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Esquivel JE, Santos AB, Hong A, Ruiz F. Spontaneous Cushing's Disease Remission Induced by Pituitary Apoplexy. Cureus 2024; 16:e64231. [PMID: 39130944 PMCID: PMC11315432 DOI: 10.7759/cureus.64231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
Spontaneous remission of Cushing's disease (CD) is uncommon and often attributed to pituitary tumor apoplexy. We present a case involving a 14-year-old female who exhibited clinical features of Cushing's syndrome. Initial diagnostic tests indicated CD: elevated 24h urinary cortisol (235 µg/24h, n < 90 µg/24h), abnormal 1 mg dexamethasone overnight test (cortisol after 1 mg dex 3.4 µg/dL, n < 1.8 µg/dL), and elevated adrenocorticotropic hormone concentrations (83.5 pg/mL, n 10-60 pg/mL). A pituitary adenoma was suspected, so a nuclear MRI was performed, with findings suggestive of a pituitary microadenoma. The patient was referred for a transsphenoidal resection of the microadenoma. While waiting for surgery, the patient presented to the emergency department with a headache and clinical signs of meningism. A computed axial tomography of the central nervous system was performed, and no structural alterations were found. The symptoms subsided with analgesia. One month later, she presented again to the emergency department with clinical findings of acute adrenal insufficiency (cortisol level of 4.06 µg/dL), and she was noted to have spontaneous biochemical remission associated with the resolution of her symptoms of hypercortisolism. For that reason, spontaneous CD remission induced by pituitary apoplexy (PA) was diagnosed. The patient has been managed conservatively since the diagnosis and remains in clinical and biochemical remission until the present time, after 10 months of follow-up. There are three unique aspects of our case: the early age of onset of symptoms, the spontaneous remission of CD due to PA, which has been rarely reported in the medical literature, and the fact that the patient presented a microadenoma because there are fewer than 10 clinical case reports of PA associated with microadenoma.
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Affiliation(s)
| | - Ana B Santos
- Medicine, University of Costa Rica, San José, CRI
| | - Anthony Hong
- Medicine, University of Costa Rica, San José, CRI
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Motomura Y, Urai S, Bando H, Yamamoto M, Suzuki M, Yamamoto N, Iguchi G, Ogawa W, Fukuoka H. Diagnostic dilemma in Cushing's syndrome: discrepancy between patient-reported and physician-assessed manifestations. Endocrine 2024:10.1007/s12020-024-03935-9. [PMID: 39037671 DOI: 10.1007/s12020-024-03935-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/14/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE Early diagnosis and immediate treatment of Cushing's syndrome (CS) are critical for a better prognosis but remain a challenge. However, few comprehensive reports have focused on this issue or investigated whether patient-reported manifestations are consistent with physician-assessed symptoms of CS. This study aimed to clarify the differences in patient-reported and physician-assessed manifestations of signs and symptoms of CS that prevent early diagnosis. METHODS This single-center retrospective study included 52 patients with CS (16 with Cushing's disease and 36 with adrenal CS). Upon clinical diagnosis, medical records were used to independently review the patient-reported and physician-assessed manifestations of typical (such as purple striae and proximal myopathy) and nonspecific features (such as hirsutism and hypertension). The correlations and differences between the patient-reported and physician-assessed manifestations were then analyzed. RESULTS We observed a positive correlation between the total number of manifestations of nonspecific features reported by patients and those assessed by physicians, but not for typical features. Moreover, manifestations reported by the patients were less frequent than those assessed by physicians for typical features, leading to discrepancies between the two groups. In contrast, there were no differences in most nonspecific features between the patient-reported and physician-assessed manifestations. Notably, the concordance between patient-reported and physician-assessed manifestations of typical features was not associated with urinary free cortisol levels. CONCLUSION Regardless of disease severity, patients often do not complain of the typical features of CS that are crucial for formulating a diagnosis.
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Affiliation(s)
- Yuma Motomura
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Shin Urai
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Hyogo, 650-0017, Japan
| | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Masaki Suzuki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Naoki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
- Medical Center for Student Health, Kobe University, Kobe, Hyogo, 657-8501, Japan
- Department of Biosignal Pathophysiology, Kobe University Graduate School of Medicine, Kobe, Hyogo, 657-8501, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Hyogo, 650-0017, Japan.
