27 F with new onset hypertension and weight gain. Rajesh Jain Endorama 10/01/2015

Transcription

1 27 F with new onset hypertension and weight gain Rajesh Jain Endorama 10/01/2015

2 HPI 27 F with hypertension x 1 year BP /90 while on amlodipine 5 mg daily She also reports weight gain, 7 LB, mainly in the abdomen Easy bruising + decrease in muscle strength Negative: HAs, vision changes, irregular menstrual periods, facial acne, palpitations

3 PMH: Hypertension PSH: Appendectomy Extended History Meds: amlodipine 5 mg qday Allergies: None Family history: Goiter in uncle, no hx of other endocrine disorders Social Hx: Never smoker, social EtOH use, no drugs.

4 Physical Exam P 68, BP 161/106, Ht 5 3, Wt 151 LB, BMI 26.8 Gen: well appearing, no acute distress Eyes: non-injected, anicteric sclera ENT: Normal hearing, thyroid normal size and texture Resp: CTAB CV: RRR, no murmurs. No LE edema Abd: Positive bowel sounds, soft, non-tender Skin: Purple striae on bilateral flanks MSK: Normal gait. Lymph: No LAD in the neck Psych: Normal mood and affect.

5 Differential Essential hypertension Cushing s syndrome Primary aldosteronism Pheochromocytoma Hypothyroidism

6 Most common features in Cushing s Syndrome Newell-Price et al. Cushing s Syndrome. Lancet 2006; 367:

7 Screening for Cushing s Nieman et al. The diagnosis of Cushing s Syndrome: An Endocrine Society Clinical Practice Guideline. JCEM 2008;93:

8 Algorithm

9 Prior workup 7:30 PM Cortisol 25.3 mcg/dl (Reference ) ACTH <1 pg/ml (Reference ) AM Cortisol after overnight 1 mg of dexamethasone: 28.8 mcg/dl (Reference ) Outside MRI without contrast report: Small 11 mm rounded nodule arising from the lateral limb of the right adrenal gland. This demonstrates prominent loss of signal on out of phase images compatible with an adrenal adenoma. There is also a large 2.9 x 2.3 cm left adrenal mass. This demonstrates mild to moderately slightly heterogeneous loss of signal intensity on the out of phase images. This is also compatible with a lipid rich adenoma.

10 Prior Adrenal Vein Sampling Time Site Cortisol (mcg/dl) (Ref. AM 6-23) Aldosterone (ng/dl) (Ref ) 1501 Right adrenal vein Left adrenal vein Right adrenal vein Left adrenal vein Superior IVC Inferior IVC

11 What issues exist with this adrenal vein sampling?

12 Adrenal Vein Sampling Usually done to localize adenoma in patients with primary aldosteronism, not for Cushing s In this test, cortisol is supposed to be the reference hormone When done for primary aldosteronism, sampling is considered successful if adrenal vein cortisol to IVC cortisol ratio is at least 5

13 Prior Adrenal Vein Sampling Time Site Cortisol (mcg/dl) (Ref. AM 6-23) Aldosterone (ng/dl) (Ref ) 1501 Right adrenal vein Left adrenal vein Right adrenal vein Left adrenal vein Superior IVC Inferior IVC

14 Additional labs ordered Lab Patient s value Reference range ACTH (8 AM) 11.9 pg/ml <52 Cortisol (8 AM) 31.0 ug/dl 8 AM: Aldosterone 12 ng/dl <21 ng/dl Renin 1.4 ng/ml/hour Na-deplete , Nareplete < Normetanephrines 0.16 nmol/l <0.90 Metanephrines 0.13 nmol/l <0.50 Midnight Salivary Cortisol 24 Hour Urinary free cortisol 24 Hour urine creatinine 1500 ng/dl < ug mg mg/24hr

15 Adrenal Cushing s Syndrome Represents 15-20% of Cushing s Syndrome Similar survival & clinical features as Cushing s disease

16 Newell-Price et al. Cushing s Syndrome. Lancet 2006; 367:

17 Case continued No protocol exists at U of C for adrenal vein sampling done for ACTH-independent hypercortisolism Patient was sent to Mayo, where protocol exists

18 Mayo s protocol: Done on second day of dexamethasone administration (0.5 or 2 mg q6h) Uses epinephrine as the reference hormone Catheterization of each adrenal vein is considered to be successful if plasma epinephrine concentration in the adrenal vein exceeds peripheral vein concentration by more than 100 pg/ml Cortisol adrenal to peripheral vein gradient > 6.5 is consistent with a cortisol-secreting adenoma Young Jr et al. World J Surg 2008;32:

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20 Lateralization Ratio Cortisol high side Cortisol low side Young Jr et al. World J Surg 2008;32:

21 Young Jr et al. World J Surg 2008;32:

22 Workup at Mayo Patient had selective adrenal venous sampling Site Right adrenal vein Left adrenal vein Cortisol (mcg/dl) (Ref. AM 6-23) Epinephrine (pg/ml) Cortisol AV/PV ratio 21 13, IVC Lateralization Ratio = 4.2 Consistent with dominant left adrenal adenoma and nonfunctional right adenoma

23 Course continued Underwent robotic-assisted laprascopic left adrenalectomy Pathology: adrenal cortical adenoma (3.0 x 3.0 x 2.4 cm) Discharged on HC 30/20 initially, follows up and is on HC 10/5 Feeling generally well, she asks How long do I need to be on this?

24 N=54 N=11 N=26 Berr et al. JCEM 2015;100(4):

25 Salivary Cortisol

26 Adrenal adenoma vs. Cushing s Disease Van Cauter and Refetoff. Evidence for two subtypes of Cushing s disease based on the analysis of episodic cortisol secretion. New Engl J Med 1985;312:

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28 Case continued What about her other nodule?

29 What about the other nodule? Followed with yearly 24-H urinary cortisol, catecholamines/metanephrin es, morning ACTH/cortisol, aldosterone/renin ratio, imaging for mean 4.6 years Barzon et al. Risk factors and long-term follow-up of adrenal incidentalomas. JCEM 1999;84.2:

30 Case conclusion When holding her HC, her AM Cortisol was 0.7 and so she was continued on HC 10/5 for now Following up in 3 months with repeat labs Repeat imaging to be done at follow-up visit

31 References Nieman et al. The diagnosis of Cushing s Syndrome: An Endocrine Society Clinical Practice Guideline. JCEM 2008;93: Newell-Price et al. Cushing s Syndrome. Lancet 2006; 367: Young Jr et al. The clinical conundrum of corticotropin-independent autonomous cortisol secretion in patients with bilateral adrenal masses. World J Surg 2008;32: Berr et al. Time to recovery of adrenal function after curative surgery for Cushing s Syndrome depends on etiology. JCEM 2015;100(4): Van Cauter and Refetoff. Evidence for two subtypes of Cushing s disease based on the analysis of episodic cortisol secretion. New Engl J Med 1985;312: Tung et al. Bilateral adrenocortical adenomas causing ACTH-independent Cushing s syndrome at different periods: A case report and discussion of corticosteroid replacement therapy following bilateral adrenalectomy. J Endocrinol Invest 2004;27: Barzon et al. Risk factors and long-term follow-up of adrenal incidentalomas. JCEM 1999;84.2: