituitary or adrenal gland.[8] It has been reported that ectopic ACTH-producing pituitary adenoma (EAPA) can occur in the sphenoid sinus, cavernous sinus, clivus, and suprasellar region,[9] with EAPA in the clivus region being extremely rare, and merely 6 cases have been reported in the English literature (Table 1).[10–15] Furthermore, as summarized in the Table 1, EAPA in the clivus area has unique symptoms, which may lead to misdiagnosis as well as delay in treatment. Therefore, we herein described a case of CS from an EAPA of the clivus region and reviewed relevant literature for the purpose of further understanding this extraordinarily unusual condition. Table 1 - Literature review of cases of primary clival ectopic ACTH-producing pituitary adenoma (including the current case). Reference Age (yr)/sex Symptoms Imaging findings Maximum tumor diameter (mm) Preoperative elevated hormone IHC Surgery RT Follow-up (mo) Outcome Ortiz et al 1975[10] 15/F NA NA NA NA NA Right transfrontal craniotomy, NA Yes NA Symptomatic relief Anand et al 1993[11] 58/F Anosphrasia, blurred vision, occasional left frontal headache, Routine radiographic evaluation revealed a clival tumor and nasopharyngeal mass with bone erosion. MRI demonstrated a Midline homogeneous mass. 30 ACTH ACTH in a few isolated cells Maxillotomy approach, GTR Yes 12 Symptomatic relief Pluta et al 1999[12] 20/F Cushing syndrome MRI revealed a hypodense contrast-enhancing lesion. NA ACTH ACTH Transsphenoidal surgery, GTR No 18 Symptomatic relief Shah et al 2011[13] 64/M Facial paresthesias, myalgias, decreased muscle strength, and fatigue CT imaging showed a clival mass. 21 ACTH ACTH NA, GTR No 7 Symptomatic relief Aftab et al 2021[14] 62/F Transient unilateral visual loss MRI showed a T2 heterogeneously enhancing hyperintense lesion. 21 No ACTH Transsphenoidal resection, GTR NO 6 Symptomatic relief Li et al 2023[15] 47/F Bloody nasal discharge, dizziness and headache CT revealed an ill-defined mass eroding the adjacent bone. MRI T1 showed a heterogeneous mass with hypointensity, hyperintensity on T2-weighted images and isointensity on diffusion-weighted images. 58 NA ACTH Transsphenoidal endoscopy, STR Yes 2 Symptomatic relief Current case 53/F Headache, and dizziness, Cushing syndrome CT demonstrated bone destruction and a soft tissue mass. MRI T1 revealed irregular isointense signal, and MRI T2 showed isointense signal/slightly high signal. 46 ACTH ACTH Transsphenoidal endoscopy, GTR NO 6 Symptomatic relief ACTH = adrenocorticotropin, CT = computed tomography, GTR = gross total resection, IHC = immunohistochemistry, MRI = magnetic resonance imaging, NA = not available, RT = radiotherapy, STR = subtotal resection. 2. Case presentation A 53-year-old female presented to endocrinology clinic of our hospital with headache and dizziness for 2 years and aggravated for 1 week. Her past medical history was hypertension, with blood pressure as high as 180/100 mm Hg. Her antihypertensive medications included amlodipine besylate, benazepril hydrochloride, and metoprolol tartrate, and she felt her blood pressure was well controlled. In addition, she suffered a fracture of the thoracic vertebrae 3 month ago; and bilateral rib fractures 1 month ago. Physical examination revealed that the patient presented classical Cushing-like appearances, including moon face and supraclavicular and back fat pads, and centripetal obesity (body mass index, 25.54 kg/m2) with hypertension (blood pressure, 160/85 mm Hg). Laboratory studies revealed high urinary free cortisol levels at 962.16 µg/24 hours (reference range, 50–437 µg/24 hours) and absence of circadian cortisol rhythm (F [0am] 33.14 µg/dL, F [8am] 33.52 µg/dL, F [4pm] 33.3 µg/dL). ACTH levels were elevated at 90.8 pg/mL (reference range, <46 pg/mL). The patient low-dose dexamethasone suppression test demonstrated the existence of endogenous hypercortisolism. High-dose dexamethasone suppression test results revealed that serum cortisol levels were suppressed by <50%, suggesting the possibility of ectopic ACTH-dependent CS. Serum luteinizing hormone and serum follicle stimulating hormone were at low levels, <0.07 IU/L (reference range, 15.9–54.0 IU/L) and 2.57 IU/L (reference range, 23.0–116.3 IU/L), respectively. Insulin-like growth factor-1, growth hormone (GH), prolactin (PRL), thyroid stimulating hormone, testosterone, progesterone and estradiol test results are all normal. Oral glucose tolerance test showed fasting glucose of 6.3 mmol/L and 2-hour glucose of 18.72 mmol/L; glycosylated hemoglobin (HbA1c) was 7.1%. Serum potassium fluctuated in the range of 3.14 to 3.38 mmol/L (reference range, 3.5–5.5 mmol/L), indicating mild hypokalemia. High-resolution computed tomography (CT) scan of the sinuses revealed osteolytic bone destruction of the occipital clivus and a soft tissue mass measuring 20 mm × 30 mm × 46 mm (Fig. 1A). The mass filled the bilateral sphenoid sinuses and involved the cavernous sinuses, but the pituitary was normal. Cranial MR scan showed the T1W1 isointense signal and the T2W1 isointense signal/slightly high signal in the sphenoid sinus and saddle area (Fig. 1B–D). Bone density test indicated osteoporosis. Figure 1.: Radiological findings. (A) CT demonstrated bone destruction and a soft tissue mass on the occipital clivus (white arrow). (B) Axial view of the MR T1 revealed irregular isointense signal in the sphenoid sinus and saddle area (white arrow). (C and D) Axial view and sagittal view of the MR T2 showed isointense signal/slightly high signal in the sphenoid sinus and saddle area (black arrow). CT = computed tomography. Subsequently, the patient underwent gross total clivus tumor resection via transsphenoidal endoscopy. During surgery, the tumor was found to be light red in color with a medium texture, and the tumor tissue protruded into the sphenoidal sinus cavity and eroded the clival area. Histologically, the tumor cells were nested, with interstitially rich blood sinuses and organoid arrangement (Fig. 2A). The tumor cells were relatively uniform in size, with light red cytoplasm, delicate pepper salt-like chromatin, and visible nucleoli (Fig. 2B). In addition, mitosis of tumor cells was extremely rare. Immunohistochemically, the neoplasm cells were diffuse positive for CK (Fig. 2C), CgA (Fig. 2D), ACTH (Fig. 2E), Syn and CAM5.2, with low Ki-67 labeling index (<1%) (Fig. 2F). Simultaneously, all other pituitary hormone markers like GH, thyroid stimulating hormone, PRL, luteinizing hormone, as well as follicle stimulating hormone were negatively expressed. On the basis of these medically historical, clinical, laboratorial, morphologic, and immunohistochemical findings, the final pathological diagnosis of an EAPA was established. Figure 2.: HE and immunohistochemical findings. (A) Histologic sections revealed morphologically homogeneous tumor cells in nests with a prominent and delicate vascularized stroma (H&E, × 200). (B) The tumor cells had fine chromatin with visible nuclei and rare mitoses (H&E, × 400). CK (C), CgA (D) and ACTH (E) immunohistochemically showed diffuse reactivity of the tumor cells (SP × 200). (F) The proliferation index is <1% on Ki-67 staining (SP × 200). When evaluated 2 months after surgery, her Cushing-like characteristics had well improved, and her blood pressure was normal. Furthermore, her serum cortisol and ACTH returned to the normal levels. Six-month postoperative follow-up revealed that serum cortisol and ACTH were stable at normal levels, and no signs of tumor recurrence were detected on imaging. 3. Discussion EAPA is defined as an ACTH-secreting ectopic adenoma located outside the ventricles, and has no continuity with the normal intrasellar pituitary gland.[9] ACTH promotes cortisol secretion by stimulating the adrenal cortical fasciculus. The clinical manifestations of hypercortisolism are diverse, and the severity is partly related to the duration of the cortisol increase.[8] Clival tumors are typically uncommon, accounting for 1% of all intracranial tumors. There are many differential diagnoses for clival lesions, including the most common chordoma (40%), meningioma, chondrosarcoma, astrocytoma, craniopharyngioma, germ cell tumors, non-Hodgkin lymphoma, melanoma, metastatic carcinoma, and rarely pituitary adenoma.[16] The commonest clival EPA is a PRL adenoma, followed by null cell adenoma, and the least common are ACTH adenoma and GH adenoma.[2] The clival EAPA is extremely unwonted, and only 6 other cases apart from ours have been reported in literature so far (Table 1). The average age of the patients with these tumors was 48 years (range, 15–64 years). There was a obvious female predominance with a female-to-male prevalence ratio of 6:1. Only 2 patients (2/6, 33.3%) with reported clinical symptoms, including our patients, presented with overt clinical manifestations of CS. Compression of the mass on adjacent structures (e.g., nerves) may result in anosphrasia, visual impairment, headache, myalgias, decreased muscle strength, dizziness and facial sensory abnormalities. The diagnosis and localization of these tumors relied heavily on radiological imaging. Head MRI was the most basic method used for them detection, for localization adenomas and their invasion of surrounding structures to guide the choice of treatment and surgical options methods. Radiographic characteristics had been reported in 6 patients with EAPA in the clivus region. All of these patients (6/6, 100%) had initial positive findings of sellar MRI (or CT) identifying an ectopic adenoma before surgery. MR T1 was usually a low-intensity or isointense signal, while MR T2 was usually an isointense or slightly higher signal. The maximum diameter of the tumor was reported in 5 cases, with the mean maximum diameter was 35.2 mm (range, 21–55 mm) according to preoperative MRI and intraoperative observations. As summarized in Table 1, 4/5 clival EAPA cases secreted ACTH. Histologically, all cases (6/6, 100%) expressed ACTH scatteredly or diffusely. The gold standard for the treatment of CS caused by EAPA was the surgical removal of EPA, which was essential to achieve remission and histological confirmation of the disease.[9] The most common method of EAPA resection in the clivus region was transsphenoidal sinus resection (4/6, 66.67%), followed by craniotomy (1/6, 16.67%) and maxillary osteotomy (1/6, 16.67%). Transsphenoidal endoscopic surgery allowed resection of the EAPA and manipulation of neurovascular structures and avoidance of cerebral atrophy, whereas craniotomy allowed full exposure of the suprasellar region, direct visualization or manipulation of the adenoma, and reduced the risk of postoperative CSF leak.[9] Both approaches had their advantages, and there was no consensus on which surgical approach was best for the treatment of EAPA in the slope area.[9] The choice of the best surgical approach was believed to be based on the condition of the adenoma, as well as the general condition of the patient and the experience of the surgeon.[9] As summarized in Table 1, most complete tumor resections were achieved regardless of the method chosen. A minority of patients underwent postoperative radiotherapy (3/7, 42.86%), and most of them had invasion of the surrounding bone tissue. All patients experienced effective postoperative relief of symptoms. In summary, due to the rarity of this disorder, an accurate preoperative diagnosis of EAPA in the slope area is extremely challenging for the clinician or radiologist. The final precise diagnosis relies on a combination of clinical symptoms, imaging findings, histology and immunohistochemical markers. For this type of tumor, surgery is an effective treatment to relieve the clinical manifestations caused by tumor compression or hormonal secretion. The choice of postoperative adjuvant radiotherapy is mainly based on the presence of invasion of the surrounding bone tissue. Further cases may be necessary to summarize the clinical features of such lesions and to develop optimal treatment strategies. Acknowledgments We would like to thank the patient and her family. Author contributions Conceptualization: Yutao He. Data curation: Ziyi Tang. Formal analysis: Na Tang. Methodology: Yu Lu, Fangfang Niu, Jiao Ye, Zheng Zhang, Chenghong Fang. Writing – original draft: Yutao He. Writing – review & editing: Yutao He, Lei Yao. Abbreviations: ACTH adrenocorticotropin CS cushing syndrome CT computed tomography EAPA ectopic ACTH-producing pituitary adenoma EPA ectopic pituitary adenoma GH growth hormone PRL prolactin References [1]. Gittleman H, Ostrom QT, Farah PD, et al. Descriptive epidemiology of pituitary tumors in the United States, 2004-2009. J Neurosurg. 