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Gadelha M, Gatto F, Wildemberg LE, Fleseriu M. Cushing's syndrome. Lancet 2023; 402:2237-2252. [PMID: 37984386 DOI: 10.1016/s0140-6736(23)01961-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/04/2023] [Accepted: 09/13/2023] [Indexed: 11/22/2023]
Abstract
Endogenous Cushing's syndrome results from excess glucocorticoid secretion, which leads to a myriad of clinical manifestations, comorbidities, and increased mortality despite treatment. Molecular mechanisms and genetic alterations associated with different causes of Cushing's syndrome have been described in the last decade. Imaging modalities and biochemical testing have evolved; however, both the diagnosis and management of Cushing's syndrome remain challenging. Surgery is the preferred treatment for all causes, but medical therapy has markedly advanced, with new drug options becoming available. Nevertheless, several comorbidities remain even after patient remission, which can affect quality of life. Accurate and timely diagnosis and treatment are essential for mitigating chronic complications of excess glucocorticoids and improving patient quality of life. In this Seminar, we aim to update several important aspects of diagnosis, complications, and treatment of endogenous Cushing's syndrome of all causes.
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Affiliation(s)
- Mônica Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Molecular Genetics Laboratory, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
| | - Federico Gatto
- Endocrinology Unit, Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Maria Fleseriu
- Pituitary Center, Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
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Guarnotta V, Emanuele F, Salzillo R, Bonsangue M, Amato C, Mineo MI, Giordano C. Practical therapeutic approach in the management of diabetes mellitus secondary to Cushing's syndrome, acromegaly and neuroendocrine tumours. Front Endocrinol (Lausanne) 2023; 14:1248985. [PMID: 37842314 PMCID: PMC10569460 DOI: 10.3389/fendo.2023.1248985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/28/2023] [Indexed: 10/17/2023] Open
Abstract
Cushing's syndrome, acromegaly and neuroendocrine disorders are characterized by an excess of counterregulatory hormones, able to induce insulin resistance and glucose metabolism disorders at variable degrees and requiring immediate treatment, until patients are ready to undergo surgery. This review focuses on the management of diabetes mellitus in endocrine disorders related to an excess of counterregulatory hormones. Currently, the landscape of approved agents for treatment of diabetes is dynamic and is mainly patient-centred and not glycaemia-centred. In addition, personalized medicine is more and more required to provide a precise approach to the patient's disease. For this reason, we aimed to define a practical therapeutic algorithm for management of diabetes mellitus in patients with glucagonoma, pheochromocytoma, Cushing's syndrome and acromegaly, based on our practical experience and on the physiopathology of the specific endocrine disease taken into account. This document is addressed to all specialists who approach patients with diabetes mellitus secondary to endocrine disorders characterized by an excess of counterregulatory hormones, in order to take better care of these patients. Care and control of diabetes mellitus should be one of the primary goals in patients with an excess of counterregulatory hormones requiring immediate and aggressive treatment.
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Affiliation(s)
| | | | | | | | | | | | - Carla Giordano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Endocrinology, University of Palermo, Piazza delle Cliniche 2, Palermo, Italy
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Liu NA, Ben-Shlomo A, Carmichael JD, Wang C, Swerdloff RS, Heaney AP, Barkhoudarian G, Kelly D, Noureddin M, Lu L, Desai M, Stolyarov Y, Yuen K, Mamelak AN, Mirocha J, Tighiouart M, Melmed S. Treatment of Cushing Disease With Pituitary-Targeting Seliciclib. J Clin Endocrinol Metab 2023; 108:726-735. [PMID: 36214832 DOI: 10.1210/clinem/dgac588] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/04/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Preclinical studies show seliciclib (R-roscovitine) suppresses neoplastic corticotroph proliferation and pituitary adrenocorticotrophic hormone (ACTH) production. OBJECTIVE To evaluate seliciclib as an effective pituitary-targeting treatment for patients with Cushing disease (CD). METHODS Two prospective, open-label, phase 2 trials, conducted at a tertiary referral pituitary center, included adult patients with de novo, persistent, or recurrent CD who received oral seliciclib 400 mg twice daily for 4 consecutive days each week for 4 weeks. The primary endpoint in the proof-of-concept single-center study was normalization of 24-hour urinary free cortisol (UFC; ≤ 50 µg/24 hours) at study end; in the pilot multicenter study, primary endpoint was UFC normalization or ≥ 50% reduction in UFC from baseline to study end. RESULTS Sixteen patients were consented and 9 were treated. Mean UFC decreased by 42%, from 226.4 ± 140.3 µg/24 hours at baseline to 131.3 ± 114.3 µg/24 hours by study end. Longitudinal model showed significant UFC reductions from baseline to each treatment week. Three patients achieved ≥ 50% UFC reduction (range, 55%-75%), and 2 patients exhibited 48% reduction; none achieved UFC normalization. Plasma ACTH decreased by 19% (P = 0.01) in patients who achieved ≥ 48% UFC reduction. Three patients developed grade ≤ 2 elevated liver enzymes, anemia, and/or elevated creatinine, which resolved with dose interruption/reduction. Two patients developed grade 4 liver-related serious adverse events that resolved within 4 weeks of seliciclib discontinuation. CONCLUSION Seliciclib may directly target pituitary corticotrophs in CD and reverse hypercortisolism. Potential liver toxicity of seliciclib resolves with treatment withdrawal. The lowest effective dose requires further determination.
