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Barlas T, Yalcin MM, Osmanov Z, Gulbahar O, Altinova AE, Akturk M, Karakoc MA, Yetkin I, Toruner FB. Detecting the interferences in adrenocorticotropic hormone measurement - three cases reinforcing the efficiency of the complementary clinical and laboratory audit. Biochem Med (Zagreb) 2024; 34:010802. [PMID: 38125613 PMCID: PMC10731737 DOI: 10.11613/bm.2024.010802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/26/2023] [Indexed: 12/23/2023] Open
Abstract
Accurate measurement of adrenocorticotropic hormone (ACTH) is crucial in the evaluation of pituitary and adrenal disorders. Although great progress has been achieved in ACTH measurement with immunometric assays, interference may occur and adversely affect the clinical management. The report contributes to compiling the evidence on the clinical challenges with the management of the interferences in the ACTH measurement by presenting three cases: two with clinically overt hypercortisolism and discrepant ACTH concentrations within the reference interval; the third case describes the falsely elevated ACTH in a patient with secondary adrenal insufficiency. In all patients, the results obtained with the two immunometric platforms, chemiluminescence (CLIA) immunoassay (Siemens, Immulite) and electrochemiluminescence (ECLIA) immunoassay (Roche, Cobas), were discordant. Serial dilution of plasma samples revealed nonlinearity. After polyethylene glycol (PEG) precipitation recoveries were less than 22%, 26%, and 3%, respectively, supporting interference. Moreover, a decrease in ACTH concentration after incubation in a heterophile antibody-blocking tube was observed in the second case. In the first case, misinterpretation of ACTH led to inferior petrosal sinus sampling (IPSS), whereas timely detection of assay interference prevented further investigations in other cases. Increasing awareness regarding ACTH interference and comprehensive approach in evaluation could allow timely detection, helping to prevent unnecessary testing and perplexing clinical outcomes.
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Affiliation(s)
- Tugba Barlas
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mehmet Muhittin Yalcin
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Zakir Osmanov
- Department of Biochemistry, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ozlem Gulbahar
- Department of Biochemistry, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Alev Eroglu Altinova
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mujde Akturk
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mehmet Ayhan Karakoc
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ilhan Yetkin
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Fusun Balos Toruner
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
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Martins Ferreira M, Moreno C, Oliveira P, Paiva I. Immunoassay interferences: laboratory pitfall in the diagnosis of adrenocortical carcinoma. BMJ Case Rep 2024; 17:e257320. [PMID: 38341198 PMCID: PMC10862333 DOI: 10.1136/bcr-2023-257320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024] Open
Abstract
A woman in her late 50s with recent onset of hypertension, diabetes, lumbar pain and unintentional weight loss was diagnosed with a cortisol and androgen-producing adrenal mass. Despite this, serum adrenocorticotropic hormone (ACTH) concentration was inappropriately elevated, which was investigated thoroughly. Investigations included a brain magnetic resonance imaging to exclude concomitant pituitary adenoma, a corticotropin-releasing hormone stimulation test and a gallium-68 DOTATATE and 18F-FDOPA PET scan, both excluding ectopic ACTH production. Considering the disparity between clinical presentation and biochemical results, the ACTH was reanalysed using the Cobas immunoassay (Roche, Switzerland), ultimately unveiling the cause for ACTH elevation. ACTH levels had previously been measured with ACTH Immulite (Siemens, Germany), a two-site immunoassay which is prone to interferences causing falsely elevated ACTH concentrations. Inaccurate laboratory levels can lead to diagnosis delay and unnecessary diagnostic procedures and a close communication between the physicians and laboratorians is of utmost importance.
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Affiliation(s)
- Mafalda Martins Ferreira
- Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Carolina Moreno
- Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Patrícia Oliveira
- Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Isabel Paiva
- Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
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Findling JW, Raff H. Recognition of Nonneoplastic Hypercortisolism in the Evaluation of Patients With Cushing Syndrome. J Endocr Soc 2023; 7:bvad087. [PMID: 37440963 PMCID: PMC10334485 DOI: 10.1210/jendso/bvad087] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 07/15/2023] Open
Abstract
The evaluation of suspected hypercortisolism is one of the most challenging problems in medicine. The signs and symptoms described by Dr Harvey Cushing are common and often create diagnostic confusion to even experienced endocrinologists. Cushing syndrome is classically defined as neoplastic hypercortisolism resulting from an ACTH-secreting tumor or from autonomous secretion of excess cortisol associated with benign or malignant adrenal neoplasia. The increasing recognition of the negative cardiometabolic effects of mild cortisol excess without overt physical signs of Cushing syndrome has led to more screening for endogenous hypercortisolism in patients with adrenal nodular disease, osteoporosis, and the metabolic syndrome. However, sustained or intermittent activation of the dynamic hypothalamic-pituitary-adrenal axis caused by chemical (alcohol), inflammatory (chronic kidney disease), psychologic (major depression), and physical (starvation/chronic intense exercise) stimuli can result in clinical and/or biochemical features indistinguishable from neoplastic hypercortisolism. Nonneoplastic hypercortisolism (formerly known as pseudo-Cushing syndrome) has been recognized for more than 50 years and often causes diagnostic uncertainty. This expert consultation describes two patients with features of Cushing syndrome who were referred for inferior petrosal sinus sampling for the differential diagnosis of ACTH-dependent hypercortisolism. Both patients were discovered to have nonneoplastic hypercortisolism: one from a covert alcohol use disorder and the other to chronic kidney disease. This consultation emphasizes the value of a good history and physical examination, appropriate laboratory testing, and the desmopressin acetate stimulation test to aid in distinguishing neoplastic from nonneoplastic hypercortisolism.
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Affiliation(s)
- James W Findling
- Department of Medicine (Endocrinology and Molecular Medicine), Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Hershel Raff
- Correspondence: Hershel Raff, PhD, Endocrinology Research HRC4150, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA.
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Flowers KC, Shipman KE. Pitfalls in the Diagnosis and Management of Hypercortisolism (Cushing Syndrome) in Humans; A Review of the Laboratory Medicine Perspective. Diagnostics (Basel) 2023; 13:diagnostics13081415. [PMID: 37189516 DOI: 10.3390/diagnostics13081415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Biochemical confirmation of a diagnosis of hypercortisolism (Cushing syndrome) is vital to direct further investigations, especially given the overlap with non-autonomous conditions, such as pseudo-Cushing, and the morbidity associated with missed diagnoses. A limited narrative review was performed focusing on the laboratory perspective of the pitfalls of making a biochemical diagnosis of hypercortisolism in those presenting with presumed Cushing syndrome. Although analytically less specific, immunoassays remain cheap, quick, and reliable in most situations. Understanding cortisol metabolism can help with patient preparation, specimen selection (e.g., consideration of urine or saliva for those with possible elevations of cortisol binding globulin concentration), and method selection (e.g., mass spectrometry if there is a high risk of abnormal metabolites). Although more specific methods may be less sensitive, this can be managed. The reduction in cost and increasing ease of use makes techniques such as urine steroid profiles and salivary cortisone of interest in future pathway development. In conclusion, the limitations of current assays, particularly if well understood, do not impede diagnosis in most cases. However, in complex or borderline cases, there are other techniques to consider to aid in the confirmation of hypercortisolism.