2014;121:527–35. Cited Here | PubMed | CrossRef | Google Scholar [2]. Karras CL, Abecassis IJ, Abecassis ZA, et al. Clival ectopic pituitary adenoma mimicking a Chordoma: case report and review of the literature. Case Rep Neurol Med. 2016;2016:8371697. Cited Here | Google Scholar [3]. Bălaşa AF, Chinezu R, Teleanu DM, et al. Ectopic intracavernous corticotroph microadenoma: case report of an extremely rare pathology. Rom J Morphol Embryol. 2017;58:1447–51. Cited Here | Google Scholar [4]. Zhu J, Wang Z, Zhang Y, et al. Ectopic pituitary adenomas: clinical features, diagnostic challenges and management. Pituitary. 2020;23:648–64. Cited Here | Google Scholar [5]. Paleń-Tytko JE, Przybylik-Mazurek EM, Rzepka EJ, et al. Ectopic ACTH syndrome of different origin-diagnostic approach and clinical outcome. experience of one clinical centre. PLoS One. 2020;15:e0242679. Cited Here | PubMed | CrossRef | Google Scholar [6]. Sharma ST, Nieman LK, Feelders RA. Cushing’s syndrome: epidemiology and developments in disease management. Clin Epidemiol. 2015;7:281–93. Cited Here | Google Scholar [7]. Aniszewski JP, Young WF Jr, Thompson GB, et al. Cushing syndrome due to ectopic adrenocorticotropic hormone secretion. World J Surg. 2001;25:934–40. Cited Here | PubMed | CrossRef | Google Scholar [8]. Mohib O, Papleux E, Remmelink M, et al. An ectopic Cushing’s syndrome as a cause of severe refractory hypokalemia in the ICU. Acta Clin Belg. 2021;76:373–8. Cited Here | Google Scholar [9]. Sun X, Lu L, Feng M, et al. Cushing syndrome caused by ectopic adrenocorticotropic hormone-secreting pituitary adenomas: case report and literature review. World Neurosurg. 2020;142:75–86. Cited Here | Google Scholar [10]. Ortiz-Suarez H, Erickson DL. Pituitary adenomas of adolescents. J Neurosurg. 1975;43:437–9. Cited Here | PubMed | CrossRef | Google Scholar [11]. Anand VK, Osborne CM, Harkey HL. Infiltrative clival pituitary adenoma of ectopic origin. Otolaryngol Head Neck Surg. 1993;108:178–83. Cited Here | PubMed | CrossRef | Google Scholar [12]. Pluta RM, Nieman L, Doppman JL, et al. Extrapituitary parasellar microadenoma in Cushing’s disease. J Clin Endocrinol Metab. 1999;84:2912–23. Cited Here | View Full Text | PubMed | CrossRef | Google Scholar [13]. Shah R, Schniederjan M, DelGaudio JM, et al. Visual vignette.s Ectopic ACTH-secreting pituitary adenoma. Endocr Pract. 2011;17:966. Cited Here | Google Scholar [14]. Aftab HB, Gunay C, Dermesropian R, et al. “An Unexpected Pit” - ectopic pituitary adenoma. J Endocr Soc. 2021;5:A557–8. Cited Here | Google Scholar [15]. Li Y, Zhu JG, Li QQ, et al. Ectopic invasive ACTH-secreting pituitary adenoma mimicking chordoma: a case report and literature review. BMC Neurol. 2023;23:81. Cited Here | Google Scholar [16]. Wong K, Raisanen J, Taylor SL, et al. Pituitary adenoma as an unsuspected clival tumor. Am J Surg Pathol. 1995;19:900–3. Cited Here | View Full Text | PubMed | CrossRef | Google Scholar Hide full references list Keywords: clivus region; Cushing; Ectopic ACTH; like appearance; producing pituitary adenoma From https://journals.lww.com/md-journal/Fulltext/2023/06230/Cushing_syndrome_caused_by_an_ectopic.32.aspx

In Italy it is estimated that there are about 3,000 patients suffering from Cushing’s syndrome, while in Europe the number rises to over 50,000. The Cushing’s syndrome, a disease caused by the excessive production of cortisol by the pituitary gland due to a benign tumor of the gland, has seen a breakthrough in its treatment. Thanks to a new drug called osilodrostat, approved in 2020 by the Food and Drug Administration and subsequently by Aifa in Italy, patients unfit for surgery can benefit from a treatment that offers the same effects as a scalpel. Furthermore, this drug reduced symptoms in 80% of cases. Cushing’s syndrome has been dubbed “full moon face disease” due to its most obvious visible effects, such as a rounding of the face caused by fat accumulation and visible weight gain also on the waist and back. Despite its symptomatic relevance, the disease has long been poorly understood by both healthcare professionals and the general public. To raise awareness of this syndrome, the #Thiscushing campaign has been launched, which aims to spread knowledge about the disease. The campaign recently stopped in Rome, during the Congress of the Italian Society of Endocrinology (SIE), where a photographic exhibition was organized which represents moments of daily life of people affected by Cushing’s syndrome and their difficulties. Despite the debilitating symptoms, Cushing’s syndrome is often underdiagnosed, resulting in delays in diagnosis of up to 5-7 years. The disease presents a wide range of symptoms, ranging from difficulty performing even simple daily activities such as tying your shoes or getting out of bed, to common manifestations such as high cholesterol, hypertension and hyperglycemia, which can be confused with symptoms of other less common pathologies. serious. It is for this reason that the EIS experts are appealing for the inclusion of Cushing’s syndrome in the list of rare pathologies recognized by the Ministry of Health, in order to facilitate timely diagnosis and faster access to the necessary treatments. From https://www.breakinglatest.news/health/cushings-syndrome-a-new-drug-allows-you-to-avoid-surgery/

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Abstract Background The diagnosis of Cushing’s syndrome is challenging; however, through the clinical picture and the search for secondary causes of osteoporosis, it was possible to reach the diagnosis of the case reported. There was an independent, symptomatic ACTH hypercortisolism manifested by typical phenotypic changes, severe secondary osteoporosis and arterial hypertension in a young patient. Case presentation A 20-year-old Brazilian man with low back pain for 8 months. Radiographs showed fragility fractures in the thoracolumbar spine, and bone densitometry showed osteoporosis, especially when evaluating the Z Score (− 5.6 in the lumbar spine). On physical examination, there were wide violaceous streaks on the upper limbs and abdomen, plethora and fat increase in the temporal facial region, hump, ecchymosis on limbs, hypotrophy of arms and thighs, central obesity and kyphoscoliosis. His blood pressure was 150 × 90 mmHg. Cortisol after 1 mg of dexamethasone (24.1 µg/dL) and after Liddle 1 (28 µg/dL) were not suppressed, despite normal cortisoluria. Tomography showed bilateral adrenal nodules with more severe characteristics. Unfortunately, through the catheterization of adrenal veins, it was not possible to differentiate the nodules due to the achievement of cortisol levels that exceeded the upper limit of the dilution method. Among the hypotheses for the differential diagnosis of bilateral adrenal hyperplasia are primary bilateral macronodular adrenal hyperplasia, McCune–Albright syndrome and isolated bilateral primary pigmented nodular hyperplasia or associated with Carney’s complex. In this case, primary pigmented nodular hyperplasia or carcinoma became important etiological hypotheses when comparing the epidemiology in a young man and the clinical-laboratory-imaging findings of the differential diagnoses. After 6 months of drug inhibition of steroidogenesis, blood pressure control and anti-osteoporotic therapy, the levels and deleterious metabolic effects of hypercortisolism, which could also impair adrenalectomy in the short and long term, were reduced. Left adrenalectomy was chosen, given the possibility of malignancy in a young patient and to avoid unnecessary definitive surgical adrenal insufficiency if the adrenalectomy was bilateral. Anatomopathology of the left gland revealed expansion of the zona fasciculate with multiple nonencapsulated nodules. Conclusion The early identification of Cushing’s syndrome, with measures based on the assessment of risks and benefits, remains the best way to prevent its progression and reduce the morbidity of the condition. Despite the unavailability of genetic analysis for a precise etiological definition, it is possible to take efficient measures to avoid future damage. Peer Review reports Background Cushing’s syndrome may be exogenous or endogenous and, in this case, can be ACTH-dependent or independent. In the case reported, there was an independent, symptomatic ACTH hypercortisolism manifested by typical phenotypic changes, severe secondary osteoporosis and arterial hypertension in a young patient. Osteoporosis secondary to hypercortisolism occurs due to chronic reduction in bone formation, loss of osteocytes and increased reabsorption caused by intense binding of cortisol to glucocorticoid receptors present in bone cells [1]. In addition, excess cortisol impairs vitamin D metabolism and reduces endogenous parathyroid hormone secretion, intestinal calcium reabsorption, growth hormone release, and lean body mass [2]. Subclinical Cushing disease occurs in up to 11% of individuals diagnosed with early-onset osteoporosis and 0.5–1% of hypertension patients. [3] A cross-sectional study published in 2023 revealed a prevalence of 81.5% bone loss in 19 patients with Cushing’s syndrome [2]. The prevalence of osteopenia ranges from 60 to 80%, and the prevalence of osteoporosis ranges from 30 to 65% in patients with Cushing’s syndrome. Additionally, the incidence of fragility fractures ranges from 30 to 50% in these patients [4] and is considered the main cause of morbidity affecting the quality of life. The diagnosis is challenging, given the presence of confounding factors; however, through the clinical picture and the search for secondary causes of osteoporosis, it was possible to reach a syndromic diagnosis. Early identification of this syndrome, with measures based on the assessment of risks and benefits, remains the best way to prevent progression and reduce morbidity related to this disease [2]. Case presentation A 20-year-old Brazilian male patient reported low back pain that had evolved for 8 months, with no related trauma. He sought emergency care and performed spinal radiographs on this occasion (03/2019). Due to the several alterations observed in the images, he was referred to the Orthopedics Service of the Hospital of Federal University of Juiz de Fora, which prescribed orthopedic braces, indicated physical therapy and was referred again to the Osteometabolic Diseases outpatient clinic of the Endocrinology and Rheumatology Services of the Hospital of Federal University of Juiz de Fora on 10/2019. The radiographs showed a marked reduction in the density of bone structures, scoliotic deviation with convexity toward the left and reduction in the height of the lumbar vertebrae, with partial collapses of the vertebral bodies at the level of T12, L1, L2, L3 and L5, with recent collapses in T12 and L1, suggesting bone fragility fractures. The same can be seen in posterior magnetic resonance imaging (Fig. 1). Fig. 1 Radiography and Magnetic Resonance Imaging (MRI) of lumbosacral spine in profile Full size image Bone scintigraphy on 08/2019 did not reveal hyper flow or anomalous hyperemia in the topography of the thoracolumbar spine, and in the later images of the exam, there was a greater relative uptake of the tracer in the lumbar spine (vertebrae T10–T12, L2–L4), of nonspecific aspect, questioning the presence of osteoarticular processes or ankylosing spondylitis. It was also observed in the bone densitometry requested in October 2019, performed by dual-energy X-ray absorptiometry (DXA), low bone mineral density (BMD) in the lumbar spine, femoral neck and total femur, when comparing the results to evaluating the Z Score (Table 1). Table 1 Dual-energy X-ray absorptiometry (DXA) Full size table Thus, the diagnosis of osteoporosis was established, and treatment with vitamin D 7000 IU per week was started due to vitamin D3 insufficiency associated with the