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Affiliation(s)
- Ning-Ai Liu
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Anat Ben-Shlomo
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - John D Carmichael
- Pituitary Center, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - Christina Wang
- Department of Medicine, The Lundquist Institute and Harbor-UCLA Medical Center, Torrance, CA 90509, USA
| | - Ronald S Swerdloff
- Department of Medicine, The Lundquist Institute and Harbor-UCLA Medical Center, Torrance, CA 90509, USA
| | - Anthony P Heaney
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA 90024, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, CA 90404, USA
| | - Daniel Kelly
- Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, CA 90404, USA
| | - Mazen Noureddin
- Karsh Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Manish Desai
- Southern California Permanente Group-Antelope Valley, Lancaster, CA 93534, USA
| | | | - Kevin Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ 85013, USA
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - James Mirocha
- Biostatistics Core, Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Mourad Tighiouart
- Biostatistics Core, Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Shlomo Melmed
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Ragonese M, Giuffrida G, Alessi Y, Giandalia A, Giovinazzo S, Cotta OR, Certo R, Casablanca R, Ferraù F, Cannavò S. Epidemiology, course, and outcomes of Sars-CoV-2 infection in patients with acromegaly and Cushing's disease: a monocentric experience in Southern Italy. J Endocrinol Invest 2023:10.1007/s40618-023-02016-4. [PMID: 36708457 PMCID: PMC9884127 DOI: 10.1007/s40618-023-02016-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/16/2023] [Indexed: 01/29/2023]
Abstract
PURPOSE Acromegaly (AC) and Cushing's disease (CD) increase morbidity and mortality due to cardio-metabolic alterations, and overall cause frailty in the affected patients, potentially making them more susceptible to infective diseases. However, up to now, very few studies evaluated the course of COVID-19 disease in this setting. METHODS We investigated epidemiology, course, and outcomes of COVID-19 disease in patients with AC or CD, managed in the Endocrine Unit of a Sicilian University Hospital during 2 years of pandemic outbreak. RESULTS We enrolled 136 patients with AC or CD (74 and 62 cases, respectively, 39 males) from Sicily and Calabria regions. Incidence of Sars-CoV-2 infection in these subjects was lower than in the general population, becoming quite similar after vaccines introduction (11%). No difference was observed concerning prevalence. Mean age of infected patients (IPs) was significantly lower than the unaffected ones (p < 0.02). No differences were found for sex, BMI, disease control, occurrence of diabetes mellitus, OSAS, cardiomyopathy, and hypopituitarism. The rate of IPs was similar in AC and CD patients' groups. None of them died. CONCLUSIONS In conclusion, we did not find a significantly different incidence of Sars-CoV-2 infection in AC or CD patients compared to the general population. IPs were younger than the unaffected patients, but sex, BMI, or diabetes mellitus were not risk factors for infection/worse outcomes. Nevertheless, these results could have been biased by a safer behavior probably adopted by older and more complicated patients.
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Affiliation(s)
- M Ragonese
- Department of Human Pathology of Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - G Giuffrida
- Department of Human Pathology of Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Y Alessi
- Unit of Endocrinology, "G. Martino" University Hospital, Messina, Italy
| | - A Giandalia
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - S Giovinazzo
- Department of Human Pathology of Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - O R Cotta
- Unit of Endocrinology, "G. Martino" University Hospital, Messina, Italy
| | - R Certo
- Unit of Endocrinology, "G. Martino" University Hospital, Messina, Italy
| | - R Casablanca
- Unit of Endocrinology, "G. Martino" University Hospital, Messina, Italy
| | - F Ferraù
- Department of Human Pathology of Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy.