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Affiliation(s)
- Kade C Flowers
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
| | - Kate E Shipman
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
- Department of Medical Education, Brighton and Sussex Medical School, University of Sussex, Falmer Campus, Brighton BN1 9PX, UK
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Gosavi V, Lila A, Memon SS, Sarathi V, Thakkar K, Dalvi A, Malhotra G, Prakash G, Patil V, Shah NS, Bandgar T. Clinical Spectrum of Adrenal Cushing's Syndrome and the Caution for Interpretation of Adrenocorticotrophic Hormone: A Single-Center Experience. Horm Metab Res 2022; 54:57-66. [PMID: 35130566 DOI: 10.1055/a-1735-3232] [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: 11/04/2022]
Abstract
UNLABELLED To describe the differences in presentation, biochemistry, and radiological evaluation of various etiologies of adrenal Cushing's syndrome (CS) from a single center. To emphasize caution for interpretation of plasma adrenocorticotropic hormone (ACTH), as a spuriously unsuppressed ACTH level by immunometric assay may lead to therapeutic misadventures in adrenal CS. DESIGN Retrospective, single-center, observational study. METHODS Fifty-eight adrenal CS patients [Adrenocortical carcinoma (ACC), n=30; Adenoma (ACA), n=15; Primary pigmented nodular adrenocortical disease (PPNAD), n=10; ACTH independent macronodular adrenal hyperplasia (AIMAH), n=3) evaluated at a tertiary care center in western India between January 2006 to March 2020 were included. Data on demography, clinical evaluation, biochemistry, imaging, management, histopathology, and outcome were recorded in a standard format and analyzed. RESULTS Cortisol secreting ACC presented at 38(1-50) years with abdominal mass in 26/30 (86.7%) and 16/30 (53.3%) had metastases at presentation. ACA with autonomous cortisol excess presented at 25(4.9-40) years with discriminating features of CS in 14/15 (93.3%), sex steroid production in 2/15, unenhanced HU <10 in only one, and relative washout >40% in 8/11 (72.7%). One ACA and eight ACC patients had plasma ACTH (by Siemens Immulite assay) > 20 pg/ml, despite hypercortisolemic state. CONCLUSIONS Cortisol-secreting ACC and ACA most often present with mass effects and florid CS, respectively. Baseline HU has low sensitivity to differentiate cortisol-secreting ACA from ACC. Plasma ACTH measured by Seimens Immulite is often unsuppressed, especially in ACC patients, which can be addressed by measuring ACTH by more accurate assays.
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Affiliation(s)
- Vikrant Gosavi
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Anurag Lila
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Kunal Thakkar
- Sterling Ramkrishna Speciality Hospital, Gandhidham, India
| | - Abhay Dalvi
- Department of Surgery, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Gaurav Malhotra
- Department of Nuclear Medicine, Bhabha Atomic Research Centre, Mumbai, India
| | - Gagan Prakash
- Department of Uro-oncology, Tata Memorial Hospital, Mumbai, India
| | - Virendra Patil
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Nalini S Shah
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
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Does concomitant prolactin measurement ıncrease the accuracy of ınferior petrosal sinus sampling? Neuroradiology 2022; 64:1411-1418. [PMID: 35064296 DOI: 10.1007/s00234-021-02886-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Prolactin (PRL) measurement during inferior petrosal sinus sampling (IPSS) can be helpful to improve the accuracy. We aimed to evaluate the effect of measuring PRL levels as a predictor for the accuracy of IPSS and evaluate its impact on the lateralization of adenomas. METHODS In this retrospective cohort study, we reviewed 51 patients who had undergone IPSS for the investigation of ACTH-dependent hypercortisolism. RESULTS Forty-nine patients had proven Cushing's disease (CD), one had EAS, and the remaining one patient had adrenal adenoma. Forty-seven patients had an above 2 ACTH IPS/P ratio at baseline, and all the post-corticotropin-releasing hormone (CRH) ACTH IPS/P ratios of patients with proven CD were above 3. In these two patients whose ACTH IPS/P ratio at baseline was below 2, PRL IPS/P ratios were above 1.8 in only the dominant side, which was considered secondary to a prolactin intersinus gradient due to the biological effects of the tumor. PRL-adjusted ACTH IPS/P ratios were > 1.3 in all patients with proven CD; it was 0.7 in the patient with EAS. Surgically confirmed positive lateralization was observed in 55.1% of patients with the ACTH gradient, but when PRL-adjusted ACTH IPS/IPS ratios were used in addition to the ACTH gradient, the ratio increased to 67.3%. CONCLUSION Although PRL-adjusted ACTH IPS/P ratios can be helpful to improve the accuracy of results during IPSS procedures, a prolactin intersinus gradient towards the ACTH-dominant side in patients with CD may invalidate PRL as an indicator of pituitary venous outflow.