bisphosphonate alendronate 70 mg, also weekly. The patient had a past pathological history of fully treated syphilis (2018) and perianal condyloma with a surgical resection on 09/2017 and 02/2018. In the family history, it was reported that a maternal uncle died of systemic sclerosis. In the social context, the young person denied drinking alcohol and previous or current smoking. On physical examination, there were no lentiginous skin areas or blue nevi; however, wide violet streaks were observed on the upper limbs and abdomen, with plethora and increased fat in the temporal facial region and hump (Fig. 2a, b), limb ecchymosis, hypotrophy of the arms and thighs, central obesity and kyphoscoliosis. Systemic blood pressure (sitting) was 150 × 90 mmHg, BMI was 26.09 kg/m2, and waist circumference was 99 cm, with no reported reduction in height, maintained at 1.55 m. Fig. 2 Changes in the physical examination. a Violet streaks on the upper limbs, b Violet streaks on abdomen Full size image An investigation of secondary causes for osteoporosis was initiated, with the following laboratory test results (Table 2). Table 2 Laboratory tests Full size table Computed tomography of the abdomen with adrenal protocol performed on 08/13/2020 characterized isodense nodular formation in the body of the left adrenal and in the lateral portion of the right adrenal, measuring 1.5 cm and 0.6 cm, respectively. The lesions had attenuation of approximately 30 HU, showing enhancement by intravenous contrast, with an indeterminate washout pattern in the late phase after contrast (< 60%) (Fig. 3). Fig. 3 Computed tomography abdomen with adrenal protocol Full size image After contact with the interventional radiology of the Hospital of Federal University of Juiz de Fora, catheterization of adrenal veins was performed on 10/2020; however, it was not possible to perform adequate lesion characterization due to obtaining serum cortisol levels that extrapolated the dilutional upper limit of the method (Table 3). Table 3 Adrenal catheterization Full size table The calculation of the selectivity index was 6.63 (Reference Value (RV) > 3), confirming the good positioning of the catheter within the vessels during the procedure. The calculated lateralization index was 1.1296 (VR < 3), denoting bilateral hormone production. However, as aldosterone was not collected from a peripheral vein, it was not possible to obtain the contralateral rate and define whether there was contralateral suppression of aldosterone production [5]. Due to pending diagnoses for a better therapeutic decision and Cushing’s syndrome in clear evolution and causing organic damage, it was decided, after catheterization, to make changes in the patient’s drug prescription. Ketoconazole 400 mg per day was started, the dose of vitamin D was increased to 14,000 IU per week, and ramipril 5 mg per day was prescribed due to secondary hypertension. In addition, given the severity of osteoporosis, it was decided to replace previously prescribed alendronate with zoledronic acid. Magnetic resonance imaging of the upper abdomen was performed on 06/19/2021, which demonstrated lobulated nodular thickening in the left adrenal gland with areas of decreased signal intensity in the T1 out-phase sequence, denoting the presence of fat, and homogeneous enhancement using contrast, measuring approximately 1.7 × 1.5 × 1.3 cm, suggestive of an adenoma. There was also a small nodular thickening in the lateral arm of the right adrenal, measuring approximately 0.8 × 0.6 cm, which was difficult to characterize due to its small dimensions and nonspecific appearance. PPNAD or carcinoma became an important etiological hypothesis for the case described when comparing the epidemiology in a young man and the clinical-laboratory-imaging findings of the differential diagnoses. According to a dialog with the patient and family, the group of experts opted for unilateral glandular surgical resection on the left side (11/11/2021), where more significant changes were visualized, as there was a possibility of malignancy in a young patient and to avoid a definitive adrenal insufficiency condition because of bilateral adrenalectomy. This would first allow the analysis of the material and follow-up of the evolution of the condition with the permanence of the contralateral gland. In the macroscopic analysis of the adrenalectomy specimen, adrenal tissue weighing 20 g and measuring 9.3 × 5.5 × 2.0 cm was described, completely surrounded by adipose tissue. The gland has a multinodular surface and varies between 0.2 and 1.6 cm in thickness, showing a cortex of 0.1 cm in thickness and a medulla of 1.5 cm in thickness (Fig. 4). Fig. 4 Left adrenal Full size image The microscopic analysis described the expansion of the zona fasciculate, with the formation of multiple nonencapsulated nodules composed of polygonal cells with ample and eosinophilic cytoplasm and frequent depletion of intracytoplasmic lipid content. No areas of necrosis or mitotic activity were observed. The histopathological picture is suggestive of cortical pigmented micronodular hyperplasia of the adrenal gland. For the final etiological definition and an indication of contralateral adrenalectomy, which could be unnecessary and would avoid chronic corticosteroid therapy, or else, it would be necessary to protect the patient from future complications with the maintenance of the disease in the right adrenal gland, it would be essential to search for mutations in the PRKAR1A, PDE11A, PDE8B and PRKACA genes [15]; however, such genetic analysis is not yet widely available, and the impossibility of carrying it out at the local level did not allow a complete conclusion of the case. Discussion Through the clinical picture presented and the research of several secondary causes for osteoporosis, it was possible to arrive at the diagnosis of Cushing syndrome [6]. There was symptomatic independent ACTH hypercortisolism, manifested by typical phenotypic changes, severe secondary osteoporosis, and arterial hypertension in a young patient. The diagnosis of Cushing’s syndrome is always challenging, given the presence of confounding factors such as the following: Physiological states of hypercortisolism—pseudo Cushing (strenuous exercise, pregnancy, uncontrolled diabetes, sleep apnea, chronic pain, alcohol withdrawal, psychiatric disorders, stress, obesity, glucocorticoid resistance syndromes); Cyclic or mild—subclinical Cushing’s pictures; Frequent and, even unknown, short- and long-term use of corticosteroids under different presentations; Increase in the general population incidence of diabetes and obesity; Screening tests with singularities for collection and individualized for different patient profiles. It is important to note that the basal morning cortisol measurement is not the ideal test to assess hypercortisolism and is better applied to the assessment of adrenal insufficiency. However, the hypercortisolism of the case was unequivocal, and this test was also shown to be altered several times. As no test is 100% accurate, the current guidelines suggest the use of at least two first-line functional tests that focus on different aspects of the pathophysiology of the hypothalamic‒pituitary‒adrenal axis to confirm the hypercortisolism state: 24-hours cortisol, nocturnal salivary cortisol, morning serum cortisol after suppression with 1 mg of dexamethasone or after Liddle 1. Given that night-time salivary cortisol would require hospitalization, the other suggested tests were chosen, which are easier to perform in this context [7, 8]. Subsequently, tests were performed to determine the cause of hypercortisolism, such as serum ACTH levels and adrenal CT. The suppressed ACTH denoted the independence of its action. CT showed bilateral adrenal nodules with more severe features: solid lesion, attenuation > 10 UI on noncontrast images, and contrast washout speed < 60% in 10 minutes. In this case, it is essential to make a broad clinical decision and dialog with the patient to weigh and understand the risks and benefits of surgical treatment [9]. Among the main diagnostic hypotheses for the differential diagnosis of bilateral adrenal hyperplasia are primary bilateral macronodular adrenal hyperplasia, McCune–Albright syndrome (MAS) and bilateral primary pigmented nodular hyperplasia (PPNAD) isolated or associated with Carney’s complex. Another possibility would be bilateral adrenocorticotropic hormone (ACTH)-dependent macronodular hyperplasia secondary to long-term adrenal stimulation in patients with Cushing’s disease (ACTH-secreting pituitary tumor) or ectopic ACTH production, but the present case did not present with ACTH elevation. Primary macronodular adrenal hyperplasia (nodules > 1 cm) predominates in women aged 50–60 years and may also be detected in early childhood (before 5 years) in the context of McCune–Albright syndrome. Most cases are considered sporadic; however, there are now several reports of familial cases whose presentation suggests autosomal dominant transmission. Several pathogenic molecular causes were identified in the table, indicating that it is a heterogeneous disease [10]. The pathophysiology occurs through the expression of anomalous ectopic hormone receptors or amplified eutopic receptors in the adrenals. It usually manifests in an insidious and subclinical way, with cortisol secretion mediated through receptors for gastric inhibitory peptide (GIP), vasopressin (ADH), catecholamines, interleukin 1 (IL-1), leptin, luteinizing hormone (LH), serotonin or others. Nodular development is not always synchronous or multiple; thus, hypercortisolism only manifests when there is a considerable increase in the number of adrenocortical cells, with severe steroidogenesis observed by cortisoluria greater than 3 times the upper limit of normal. Patients with mild Cushing’s syndrome should undergo screening protocols to identify aberrant receptors, as this may alter the therapeutic strategy. If there is evidence of abnormal receptors, treatment with beta-blockers is suggested for patients with beta-adrenergic receptors or with gonadotropin-releasing hormone (GnRH) agonists (and sex steroid replacement) for patients with LH/hCG receptors. In patients in whom aberrant hormone receptors are not present or for whom no specific pharmacological blockade is available or effective, the definitive treatment is bilateral adrenalectomy, which is known to make the patient dependent on chronic corticosteroid therapy [11]. Studies have shown the effectiveness of unilateral surgery in the medium and long term, opting for the resection of the adrenal gland of greater volume and nodularity by CT, regardless of the values obtained by catheterization of adrenal veins, but with the possibility of persistence or recurrence in the contralateral gland. Another possibility would be total unilateral adrenalectomy associated with subtotal contralateral adrenalectomy [12]. In McCune–Albright syndrome (MAS), there are activating mutations in the G-protein GNAS1 gene, generating autonomic hyperfunction of several tissues, endocrine or not, and there may be, for example, a constant stimulus similar to ACTH on the adrenal gland. In this case, pituitary levels of ACTH are suppressed, and adrenal adenomas with Cushing’s syndrome appear. Hypercortisolism may occur as an isolated manifestation of the syndrome or be associated with the triad composed of polyostotic fibrous dysplasia, café au lait spots with irregular borders and gonadal hyperfunction with peripheral precocious puberty. The natural history of Cushing’s syndrome in McCune-Albright syndrome (MAS) is heterogeneous, with some children evolving with spontaneous resolution of hypercortisolism, while others have a more severe condition, eventually requiring bilateral adrenalectomy [13]. PPNAD predominates in females, in people younger than 30 years, multiple and small (< 6 mm) bilateral pigmented nodules (surrounded by atrophied cortex), which can reach 1.5 cm in adulthood, with family genetic inheritance (66%) or sporadic inheritance (33%), and as part of the Carney complex reported in 40% of cases. In 70% of cases, inactivating mutations are identified in the PKA regulatory 1-alpha subunit (PRKAR1A), a tumor suppressor gene [14]. Osteoporosis is