- Unit of Endocrinology, "G. Martino" University Hospital, Messina, Italy.
| | - S Cannavò
- Department of Human Pathology of Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
- Unit of Endocrinology, "G. Martino" University Hospital, Messina, Italy
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Moreno Parro I, Ortiz Sánchez D, García Moreno R, Gómez Rioja R, Frutos Martínez R, Álvarez-Escolá C. Bilateral inferior petrosal sinus sampling in the diagnosis of ACTH-dependent Cushing's syndrome: experience in a tertiary hospital. ADVANCES IN LABORATORY MEDICINE 2022; 3:282-294. [PMID: 37362143 PMCID: PMC10197771 DOI: 10.1515/almed-2022-0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/01/2022] [Indexed: 06/28/2023]
Abstract
Objectives Bilateral inferior petrosal sinus sampling (BIPSS) is a useful test for differential diagnosis of central vs. ectopic adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome (CS). We provide a description of the protocol used in our Center and an analysis of its diagnostic accuracy. Methods A retrospective study was conducted of 28 patients who underwent BIPSS combined with corticotropin-releasing hormone (CRH) stimulation. The procedure is performed in an interventional neuroradiology suite, involving a multidisciplinary team of neuroradiologists, endocrinologists and laboratory professionals. The two petrosal sinuses are catheterized and a peripheral blood sample is obtained simultaneously, at baseline and at 3, 6 and 10 min following stimulation. ACTH and prolactin are determined by immunochemiluminescence. Results A total of 19 cases of Cushing's disease (CD) and 1 case of ectopic CS were confirmed. In all cases, BIPSS provided accurate diagnostic guidance, with a sensitivity and specificity of 100%. In 8 patients, remission was not achieved after surgery. In 84% of catheterizations, ACTH ratio peaked at 3-6 min following stimulation. Patients with histologically-confirmed CD exhibited higher sinus ACTH ratios and values. Prolactin ratio helped us identify and exclude 28.6% of the samples with inconsistent results. Conclusions In our series, BIPSS combined with CRH stimulation demonstrated to be a safe, effective procedure. Prolactin emerges as a useful marker of correct catheterization. The participation of a multidisciplinary team is essential.
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Affiliation(s)
- Isabel Moreno Parro
- Laboratory Medicine Department, La Paz University Hospital-Carlos III-Cantoblanco, Madrid, Spain
| | - David Ortiz Sánchez
- Laboratory Medicine Department, La Paz University Hospital-Carlos III-Cantoblanco, Madrid, Spain
| | - Rosa García Moreno
- Endocrinology Department, La Paz University Hospital-Carlos III-Cantoblanco, Madrid, Spain
| | - Rubén Gómez Rioja
- Laboratory Medicine Department, La Paz University Hospital-Carlos III-Cantoblanco, Madrid, Spain
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Vanek C, Loriaux L. The 1 mg overnight dexamethasone suppression test: a danger to the adrenal gland? Curr Opin Endocrinol Diabetes Obes 2022; 29:403-405. [PMID: 35799460 DOI: 10.1097/med.0000000000000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The 1 mg overnight dexamethasone suppression test (ONDST) with a cutoff cortisol value of 1.8 mcg/dl (50 nmol/l) is routinely used for the assessment of incidental, benign adrenal nodules. Patients with an abnormal test are diagnosed with mild autonomous cortisol secretion (MACS). This timely commentary reviews the origins of the ONDST, its relationship to the diagnoses of MACS, and whether this is clinically relevant for clinical care. RECENT FINDINGS Millions of incidental adrenal nodules are found on CT scans annually. Several papers in the last three years discuss and advocate for the diagnose of MACS via the ONDST. SUMMARY An ONDST cutoff of 1.8 mcg/dl (50 nmol/l) in patients with no clinical features of Cushing's syndrome will produce false positive results and a diagnosis of MACS that could result in unnecessary adrenalectomy.
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Affiliation(s)
- Chaim Vanek
- Oregon Health & Science University, Division of Endocrinology, Diabetes, and Clinical Nutrition
| | - Lynn Loriaux
- Oregon Health & Science University, Division of Endocrinology, Diabetes, and Clinical Nutrition, Portland, Oregon, USA
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