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Yang YY, Kuo CC, Lin MH, Chang CY, Hsieh CH, Lu CH. A Pitfall of Falsely Elevated ACTH: A Case Report and Literature Review. J Investig Med High Impact Case Rep 2022; 10:23247096221103368. [PMID: 35699218 PMCID: PMC9201346 DOI: 10.1177/23247096221103368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 35-year-old woman with unintentional weight gain, hyperpigmentation of
bilateral palms, and general fatigue was initially suspected of Cushing’s
syndrome or adrenal insufficiency based on the isolated elevation of the plasma
adrenocorticotropic hormone (ACTH) level (113.0 pg/mL) in the Siemens ACTH
Immulite assay (ACTH [Immulite]). However, both of the diagnoses were excluded
by screening tests including the overnight dexamethasone suppression test, the
24-hour urinary free cortisol excretion, and the ACTH stimulation test in spite
of the consistent elevation of the plasma ACTH levels. We speculated that the
existence of the immunoassay interference may be the underlying cause because
the plasma ACTH level analyzed by the CIS Bio International ELSA-ACTH
immunoassay (ELSA-ACTH) was within the normal range. After reviewing our case
and several reported cases of falsely elevated plasma ACTH levels, we conclude
that when discrepancy between clinical symptoms and laboratory measurements
exists, medical practitioners ought to rely on formal diagnostic criteria rather
than misleading laboratory results to avoid misdiagnosis or even unnecessary
invasive testing and procedures. In addition, current methods for investigation
and elimination of immunoassay interferences should be applied with caution due
to variable efficacy and inevitable deviations.
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Affiliation(s)
- Yung-Yu Yang
- Departement of General Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Chun Kuo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ming-Hsun Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Yung Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chang-Hsun Hsieh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chieh-Hua Lu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Bi Y, Adam S, Chatzimavridou V, Lorigan P, Huang Y. Potential pitfalls in diagnosis of immunotherapy-induced hypothalamic-pituitary-adrenal axis abnormalities: a clinical case. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:K5-K9. [PMID: 37435468 PMCID: PMC10259291 DOI: 10.1530/eo-21-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/28/2022] [Indexed: 07/13/2023]
Abstract
SUMMARY Short synacthen tests (SST) are frequently used for assessing adrenocorticotropin hormone (ACTH) deficiency. In this study, we present the case of a 53-year-old man receiving immunotherapy for metastatic melanoma, who subsequently developed immune checkpoint inhibitor (ICI)-induced hypothyroidism and was investigated for the presence of ICI-induced hypocortisolaemia on different occasions. Despite two reassuring SSTs, he subsequently developed clinical and biochemical evidence of ACTH deficiency. The ACTH on local measurement was not conclusive in keeping with ICI-related ACTH deficiency but when repeated using an alternative assay confirmed the diagnosis. The case illustrates the evolution of ACTH deficiency and exposes the potential pitfalls of screening strategies. Two important lessons may be gleaned from this case: (i) SSTs can be normal in early cases of secondary adrenal insufficiency, for example, hypophysitis due to adrenal reserve and (ii) when there is mismatch between the clinical and biochemical presentation, the ACTH should be repeated using a different assay. LEARNING POINTS Short synacthen tests, useful for ruling out adrenalitis and primary adrenal failure, may be normal in early adrenocorticotrophic hormone deficiency and secondary adrenal failure due to residual adrenal reserve.If clinical suspicion of adrenal insufficiency persists despite an initial satisfactory SST, it is important to recognise the need for re-assessment of cortisol levels.Insulin tolerance test remains a useful tool in the investigation of secondary adrenal insufficiency.Levothyroxine replacement may accelerate the metabolism of cortisol in cases of concurrent hypothyroidism and hypoadrenalism, and therefore, glucocorticoid replacement must precede levothyroxine treatment, to avoid adrenal crisis.The prevalence of immunotherapy-related endocrinopathies is likely to increase with increasing use of ICI and it is crucial that clinicians are alert to their subtle symptoms.