often associated with this condition [15]. One test that can distinguish patients with PPNAD from other primary adrenocortical lesions is cortisoluria after sequential suppression with low- and high-dose dexamethasone. In contrast to most patients with primary adrenocortical disease, who demonstrate no change in urinary cortisol, 70% of PPNAD patients have a paradoxical increase in urinary cortisol excretion [16]. The treatment of choice for PPNAD is bilateral adrenalectomy due to the high recurrence rate for primary adrenal disease [17]. Carney complex is a multiple neoplastic syndrome with autosomal dominant transmission, characterized by freckle-like cutaneous hyperpigmentation (lentiginosis), endocrine tumors [(PPNAD), testicular and/or thyroid tumors and acromegaly] and nonendocrine tumors, including cutaneous, cardiac, mammary, and osteochondral myxomas, among others. In the above case, the transthoracic echocardiogram of the patient on 03/18/2021 showed cavities of normal dimensions, preserved systolic and diastolic functions, no valve changes and no lentiginous skin areas and blue nevi, making the diagnosis of the syndrome less likely. The definitive diagnosis of Carney requires two or more main manifestations. Several related clinical components may suggest the diagnosis but not define it. The diagnosis can also be made if a key criterion is present and a first-degree relative has Carney or an inactivating mutation of the gene encoding PRKAR1A [18]. The adenoma is usually small in size (< 3 cm), similar to the nodules in this case; however, it is usually unilateral, with an insidious and mild evolution, especially in adult women over 35 years of age, producing only 1 steroid class. Carcinomas are usually large (> 6 cm), and only 10% are bilateral. They should be suspected mainly when the tumor presents with hypercortisolism associated with hyperandrogenism. They have a bimodal age distribution, with peaks in childhood and adolescence, as well as at the end of life [3]. Conclusion Early identification of Cushing’s syndrome, with measures based on the assessment of risks and benefits, remains the best way to prevent progression and reduce morbidity [2]. After 6 months of drug inhibition of steroidogenesis, blood pressure control and anti-osteoporotic therapy, the objective was to minimize the levels and deleterious metabolic effects of hypercortisolism, which could also harm the surgical procedure in the short and long term through infections, dehiscence, nonimmediate bed mobilization and cardiovascular events. Unilateral adrenalectomy was chosen, given the possibility of malignancy in a young patient and to avoid definitive surgical adrenal insufficiency if the adrenalectomy was bilateral. Despite the unavailability of genetic analysis for a precise etiological definition, it is possible to take efficient measures to avoid unnecessary consequences or damage. Availability of data and materials All data generated or analysed during this study are included in this published article [and its Additional file 1]. The datasets generated and/or analysed during the current study are available in the link https://ufjfedubr-my.sharepoint.com/:v:/g/personal/barbara_reis_ufjf_edu_br/EVpIR005sPZGlQvMJhIwSaUB0Hig4KOjhkG4D4cMggUwHA?e=Dk8tng. Abbreviations ACTH: Adrenocorticotropic hormone PPNAD: Bilateral primary pigmented nodular hyperplasia DXA: Dual energy X-ray absorptiometry GIP: Gastric inhibitory peptide GnRH: Gonadotropin-releasing hormone IL-1: Interleukin 1 BMD: Low bone mineral density LH: Luteinizing hormone MAS: McCune–Albright syndrome PRKAR1A: PKA regulatory 1-alpha subunit ADH: Vasopressin References Pedro AO, Plapler PG, Szejnfeld VL. 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Author information Authors and Affiliations Serviço de Endocrinologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil Bárbara Oliveira Reis, Christianne Toledo Sousa Leal, Danielle Guedes Andrade Ezequiel, Ana Carmen dos Santos Ribeiro Simões Juliano, Flávia Lopes de Macedo Veloso, Leila Marcia da Silva, Lize Vargas Ferreira, Mariana Ferreira & Gabriel Zeferino De Oliveira Souza Contributions All the authors contributed to the conception and design of the work and have approved the submitted version. All authors read and approved the final manuscript. Corresponding author Correspondence to Bárbara Oliveira Reis. Ethics declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. 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Abstract The association between empty sella turcica (EST) syndrome and Cushing's disease has been rarely reported. It is plausible to hypothesize that EST syndrome in association with Cushing's disease can be attributed to intracranial hypertension. In this case report, we present a 47-year-old male patient who presented with weight loss, fatigue, easy bruising, acanthosis nigricans, and skin creases hyperpigmentation. Investigations revealed hypokalemia and confirmed the diagnosis of Cushing's disease. Magnetic resonance imaging (MRI) brain showed a partial EST syndrome and a new pituitary nodule as compared with previous brain imaging. Transsphenoidal surgery was pursued and was complicated by cerebrospinal fluid leakage. This case reflects the rare association of EST syndrome and Cushing's disease, suggesting the increased risk of postoperative complications in this setting and the diagnostic challenge that EST syndrome imposes. We review the literature for a possible mechanism of this association. Introduction Cushing's disease is commonly caused by an adrenocorticotropic hormone (ACTH)-producing pituitary adenoma, which can be very challenging to be seen on brain magnetic resonance imaging (MRI) [1]. Empty sella turcica (EST) syndrome is a radiological diagnosis of apparently empty turcica secondary to outpouching of the arachnoid mater into the turcica, which can be attributed to intracranial hypertension (ICHTN). This can make the visual diagnosis of pituitary adenoma even more challenging in clinical practice. ICHTN has been also associated with Cushing's disease and might explain this infrequent association between EST and Cushing's disease [1]. EST syndrome can be either partial or complete, primary or secondary and has been seen infrequently with Cushing's disease. In this setting, not only that it is likely to obscure an underlying pituitary lesion, but also it does contribute to the risk of postoperative complications [2]. Case Presentation A 47-year-old male presented to the emergency department (ED) with slowly progressive generalized limb muscle weakness affecting both distal and proximal muscles over a few weeks and gait instability for three days prior to presentation. He also reported unintentional 40 pounds weight loss over the previous four months. Past medical history was significant for type II diabetes mellitus, hypothyroidism, hypertension, and dyslipidemia. In the ED, vital signs included a blood pressure of 140/90 mmHg, a heart rate of 66 beats per minute, a respiratory rate of 16 cycles per minute, and SpO2 of 97% on room air. Body mass index has decreased to 22 kg/m2 from a baseline of 26 kg/m2 one month prior. On the physical exam, he exhibited cachexia, easy bruising, acanthosis nigricans, and hyperpigmentation of skin creases. All other systems were negative. Complete metabolic panel and complete blood count were obtained showing hyperglycemia of 311 mg/dl, see Table 1. Further lab evaluation showed elevated salivary cortisol at 2.96 microgram/dl (reference range 0.094-1.551 mcg/dl), elevated 24-hour urinary free cortisol at 156 mcg/24 hour (reference 10-100 mcg/24h), positive overnight dexamethasone suppression test with serum cortisol at 2.8 mcg/dl (reference more than 2 mcg/dl), negative anti-adrenal antibodies, normal aldosterone, and elevated dehydroepiandrostenedione at 401 mcg/dl (reference 32-240 mcg/dl), with lack of suppression of the ACTH level at 35.1 pg/ml (reference 10-60 pg/ml). This confirmed the diagnosis of Cushing's disease. Variable Finding Reference Random glucose 311 Less than 200 mg/dl Sodium 141 137-145 mmol/L Potassium 2.5 3.5-5.1 mmol/L Chloride 96 98-107 mmol/L Bicarbonate 32 22-30 mmol/L Blood urea nitrogen 32 9-20 mg/dl Creatinine 0.52 0.66-1.25 mg/dl Calcium 8.7 8.6-10.3 mg/dl Total protein 5.5 6.5-8.5 g/dl Albumin 3.3 3.5-5 g/dl Total bilirubin 0.6 0.2-1.3 mg/dl Alkaline phosphatase 115 38-126 U/L Aspartate transaminase 17 17-59 U/L Alanine transaminase 39 Less than 49 U/L White blood cell count 10x10^3 cells/mcl 4-10x1063 cells/mcl Hemoglobin 15.3 13.7-17.5 g/dl Platelet 281 150-400x10^3 cells/mcl Table 1: Lab Findings Computed tomography (CT) scan of the head was unremarkable. CT scan of the chest was also unremarkable. CT scan of abdomen and pelvis showed no adrenal mass. Ultrasound of the kidneys was unremarkable. Pituitary MRI brain protocol for adenoma showed a partial EST, shortening within neurohypophysis and a new 10 x 8 x 4 mm nodule along the floor of pituitary sella as compared to MRI four years ago (Figure 1). Figure 1: Magnetic Resonance Imaging (MRI) Brain MRI brain showing partially empty sella turcica syndrome ( black arrow) with a small nodule at the floor of the turcica (white arrow). The diagnosis of Cushing’s disease was confirmed, and the patient underwent trans-sphenoidal resection of pituitary adenoma. Histological examination showed positive CAM 5.2, positive chromogranin, and ACTH immunostains. The patient presented to the ED five days after discharge home. He stated that he noticed drainage from the nose that transitioned from bloody to clear fluid and has been increasing in quantity for two days with associated intermittent headaches since the surgery. He was afebrile with stable vital signs. No signs of infection were noted on basic labs. These were significant only for mild asymptomatic hyponatremia of 131 mmol/L and hypokalemia of 3.3 mmol/L. The patient was diagnosed with cerebrospinal fluid (CSF) leakage and had a lumbar drain trial. The trial was unsuccessful after several days, and the patient underwent a transnasal endoscopic repair of CSF rhinorrhea using nasoseptal flaps. At an outpatient follow-up one month and three months after the surgery, prior lab abnormalities including hypokalemia, hyponatremia, and hyperglycemia resolved. No further evidence of CSF leakage was appreciated, and he remained asymptomatic. Discussion EST syndrome is characterized by herniation of the subarachnoid space into the intrasellar space with compression of the pituitary gland into the posteroinferior wall [3]. This is likely to obscure the presence of underlying pituitary mass. The incidence of EST syndrome in the general population is estimated at 20%. The association between EST syndrome and Cushing's disease has been reported infrequently. A retrospective study of 68 patients with Cushing's disease found that 16% of these have EST syndrome [3]. Cushing's disease usually results from pituitary adenomas secreting ACTH, and even the smallest microadenomas can produce a systemic disease. These microadenomas can be very difficult to recognize on brain MRI [4]. This is complicated in EST syndrome and even further with the possibility of ectopic ACTH production. A retrospective study of 197 patients diagnosed with Cushing's disease concluded that EST syndrome is associated with higher prevalence of MRI-negative Cushing's disease. This was attributed to ICHTN and pituitary gland compression [1]. Although surgery is curative in 70-90% of cases, EST syndrome was found to have higher risk of postoperative complications among those with Cushing's disease including diabetes insipidus, hypopituitarism, and CSF leakage [3]. This is usually because in the case of MRI-negative Cushing's disease with total EST syndrome, empiric surgical exploration is sought after inferior petrosal sampling confirms the pituitary origin of excess ACTH, and postoperative remission indicates adequate tumor resection [2]. This entails a higher chance of uncertainty and injury to healthy pituitary tissue. EST syndrome can be either primarily due to defects in the sellar diaphragm or anatomical variant or secondary to ICHTN. EST syndrome has been reported in association with many conditions associated with elevated intracranial pressure including tumors, thrombosis, meningitis, hydrocephalus, and Arnold-Chiari malformation [5]. Reversal of EST syndrome has been reported in those with idiopathic ICHTN with therapy by acetazolamide, ventriculoperitoneal shunt, and lumbar puncture [6,7]. A study has shown correlation between CSF circulation impairment or blockage and EST syndrome [8]. The incidence of EST syndrome in association with symptomatic intracranial hypertension is variable and ranges from 2.5% for total EST syndrome to 94% for partial EST syndrome [9]. Impaired CSF circulation and dynamics have been reported in 77% of patients with EST syndrome [10]. In addition to intracranial hypertension, EST syndrome has also been described in association with obesity, meningioma, pediatric nevoid basal cell carcinoma, therapy for growth hormone deficiency and even in healthy individuals [9]. Lack of symptoms of intracranial hypertension in this patient does not rule it out as intracranial hypertension in EST syndrome represents a spectrum that ranges from asymptomatic, milder intracranial hypertension to symptomatic intracranial hypertension with headache, visual disturbance, and papilledema [10]. This explains the fact that only 8-14% of EST syndrome progress to symptomatic ICHTN, while symptomatic ICHTN has been associated with EST syndrome in 94% of cases. ICHTN has been seen in association with disturbance of the hypothalamic-pituitary-adrenal axis. This has been reported after surgical and medical treatment of Cushing's disease, withdrawal of long-term steroid therapy, initial presentation of Addison’s disease, or relative glucocorticoids deficiency [11]. Cortisol excess increases CSF production and reduces its absorption, hence increasing intracranial pressure [12]. Another possible mechanism is the expression of both mineralocorticoid responsive epithelial sodium channel receptors on the basolateral membrane of the CSF producing epithelial cells of the choroid plexus as well as the expression of 11-beta hydroxysteroid dehydrogenase type 1 enzyme, which is a bidirectional enzyme that mainly functions to convert the inactive cortisone to active cortisol. These mechanisms play a role in maintaining the balance between CSF production and absorption [13,14]. In this case, the patient presented some clinical findings that are rarely associated with Cushing's disease, combined with a radiological feature that masked the true diagnosis. Our patient presented with significant weight loss, rather than central obesity, which is normally associated with Cushing’s disease. Although possible, the increase in ACTH due to Cushing's disease is not sufficient to cause hyperpigmentation, which is a classical finding of Addison's disease, where the entire adrenal cortex is usually affected due to an autoimmune destruction; however, the zona glomerulosa of the adrenal cortex produces aldosterone and its deficiency would lead to hyperkalemia [15]. Our patient presented with both hyperpigmentation and hypokalemia. Conclusions EST syndrome is an uncommon radiological finding of apparently EST that has been reported in association with ICHTN. The latter has also been seen in association with Cushing's disease/syndrome. This is likely to result from glucocorticoid excess-induced change in CSF flow dynamics. EST has been infrequently described in association with Cushing's disease. This association has a clinical implication as it is likely to obscure the visualization of pituitary lesions responsible for Cushing's disease, contribute to diagnostic uncertainty, and increase the risk of healthy pituitary tissue injury and the risk of postoperative complications including CSF leakage. References Himes BT, Bhargav AG, Brown DA, Kaufmann TJ, Bancos I, Van Gompel JJ: Does pituitary compression/empty sella syndrome contribute to MRI-negative Cushing's disease? A single-institution experience. Neurosurg Focus. 2020, 48:E3. 10.3171/2020.3.FOCUS2084 Sun Y, Sun Q, Fan C, et al.: Diagnosis and therapy for Cushing's disease with negative dynamic MRI finding: a single-centre experience. Clin Endocrinol (Oxf). 2012, 76:868-76. 10.1111/j.1365-2265.2011.04279.x Manavela MP, Goodall CM, Katz SB, Moncet D, Bruno OD: The association of Cushing's disease and primary empty sella turcica. Pituitary. 2001, 4:145-51. 10.1023/a:1015310806063 Chatain GP, Patronas N, Smirniotopoulos JG, et al.: Potential utility of FLAIR in MRI-negative Cushing's disease. J Neurosurg. 2018, 129:620-8. 10.3171/2017.4.JNS17234 Friedman DI, Jacobson DM: Diagnostic criteria for idiopathic intracranial hypertension. Neurology. 2002, 59:1492-5. 10.1212/01.wnl.0000029570.69134.1b Triggiani V, Giagulli VA, Moschetta M, Guastamacchia E: An unusual case of reversible empty sella. Endocr Metab Immune Disord Drug Targets. 2016, 16:154-6. 10.2174/1871530315666151001141507 Wind JJ, Lonser RR, Nieman LK, DeVroom HL, Chang R, Oldfield EH: The lateralization accuracy of inferior petrosal sinus sampling in 501 patients with Cushing's disease. J Clin Endocrinol Metab. 2013, 98:2285-93. 10.1210/jc.2012-3943 Brismar K, Bergstrand G: CSF circulation in subjects with the empty sella syndrome. Neuroradiology. 1981, 21:167-75. 10.1007/BF00367338 Ranganathan S, Lee SH, Checkver A, Sklar E, Lam BL, Danton GH, Alperin N: Magnetic resonance imaging finding of empty sella in obesity related idiopathic intracranial hypertension is associated with enlarged sella turcica. Neuroradiology. 2013, 55:955-61. 10.1007/s00234-013-1207-0 Maira G, Anile C, Mangiola A: Primary empty sella syndrome in a series of 142 patients. J Neurosurg. 2005, 103:831-6. 10.3171/jns.2005.103.5.0831 Zada G, Tirosh A, Kaiser UB, Laws ER, Woodmansee WW: Cushing's disease and idiopathic intracranial hypertension: case report and review of underlying pathophysiological mechanisms. J Clin Endocrinol Metab. 2010, 95:4850-4. 10.1210/jc.2010-0896 Sinclair AJ, Ball AK, Burdon MA, Clarke CE, Stewart PM, Curnow SJ, Rauz S: Exploring the pathogenesis of IIH: an inflammatory perspective. J Neuroimmunol. 2008, 201:212-20. 10.1016/j.jneuroim.2008.06.029 Sinclair AJ, Onyimba CU, Khosla P, et al.: Corticosteroids, 11beta-hydroxysteroid dehydrogenase isozymes and the rabbit choroid plexus. J Neuroendocrinol. 2007, 19:614-20. 10.1111/j.1365-2826.2007.01569.x Amin MS, Wang HW, Reza E, Whitman SC, Tuana BS, Leenen FH: Distribution of epithelial sodium channels and mineralocorticoid receptors in cardiovascular regulatory centers in rat brain. Am J Physiol Regul Integr Comp Physiol. 2005, 289:R1787-97. 10.1152/ajpregu.00063.2005 Stratakis CA: Skin manifestations of Cushing's syndrome. Rev Endocr Metab Disord. 2016, 17:283-6. 10.1007/s11154-016-9399-3 From https://www.cureus.com/articles/161111-cushings-disease-associated-with-partially-empty-sella-turcica-syndrome-a-case-report#!/

The Cushing’s Hub Editorial Board announces the final call for the 2023 Cushing’s Hub Competition!Now is your last chance to submit your favourite clinical scenario for a chance to see it appear as an Interactive Clinical Case on Cushing’s Hub. While any Cushing’s-focused scenario is welcome, submissions that examine interesting presentations of mild-to-severe hypercortisolaemia, or long-term disease outcomes (including health-related quality of life) are particularly encouraged.The successful entrant will see their clinical scenario developed into a pedagogically enhanced, interactive e-learning module. The winner will also be invited to take part in a short film sequence to introduce their work, which will be promoted at launch worldwide via social media.Don’t miss a chance to share your work with the endocrine community, click here for details on how to enter.Closing date for entries 30 June 2023

I'm glad I didn't know this before my recent knee surgery! Abstract Background Cushing’s syndrome (CS) is a disorder characterized by exposure to supraphysiologic levels of glucocorticoids. The purpose of this study was to evaluate the association between CS and postoperative complication rates following total joint arthroplasty (TJA). Methods Patients diagnosed with CS undergoing TJA for degenerative etiologies were identified from a large national database and matched 1:5 to a control cohort using propensity scoring. Propensity score matching resulted in 1,059 total hip arthroplasty (THA) patients with CS matched to 5,295 control THA patients and 1,561 total knee arthroplasty (TKA) patients with CS matched to 7,805 control TKA patients. Rates of medical complications occurring within 90 days of TJA and surgical-related complications occurring within 1 year of TJA were compared using odds ratios. Results The THA patients with CS had higher incidences of pulmonary embolism (Odds Ratio (OR) 2.21, P=0.0026), urinary tract infection (OR 1.29, P=0.0417), pneumonia (OR 1.58, P=0.0071), sepsis (OR 1.89, P=0.0134), periprosthetic joint infection (OR 1.45, P=0.0109), and all-cause revision surgery (OR 1.54, P=0.0036). The TKA patients with CS had significantly higher incidences of urinary tract infection (OR 1.34, P=0.0044), pneumonia (OR 1.62, P=0.0042), and dislocation (OR 2.43, P=0.0049) and a lower incidence of manipulation under anesthesia (MUA) (OR 0.63, P=0.0027). Conclusion Cushing’s syndrome is associated with early medical- and surgical-related complications following TJA and a reduced incidence of MUA following TKA. Introduction Cushing’s syndrome (CS) is characterized by exposure to supraphysiologic levels of glucocorticoids, whether endogenous or exogenous. Chronic exposure to hypercortisolism can lead to the development of comorbidities known to be risk factors for complications following total joint arthroplasty (TJA) including obesity, hypertension, diabetes, hyperlipidemia, and cerebrovascular disease.[1,2] Hypercortisolism is also a known risk factor for the development of osteonecrosis, and there have been several case reports of this disease being caused by endogenous production of corticosteroids.[3, 4, 5, 6, 7, 8] It can therefore be expected that the incidence of arthroplasty procedures among CS patients is likely higher than the general population. It is important to identify and understand patient specific risk factors for complications following TJA. There has been a major push recently to investigate the association between uncommon disorders and complication rates following TJA in order to risk stratify, counsel, and optimize these patients appropriately.[9, 10, 11, 12, 13, 14, 15] The typical clinical features of CS include increased central adiposity, purple striae, thin skin, fatigue, and proximal atrophy of the upper and lower limbs.[16,17] The most common etiology of endogenous CS is overproduction of adrenocorticotropic hormone (ACTH) from a pituitary adenoma, although ACTH-independent forms of CS may be caused by overproduction of glucocorticoids from the adrenal glands.[2] First-line laboratory tests for the diagnosis of CS include 24-hour urinary free cortisol, late night salivary cortisol, and the dexamethasone suppression test to determine if the negative feedback of the hypothalamic-pituitary-adrenal axis is functioning appropriately.[16] Hypercortisolism associated with CS is known to have a deleterious effect on bone health by decreasing osteoblast function and increasing bone resorption and has been associated with decreased bone mineral density at various sites in the femur including Ward’s triangle, the femoral neck, and the greater trochanter.[18] The effect of these changes in physiology on outcomes following TJA remains unclear. There are few prior case reports describing arthroplasty procedures for CS patients,[3, 4, 5] with one case report of total hip arthroplasty (THA) for femoral head osteonecrosis complicated by pulmonary thromboembolism requiring a 10-day admission to the ICU.[3] However, no large scale studies to date have investigated complication rates following TJA within this patient population. It is therefore important to better understand the risks associated with this pathology. The purpose of this study was to evaluate the association between CS and postoperative complication rates following TJA. We hypothesized that patients who have CS would have increased incidences of early medical- and surgical-related complications. Section snippets Methods This is a retrospective cohort study utilizing the commercially available M151Ortho database via PearlDiver (PearlDiver Inc., Colorado Springs, Colorado). This database contains deidentified records for 151 million patients in the United States in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Patient records were queried using International Classification of Diseases (ICD) codes and Current Procedural Terminology (CPT) codes. This study was deemed exempt from Results The THA patients who had CS had significantly higher 90-day incidences of PE (OR 2.21, P=0.0026), UTI (OR 1.29, P=0.0417), pneumonia (OR 1.58, P=0.0071), and sepsis (OR 1.89, P=0.0134) (Table 2). The TKA patients who had CS had significantly higher 90-day incidences of UTI (OR 1.34, P=0.0044) and pneumonia (OR 1.62, P=0.0042) (Table 3). Regarding surgical-related complications, CS patients undergoing THA had significantly higher incidences of PJI (OR 1.45, P=0.0109) and all-cause revision Discussion This study revealed that patients who have CS are at increased risk of developing early postoperative complications following TJA. Understanding this risk profile is important for accurate shared decision making between CS patients and their clinicians. Interestingly, CS seems to influence rates of instability and stiffness following TKA as patients in the test cohort were more likely to sustain a dislocation and less likely to undergo MUA. Rates of infectious medical complications including Conclusion Cushing’s syndrome is associated with an increased risk of early infectious complications following TJA including UTI, pneumonia, sepsis, and hip PJI and an increased incidence of dislocation following TKA. Interestingly, CS appears to be protective against arthrofibrosis as patients who have CS had lower incidences of MUA following TKA. Clinicians may be guided by this study to accurately risk stratify and counsel patients with CS prior to undergoing TJA. References (29) A. Lacroix et al. Cushing’s syndrome Lancet (2015) H.G. Moore Total Joint Arthroplasty in Patients With Achondroplasia: Comparison of 90-Day Adverse Events and 5-Year Implant Survival Arthroplast Today (2021) M.J. Gouzoulis et al. Hidradenitis Suppurativa Leads to Increased Risk of Wound-Related Complications following Total Joint Arthroplasty Arthroplast Today (2022) H.G. Moore Total Hip Arthroplasty in Patients With Cerebral Palsy: A Matched Comparison of 90-Day Adverse Events and 5-Year Implant Survival J. Arthroplasty (2021) M.W. Cole et al. The Impact of Celiac Disease on Complication Rates After Total Joint Arthroplasty: A Matched Cohort Study Arthroplast Today (2022) M.R. Mercier et al. Outcomes Following Total Hip Arthroplasty in Patients With Postpolio Syndrome: A Matched Cohort Analysis J. Arthroplasty (2022) M. Barbot et al. Cushing’s syndrome: Overview of clinical presentation, diagnostic tools and complications Best Pract. Res. Clin. Endocrinol. Metab (2020) E. Salt Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis Semin. Arthritis Rheum (2017) R. Gandhi Predictive risk factors for stiff knees in total knee arthroplasty J. Arthroplasty (2006) P.E. Scranton Management of knee pain and stiffness after total knee arthroplasty J. Arthroplasty (2001) From https://www.sciencedirect.com/science/article/abs/pii/S0883540323006484

Abstract Summary Cushing’s syndrome due to ectopic adrenocorticotropic hormone (ACTH) secretion (EAS) by a pheochromocytoma is a challenging condition. A woman with hypertension and an anamnestic report of a ‘non-secreting’ left adrenal mass developed uncontrolled blood pressure (BP), hyperglycaemia and severe hypokalaemia. ACTH-dependent severe hypercortisolism was ascertained in the absence of Cushingoid features, and a psycho-organic syndrome developed. Brain imaging revealed a splenial lesion of the corpus callosum and a pituitary microadenoma. The adrenal mass displayed high uptake on both 18F-FDG PET/CT and 68Ga-DOTATOC PET/CT; urinary metanephrine levels were greatly increased. The combination of antihypertensive drugs, high-dose potassium infusion, insulin and steroidogenesis inhibitor normalized BP, metabolic parameters and cortisol levels; laparoscopic left adrenalectomy under intravenous hydrocortisone infusion was performed. On combined histology and immunohistochemistry, an ACTH-secreting pheochromocytoma was diagnosed. The patient's clinical condition improved and remission of both hypercortisolism and catecholamine hypersecretion ensued. Brain magnetic resonance imaging showed a reduction of the splenial lesion. Off-therapy BP and metabolic parameters remained normal. The patient was discharged on cortisone replacement therapy for post-surgical hypocortisolism. EAS due to pheochromocytoma displays multifaceted clinical features and requires prompt diagnosis and multidisciplinary management in order to overcome the related severe clinical derangements. Learning points A small but significant number of cases of adrenocorticotropic hormone (ACTH)-dependent Cushing’s syndrome are caused by ectopic ACTH secretion by neuroendocrine tumours, which is usually associated with severe hypercortisolism causing severe clinical and metabolic derangements. Ectopic ACTH secretion by a pheochromocytoma is exceedingly rare but can be life-threatening, owing to the simultaneous excess of both cortisol and catecholamines. The combination of biochemical and hormonal testing and imaging procedures is mandatory for the diagnosis of ectopic ACTH secretion, and in the presence of an adrenal mass, the possibility of an ACTH-secreting pheochromocytoma should be taken into account. Immediate-acting steroidogenesis inhibitors are required for the treatment of hypercortisolism, and catecholamine excess should also be appropriately managed before surgical removal of the tumour. A multidisciplinary approach is required for the treatment of this challenging entity. Keywords: Adult; Female; White; Italy; Adrenal; Pituitary; Unique/unexpected symptoms or presentations of a disease; May; 2023 Background Cushing’s syndrome (CS) is a rare endocrine disease characterized by high levels of glucocorticoids; it increases morbidity and mortality due to cardiovascular and infectious diseases (1, 2, 3). To diagnose CS, adrenocorticotropic hormone (ACTH)-dependent disease must be distinguished from ACTH-independent disease, and pituitary ACTH production from ectopic production. About 20% of ACTH-dependent cases arise from ectopic ACTH secretion (EAS) (2, 3, 4). EAS is most often due to aberrant ACTH production by small-cell lung carcinoma or neuroendocrine tumours originating in the lungs or gastrointestinal tract; this, in turn, strongly increases cortisol production by the adrenal glands (3, 4, 5). Since the first-line treatment of EAS is the surgical removal of the ectopic ACTH-secreting tumour, its prompt and accurate localization is crucial. Rapid cortisol reduction by means of immediate-acting steroidogenesis inhibitors (4) is mandatory in order to treat the related endocrine, metabolic and electrolytic derangements. EAS by a pheochromocytoma is exceedingly rare and can be life-threatening. We describe the case of a woman with hypertension and a known ‘non-secreting’ left adrenal mass, who manifested uncontrolled blood pressure (BP), hyperglycaemia, hypokalaemia and psycho-organic syndrome associated with damage of the splenium of the corpus callosum. These findings were eventually seen to be related to an ACTH-secreting left pheochromocytoma, which was ascertained by hormonal evaluation and morphological and functional imaging assessment and confirmed by histopathology/immunostaining. Hormonal hypersecretion resolved after adrenalectomy and metabolic derangements normalized. Case presentation A 72-year-old woman with hypertension was taken to the emergency department because of increased BP (200/100 mm Hg). High BP (190/100 mmHg) was confirmed, whereas oxygen saturation (98%), heart rate (84 bpm) and lung and abdomen examination were normal. Electrocardiogram and chest x-ray were unremarkable. Captopril 50 mg orally, followed by intramuscular clonidine, normalized BP. The patient looked thin and reported significant weight loss (10 kg) over the previous 6 months; she was on antihypertensive therapy with bisoprolol 5 mg/day and irbesartan 150 mg/day, and ezetimibe 10 mg/day for dyslipidaemia. The patient’s records included a previous diagnosis in another hospital of normofunctioning multinodular goitre and a 2.5 cm-left solid inhomogeneous adrenal mass with well-defined margins, which was found on CT performed 6 years earlier during the work-up for hypertension. On the basis of hormonal data and absent uptake on 123I metaiodobenzylguanidine scintigraphy, the adrenal lesion had been deemed to be non-functioning and follow-up had been advised. Unfortunately, only initial cortisol (15.7 μg/dL) and 24-h urine-free cortisol (UFC) levels (32.5 μg/24 h) were retrievable; both proved normal. Investigations Blood chemistry showed neutrophilic leucocytosis, hyperglycaemia with increased glycated haemoglobin, severe hypokalaemia and metabolic alkalosis (Table 1). Potassium infusion (50 mEq in 500 mL saline/24 h) was rapidly started, together with a subcutaneous rapid-acting insulin analogue and prophylactic enoxaparin. The patient experienced mental confusion, hallucinations and restlessness; non-enhanced computed tomography (CT) of the brain revealed a hypodense area of the splenium of the corpus callosum, possibly due to metabolic damage (Fig. 1A). View Full Size Figure 1 Non-enhanced CT showing a hypodense area of the splenium of the corpus callosum (arrows), without mass effect (A, axial view). Contrast-enhanced MR image showing a hypointense pituitary lesion (arrow) which enhances more slowly than normal pituitary parenchyma, deemed suspicious for microadenoma (B, coronal view). FLAIR MR image showing hyperintense signal of the splenium of the corpus callosum (asterisk), which partially extended to the crux of the left fornix (arrow) (C, axial view). As the lesion showed no restricted diffusion on DWI (D, axial view), an ischaemic lesion was excluded. A progressive reduction in the extension of the hyperintense signal in the splenium of the corpus callosum (arrowheads) and in the crux of the left fornix (arrows) was observed on FLAIR MR images (2 months (E); 3 months (F); axial view). CT, computed tomography; DWI, diffusion-weighted imaging; FLAIR, fluid-attenuated inversion recovery; MR, magnetic resonance. Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 2; 10.1530/EDM-22-0308 Download Figure Download figure as PowerPoint slide Table 1 Hormonal and biochemical evaluation of patient throughout hospitalization and follow-up. Normal range On hospital admission After surgery 10 days 2 months 3 months 6 months 9 months 12 months 16 months ACTH (pg/mL) 9–52 551 7 37 50 29.5 26 40.9 52 Morning cortisol† (µg/dL) 7–19.2 63.4 14 5.1 3.5 3.8 4.2 7.2 12.8 After 1 mg overnight dexamethasone  ACTH 583  Cortisol 60 DHEAS (µg/dL) 9.4–246 201 24-h urinalysis (µg/24 h)  Adrenaline 0–14.9 95.5  Noradrenaline 0–66 1133  Metanephrine 74–297 1927  Normetanephrine 105–354 1133 Chromogranin A 0–108 290 Renin (supine) (µU/mL) 2.4–29 3.9 14.6 Aldosterone (supine) (ng/dL) 3–15 3.4 12.5 LH (mIU/mL)* > 10 0.3 65.8 FSH (mIU/mL)* > 25 1.9 116 PRL (ng/mL) 3–24 13.7 FT4 (ng/dL) 0.9–1.7 1.1 1.2 FT3 (pg/mL) 1.8–4.6 1.1 2.7 TSH (µU/mL) 0.27–4.2 0.23 1.3 PTH (pg/mL) 15–65 166 Calcium (mg/dL) 8.2–10.2 8.2 Calcitonin (pg/mL) 0–10 1 Glycaemia (mg/dL) 60–110 212 69 73 83 Potassium (mEq/L) 3.5–5 2.4 3.3 3.9 4.2 3.7 5 4.4 3.9 Leucocytes (K/µL) 4.0–9.3 15.13 HbA1c (mmol/mol) 20–42 55 30 HCO3− (mEq/L) 22–26 41.8 *For menopausal age; †07:00–10:00 h. The patient was transferred to the internal medicine ward. Although potassium infusion was increased to 120 mEq/day, serum levels did not normalize; a mineralocorticoid receptor antagonist (potassium canreonate) was therefore introduced, but the effect was partial. In order to control BP, the irbersartan dose was increased (300 mg/day) and amlodipine (10 mg/day) was added. The combination of severe hypertension, newly occurring diabetes and resistant hypokalaemia prompted us to hypothesize a common endocrine aetiology. A thorough hormonal array showed very high ACTH and cortisol levels, whereas supine renin and aldosterone levels were in the low-normal range (Table 1). Since our patient proved repeatedly non-compliant with 24-h urine collection, UFC could not be measured. After an overnight 1 mg dexamethasone suppression test, cortisol levels remained unchanged, whereas ACTH levels slightly increased (Table 1). Notably, the patient showed no Cushingoid features. Gonadotropin levels were inappropriately low for the patient’s age; FT4 levels were normal, whereas FT3 and thyroid-stimulating hormone (TSH) levels were reduced and calcitonin levels were normal (Table 1). HbA1c levels were increased (Table 1). Finally, secondary hyperparathyroidism, associated with low-normal calcium levels and reduced vitamin D levels, was found (Table 1). Brain contrast-enhanced magnetic resonance (MR) imaging revealed a 5-mm median posterior pituitary microadenoma (Fig. 1B) and a hyperintense lesion of the splenium of the corpus callosum (Fig. 1C). Diffusion-weighted MR images of the lesion showed no restricted diffusion (Fig. 1D), thus excluding an ischaemic origin. Petrosal venous sampling for ACTH determination at baseline and after CRH stimulation was excluded, as it was deemed a high-risk procedure, given the patient's poor condition. Since the ACTH and cortisol levels were greatly increased and were associated with severe hypokalaemia, EAS was hypothesized; total-body contrast-enhanced CT revealed the left adrenal mass (3 cm), which showed regular margins and heterogeneous enhancement (Fig. 2A and B) and measured 25 Hounsfield units. There was no evidence of adrenal hyperplasia in the contralateral adrenal gland. The adrenal mass showed intense tracer uptake on both 18F-FDG PET/CT (Fig. 2C and D), suggestive of adrenal malignancy or functioning tumour, and 68Ga-DOTATOC PET/CT (Fig. 3), which is characteristic of a neuroendocrine lesion. No other sites of suspicious tracer uptake were detected. View Full Size Figure 2 Contrast-enhanced abdominal computed tomography showing a 3-cm left adrenal mass (arrow) with well-defined margins and inhomogeneus enhancement, deemed compatible with an adenoma (A, coronal view; B, axial view). The adrenal mass showed high uptake (SUV max: 7.3) on 18F-FDG PET/CT (C, coronal view; D, axial view). Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 2; 10.1530/EDM-22-0308 Download Figure Download figure as PowerPoint slide View Full Size Figure 3 The left adrenal mass displaying very high uptake (SUV max: 40) on 68Ga-DOTATOC PET/CT (arrow, axial view). Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 2; 10.1530/EDM-22-0308 Download Figure Download figure as PowerPoint slide Bisoprolol was withdrawn, and 24-h urinary catecholamine, metanephrine and normetanephrine levels proved significantly increased, as were chromogranin A levels (Table 1). In sum, an ACTH-secreting pheochromocytoma was suspected and the pituitary microadenoma was deemed a likely incidental finding. The patient’s mental state worsened, fluctuating from sopor to restlessness, which required parenteral neuroleptics and restraint. An electroencephalogram revealed a specific slowdown of cerebral electrical activity. Following rachicentesis, the cerebrospinal fluid showed pleocytosis (lympho-monocytosis), whereas a culture test and polymerase chain reaction for common neurotropic agents were negative. The neurologist hypothesized a psycho-organic syndrome secondary to severe metabolic derangement. Intravenous ampicillin, acyclovir and B vitamins were empirically started. The patient was transferred to the subintensive unit, where a nasogastric tube and central venous catheter were inserted, and enteral nutrition was started. Treatment Ketoconazole was started at a dosage of 200 mg twice daily; both cortisol and ACTH levels significantly decreased over a few days (Fig. 4), with a progressive decrease in glucose levels and normalization of potassium levels and BP on therapy. Subsequently, ketoconazole was titrated to 600 mg/day owing to a new increase in cortisol levels, which eventually normalized (Fig. 4). Of note, ACTH levels partially decreased on ketoconazole treatment (Fig. 4). View Full Size Figure 4 ACTH and cortisol levels throughout the patient’s hospitalization and follow-up. Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 2; 10.1530/EDM-22-0308 Download Figure Download figure as PowerPoint slide Doxazosin 2 mg/day was added and the patient's systolic BP blood settled at around 100 mm Hg; after a few days, bisoprolol was restarted. Contrast-enhanced MR showed a partial reduction of the hyperintense splenial lesion (Fig. 1E). Despite the severe clinical condition and the high risks of adrenal surgery, the patient’s relatives strongly requested the procedure and laparoscopic left adrenalectomy was planned. Alpha-blocker and fluid infusion were continued, ketoconazole was withdrawn the day before surgery, and a 100 mg IV bolus of hydrocortisone was administered just before the operation, followed by 200 mg/day, at first in continuous infusion, then as a 100 mg bolus every 8 h. After the removal of the left adrenal mass, noradrenaline infusion was required, owing to the occurrence of severe hypotension. Outcome and follow-up Pathology revealed a 2.5 cm reddish-brown encapsulated tumour, which was compatible with pheochromocytoma (Fig. 5A and B); ACTH immunostaining was positive in about 30% of tumour cells (Fig. 5C). This confirmed the diagnostic hypothesis of an ACTH-secreting pheochromocytoma. The tumour was stained for Chromogranin A (Fig. 5D). There were no signs of adrenal cortex hyperplasia in the resected gland. Thorough germinal genetic testing, comprising the commonest pheochromocytoma/paraganglioma genes: CDKN1B, KIF1B, MEN1, RET, SDHA, SDHB, SDHC, SDHD, SDHAF2 and TMEM127, was negative. View Full Size Figure 5 Histological images of adrenal pheochromocytoma: the tumour is composed of well-defined nests of cells (‘zellballen’) (A; haematoxylin-eosin stain (HE), ×20) with pleomorphic nuclei with prominent nucleoli, basophilic or granular amphophilic cytoplasm (B; HE, ×40). The mitotic index was low: 1 mitosis per 30 high-power fields, and Ki-67 was 1%. On immunohistochemistry, cytoplasmatic ACTH staining was found in about 30% of tumour cells (C; ×20), whereas most tumour cells were stained for chromogranin A (D; ×20). Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 2; 10.1530/EDM-22-0308 Download Figure Download figure as PowerPoint slide One week after surgery ACTH levels had dropped to a low-normal value: 7 pg/mL, and cortisol levels (before morning hydrocortisone bolus administration) were normal: 14 µg/dL (Fig. 4). The patient’s clinical status slowly improved and the nasogastric tube was removed; intravenous hydrocortisone was carefully tapered until withdrawal and high-dose oral cortisone acetate (62.5 mg/day) was started. This dose was initially required since BP remained low (systolic: 90 mm Hg); thereafter, cortisone was reduced to 37.5 mg/day. Plasma cortisol levels before morning cortisone administration were reduced (Fig. 4). A new MR of the brain showed a further partial reduction of the splenial lesion (Fig. 1F). The patient was discharged with normal off-therapy BP and metabolic parameters. During follow-up, she fully recovered, and BP and metabolic parameters remained normal. Gonadotropin levels became adequate for the patient’s age, and TSH and renin/aldosterone levels normalized (Table 1). Hypoadrenalism, however, persisted for more than 1 year; as the last hormonal evaluation, 16 months after surgery, showed normal baseline cortisol levels, the cortisone dose was tapered (12.5 mg/day) and further hormonal examination was scheduled (Table 1). ACTH and cortisol levels throughout the patient’s hospitalization and follow-up are shown in Fig. 4. Discussion The diagnosis of EAS is challenging and requires two steps: confirmation of increased ACTH and cortisol levels and anatomic distinction from pituitary sources of ACTH overproduction. Besides metabolic derangements (hyperglycaemia, hypertension), EAS-related severe hypercortisolism may cause profound hypokalaemia (3, 4, 5). In our patient, the combination of worsening hypertension, newly occurring diabetes and resistant hypokalaemia raised the suspicion of a common endocrine cause. ACTH-dependent severe hypercortisolism was ascertained, and subsequent brain MR revealed a pituitary microadenoma. The diagnosis of CS requires the combination of two abnormal test results: 24-h UFC, midnight salivary cortisol and/or abnormal 1 mg dexamethasone suppression testing (2, 6). ACTH evaluation (low/normal-high) is fundamental to tailoring the imaging technique. The very high cortisol levels found in our patient were unchanged after overnight dexamethasone testing, whereas UFC could not be assessed owing to the lack of compliance with urine collection. The accuracy of the UFC assays, however, may be impaired by cortisol precursors and metabolites. Salivary cortisol assessment was not performed since the specific assay is not available in our hospital. The combination of ACTH-dependent severe hypercortisolism and hypokalaemia prompted us to suspect EAS. The differential diagnosis between pituitary and ectopic ACTH-dependent CS involves high-dose (8 mg) dexamethasone suppression testing, which has relatively low diagnostic accuracy (6). Owing to the patient's very high cortisol levels and severe hypokalaemia, this testing was not performed, on account of the risks of administering corticosteroids in a patient already exposed to excessive levels (6). Furthermore, owing to the increase in ACTH levels observed after overnight dexamethasone testing, we postulated the possible occurrence of glucocorticoid-driven positive feedback on ACTH secretion, which has been described in EAS, including cases of pheochromocytoma (7). Finally, in the case of EAS suspected of being caused by pheochromocytoma, we do not recommend performing high-dose dexamethasone suppression testing, owing to the risk of triggering a catecholaminergic crisis (8). The dynamic tests commonly used to distinguish patients with EAS from those with Cushing's disease are the CRH stimulation test and the desmopressin stimulation test, either alone or in combination with CRH testing (6). Owing to the rapid worsening of our patient’s condition, dynamic testing was not done; however, the clinical picture and hormonal/biochemical data were suggestive of EAS. EAS is mainly (45–50%) due to neuroendocrine tumours, mostly of the lung (small-cell lung cancer and bronchial tumours), thymus or gastrointestinal tract; however, up to 20% of ACTH-secreting tumours remain occult (3, 4, 5). ACTH-secreting pheochromocytomas are responsible for about 5% of cases of EAS (3, 4, 9, 10). Indeed, this rate ranges widely, from 2.5% (11) to 15% (12), according to the different case series. Patients with EAS due to pheochromocytoma present with severe CS, overt diabetes mellitus, hypertension and hypokalaemia (3); symptoms of catecholamine excess may be unapparent (3), making the diagnosis more challenging. A recent review of 99 patients with ACTH- and/or CRH-secreting pheochromocytomas found that the vast majority displayed a Cushingoid phenotype (10); by contrast, another review of 24 patients reported that typical Cushingoid features were observed in only 30% of patients, whereas weight loss was a prevalent clinical finding (13). We hypothesized that the significant weight loss reported by our patient was largely due to the hypermetabolic state induced by catecholamines, which directly reduce visceral and subcutaneous fat, as recently reported (14). Our patient showed no classic stigmata of CS, owing to the rapid onset of severe hypercortisolism (10, 13), whereas she had worsening hypertension and newly occurring diabetes mellitus, which were related to both cortisol and catecholamine hypersecretion; hypokalaemia was deemed to be secondary to severe hypercortisolism. Indeed, greatly increased cortisol levels act on the mineralocorticoid receptors of the distal tubule after saturating 11β-hydroxysteroid dehydrogenase type 2, leading to hypokalaemia (4). Consequently, hypokalaemia is much more common (74–95% of patients) in EAS than in classic Cushing’s disease (10%) (3, 4, 10). This apparent mineralocorticoid excess suppresses renin and aldosterone secretion, as was ascertained in our patient. In this setting, the most effective way to manage hypokalaemia is to treat the hypercortisolism itself by administering immediate-acting steroidogenesis inhibitors, combined with potassium infusion and a mineralocorticoid receptor-antagonist (e.g. spironolactone) at an appropriate dosage (100–300 mg/day) (4). In ACTH-secreting pheochromocytoma, cortisol hypersecretion potentiates catecholamine-induced hypertension by stimulating the phenol-etholamine-N-methyl–transferase enzyme, which transforms noradrenaline to adrenaline (4). Indeed, in our patient, the significant ketoconazole-induced reduction in cortisol secretion led to satisfactory BP control on antihypertensive drugs. After the biochemical diagnosis of pheochromocytoma, a selective alpha-blocker was added, and after a few days, a beta-blocker was restarted in order to control reflex tachycardia (15). Our patient had greatly increased ACTH levels (>500 pg/mL) associated with very high cortisol levels (>60 µg/dL), which, together with the finding of hypokalaemia, prompted us to hypothesize EAS. With regard to these findings, ACTH levels are usually higher (>200 pg/mL) in patients with EAS than in those with CS due to a pituitary adenoma; however, considerable overlapping occurs (3, 11, 16). Most patients with ACTH-secreting pheochromocytomas in those series had ACTH levels >300 pg/mL, and a few had normal ACTH levels (9), thus complicating the diagnosis. In addition, patients with EAS usually have higher cortisol levels than those with ACTH-secreting adenomas (3, 11). In our patient, the left adrenal mass was deemed the culprit of EAS, and owing to very high urinary metanephrine levels, a pheochromocytoma was suspected. It can be assumed that the adrenal tumour, which was anamnestically reported as ‘non-secreting’, but on which only part of the initial hormonal data were available, was actually a pheochromocytoma at the time of the first diagnosis but displayed a silent clinical and hormonal behaviour. The mass subsequently showed significant uptake on both 18F-FDG PET/CT and 68Ga-DOTATOC PET/CT (4, 5). It is claimed that 68Ga-DOTATOC PET/CT provides a high grade (90%) of sensitivity and specificity in the diagnosis of tumours that cause EAS (4, 5); nevertheless, a recent systematic review reported much lower sensitivity (64%), which increased to 76% in histologically confirmed cases (17). In patients with EAS, immediate-acting steroidogenesis inhibitors are required in order to achieve prompt control of severe hypercortisolism (4). Ketoconazole is one of the drugs of choice since it inhibits adrenal steroidogenesis at several steps. In our patient, ketoconazole rapidly reduced cortisol levels to normal values, without causing hepatic toxicity (4). Moreover, ketoconazole proved effective at a moderate dosage (600 mg/day), which falls within the mean literature range (18, 19). However, dosages up to 1200–1600 mg/day are sometimes required in severe cases (usually EAS) (18, 19). Speculatively, our results might reflect an enhanced inhibitory action of ketoconazole at the adrenal level, which was able to override the strong ectopic ACTH stimulation. In addition, the finding that, following cortisol reduction, ACTH levels paradoxically decreased suggests an additive and direct effect of the drug. This effect has been observed in a few patients with EAS (20) and is supported by in vitro studies showing a direct anti-proliferative and pro-apoptotic effect of ketoconazole on ectopic ACTH secretion by tumours (21). Finally, the reduction in ACTH levels during treatment with steroidogenesis inhibitors prompts us to postulate the presence of glucocorticoid-driven positive feedback on ACTH secretion, as already described in neuroendocrine tumours (7, 20, 21). The coexistence of EAS and ACTH-producing pituitary adenoma is very rare but must be taken into account. In our case, we deemed the pituitary mass found on MR to be a non-secreting microadenoma. This hypothesis was strengthened by the finding that, following exeresis of the ACTH-secreting pheochromocytoma, ACTH normalized, hypercortisolism vanished and pituitary function recovered. These findings suggest that: (i) altered pituitary function at the baseline was secondary to the inhibitory effect of hypercortisolism; (ii) the excessive production of cortisol was driven by ACTH overproduction outside the pituitary gland, specifically within the adrenal gland tumour. In our patient, a few days after surgery, morning cortisol levels before hydrocortisone bolus administration were ‘normal’. Owing to both the half-life of hydrocortisone (8–12 h) and the supraphysiological dosage used, it is likely that a residual part of the drug, which cross-reacts in the cortisol assay, was still circulating at the time of blood collection, thus resulting in ‘normal’ cortisol values. Following the switch to oral cortisone, cortisol levels before therapy were low, thus confirming post-surgical hypocortisolism. Hypocortisolism remained throughout the first year after surgery, and glucocorticoid therapy was continued. Sixteen months after surgery, baseline cortisol levels returned to the normal range; cortisone therapy was therefore tapered and a further hormonal check was scheduled. Assessment of the cortisol response to ACTH stimulation testing would be helpful in order to check the resumption of the residual adrenal function. A peculiar aspect of our case was the occurrence of a psycho-organic syndrome together with the finding of a splenial lesion on brain imaging, which was deemed secondary to metabolic injury. Indeed, the increased cortisol levels present in patients with Cushing’s disease are detrimental to the white matter of the brain, including the corpus collosum, causing subsequent clinical derangements (22). Besides the direct effects of hypercortisolism, the splenial damage was also probably due to long-standing hypertension, worsened by newly occurring catecholamine hypersecretion and diabetes. Together with the normalization of cortisol and glycaemic levels, and of BP, a partial reduction in the splenial damage was observed on two subsequent MR examinations, and the patient's neurological condition slowly improved until she fully recovered. In our patient, thorough germinal genetic testing for the commonest pheochromocytoma/paraganglioma (PPGL) genes proved negative. Since approximately 40% of these tumours have germline mutations, genetic testing is recommended regardless of the patient’s age and family history. In the absence of syndromic, familial or metastatic presentation, the selection of genes for testing may be guided by the tumour location and biochemical phenotype. Alterations of the PPGL genes can be divided into two groups: 10 genes (RET, VHL, NF1, SDHD, SDHAF2, SDHC, SDHB, SDHA, TMEM127 and MAX) that have well-defined genotype–phenotype correlations, thus allowing to tailor imaging procedures and medical management, and a group of other emerging genes, which lack established genotype–phenotype associations; for patients in whom mutations of genes belonging to this second group are detected, and hence hereditary predisposition is established, only general medical surveillance and family screening can be planned (23, 24). In conclusion, our case highlights the importance of investigating patients with hypertension and metabolic derangements such as diabetes and hypokalaemia, since these findings may be a sign of newly occurring EAS, which, in rare cases, may be due to an ACTH-secreting pheochromocytoma. Since the additive effect of cortisol and catecholamine can cause dramatic clinical consequences, the possibility of an ACTH-secreting pheochromocytoma should be taken into account in the presence of an adrenal mass. EAS must be considered an endocrine emergency requiring urgent multi-specialist treatment. Surgery, whenever possible, is usually curative, and anatomic brain damage, as ascertained in our patient, may be at least partially reversible. Declaration of interest The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. Funding This study did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector. The study was approved by the Local Ethics Committee (no: 732/2022). Patient consent The patient provided written informed consent. Author contribution statement All authors contributed equally to the conception, writing and editing of the manuscript. L Foppiani took care of the patient during hospitalization and in the outpatient department, performed the metabolic and endocrine work-up, conceived the study, analysed the data and wrote the manuscript. MG Poeta evaluated the patient during hospitalization with regard to neurological problems and planned the related work-up (brain imaging procedures and rachicentesis). M Rutigliani analysed the histological specimens and performed immunohistochemical studies. S Parodi performed CT and MR scans and analysed the related images. U Catrambone performed the left adrenalectomy. L Cavalleri performed general anaesthesia and assisted the patient during the surgical and post-surgical periods. G Antonucci revised the manuscript. P Del Monte helped in the endocrine work-up, in the evaluation of hormonal data and in the revision of the manuscript. A Piccardo performed 18F-FDG PET/CT and analysed the related images. Acknowledgement The work of Prof Silvia Morbelli in performing and analysing 68Ga-DOTATOC PET/CT is gratefully acknowledged. References 1↑ Pivonello R, Isidori AM, De Martino MC, Newell-Price J, Biller BMK, Colao A. Complications of Cushing's syndrome: state of the art. The Lancet Diabetes & Endocrinology 2016 4 611–629. (https://doi.org/10.1016/S2213-8587(1600086-3) Search Google Scholar Export Citation 2↑ Fleseriu M, Auchus R, Bancos I, Ben-Shlomo A, Bertherat J, Biermasz NR, Boguszewski CL, Bronstein MD, Buchfelder M, Carmichael JD, et al.Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet. 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The following is a summary of “Treatment of Cushing Disease With Pituitary-Targeting Seliciclib,” published in the March 2023 issue of Endocrinology & Metabolism by Liu, et al. Seliciclib (R-roscovitine) has been shown in preclinical studies to inhibit neoplastic corticotroph proliferation and the production of adrenocorticotropic hormone (ACTH) in the pituitary gland. Therefore, for a study, researchers sought to investigate the effectiveness of seliciclib as a pituitary-targeting treatment for patients with Cushing’s disease (CD). Two prospective, open-label, phase 2 trials were conducted at a tertiary referral pituitary center. Adult patients with de novo, persistent, or recurrent CD received oral seliciclib 400 mg twice daily for four consecutive days each week for four weeks. The primary endpoint in the single-center study was normalization of 24-hour urinary free cortisol (UFC; ≤ 50 µg/24 hours) at the end of the study, and in the multicenter study, the primary endpoint was UFC normalization or a ≥ 50% reduction in UFC from baseline to the end of the study. Of the 16 patients who consented, 9 were treated with seliciclib. The mean UFC decreased by 42% from 226.4 ± 140.3 µg/24 hours at baseline to 131.3 ± 114.3 µg/24 hours at the end of the study. The longitudinal model showed significant reductions in UFC from baseline to each treatment week. Three patients achieved a ≥ 50% reduction in UFC (range, 55%-75%), and two exhibited a 48% reduction; none achieved UFC normalization. Plasma ACTH decreased by 19% (P = 0.01) in patients with ≥48% UFC reduction. Three patients developed grade ≤ 2 elevated liver enzymes, anemia, and/or elevated creatinine, resolved with dose interruption/reduction. Two patients developed grade 4 liver-related serious adverse events that resolved within four weeks of seliciclib discontinuation. The results suggested that seliciclib may target pituitary corticotrophs in CD and reverse hypercortisolism. Although potential liver toxicity of seliciclib resolves with treatment withdrawal, a further determination is required to establish the lowest effective dose. Source: academic.oup.com/jcem/article-abstract/108/3/726/6754906?redirectedFrom=fulltext