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Affiliation(s)
- Yixi Bi
- The Christie’s NHS Foundation Trust, Manchester, UK
| | - Safwaan Adam
- The Christie’s NHS Foundation Trust, Manchester, UK
| | | | - Paul Lorigan
- The Christie’s NHS Foundation Trust, Manchester, UK
| | - Yinglai Huang
- Division of Breast and Endocrine Surgery, Borås Hospital, Borås, Sweden
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van der Spoel E, Roelfsema F, van Heemst D. Relationships Between 24-hour LH and Testosterone Concentrations and With Other Pituitary Hormones in Healthy Older Men. J Endocr Soc 2021; 5:bvab075. [PMID: 34337275 PMCID: PMC8315483 DOI: 10.1210/jendso/bvab075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the relationship between LH and testosterone (T), which characteristics associate with the strength of this relationship, and their interrelationships with GH, TSH, cortisol, and ACTH. Design Hormones were measured in serum samples collected every 10 minutes during 24 hours from 20 healthy men, comprising 10 offspring of long-lived families and 10 control subjects, with a mean (SD) age of 65.6 (5.3) years. We performed cross-correlation analyses to assess the relative strength between 2 timeseries for all possible time shifts. Results Mean (95% CI) maximal correlation was 0.21 (0.10-0.31) at lag time of 60 minutes between LH and total T concentrations. Results were comparable for calculated free, bioavailable, or secretion rates of T. Men with strong LH-T cross-correlations had, compared with men with no cross-correlation, lower fat mass (18.5 [14.9-19.7] vs. 22.3 [18.4-29.4] kg), waist circumference (93.6 [5.7] vs. 103.1 [12.0] cm), high-sensitivity C-reactive protein (0.7 [0.4-1.3] vs. 1.8 [0.8-12.3] mg/L), IL-6 (0.8 [0.6-1.0] vs. 1.2 [0.9-3.0] pg/mL), and 24-hour mean LH (4.3 [2.0] vs. 6.1 [1.5] U/L), and stronger LH-T feedforward synchrony (1.5 [0.3] vs. 1.9 [0.2]). Furthermore, T was positively cross-correlated with TSH (0.32 [0.21-0.43]), cortisol (0.26 [0.19-0.33]), and ACTH (0.26 [0.19-0.32]). Conclusions LH is followed by T with a delay of 60 minutes in healthy older men. Men with a strong LH-T relationship had more favorable body composition, inflammatory markers, LH levels, and LH-T feedforward synchrony. We observed positive correlations between T and TSH, cortisol, and ACTH.
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Affiliation(s)
- Evie van der Spoel
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Ferdinand Roelfsema
- Section Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Diana van Heemst
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Yin Y, Zhao F, Hu Y, Lu L, Qiu L. Consideration triggered by the choice of heterophilic antibody interference detection tests in measuring ACTH for a teenager boy with a rare adrenal disease. Clin Chim Acta 2021; 519:210-213. [PMID: 33991519 DOI: 10.1016/j.cca.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 04/14/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Plasma ACTH is an important marker for Cushing syndrome; inaccurate measurement of ACTH concentrations due to the serum heterophile antibody may mislead diagnosis by physicians. We describe the case of a teenage boy with a rare adrenal disease who presented falsely increased ACTH concentrations (20.3 pg/ml; Siemens Immulite). METHODS Low dose dexamethasone inhibition test showed no inhibition of serum cortisol. While biochemical evidence suggested ACTH-dependent Cushing, the imaging tests suggested otherwise. Hence, further tests for interference identification, including test platform replacement, sample dilution, PEG precipitation, and use of blocking antibodies, were conducted. RESULTS The measurements of the same patient sample on three different analytical platforms suggested ACTH concentrations below 5 pg/ml. Serial dilutions of serum samples revealed nonlinearity, PEG recovery resulted in ACTH concentrations dropping to < 5 pg/ml, and interferences in plasma were blocked by a heterophilic blocking reagent (21.2 vs < 5 pg/ml), suggesting that assay interference performed on Siemens Immulite led to false-positive ACTH. Finally, the boy was diagnosed with a rare type of ACTH-independent Cushing syndrome. CONCLUSIONS The inaccurate evaluation of ACTH misled the physicians, increasing treatment time and diagnostic testing. Thus, an anti-interference workflow should be established between physicians and laboratories to avoid such cases in the future.
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Affiliation(s)
- Yicong Yin
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China
| | - Fang Zhao
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China
| | - Yingying Hu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China.
| | - Ling Qiu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China.
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Hinojosa-Amaya JM, Cuevas-Ramos D. The definition of remission and recurrence of Cushing's disease. Best Pract Res Clin Endocrinol Metab 2021; 35:101485. [PMID: 33472761 DOI: 10.1016/j.beem.2021.101485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Accurate classification of postsurgical remission, and early recognition of recurrence are crucial to timely treat and prevent excess mortality in Cushing's Disease, yet the criteria used to define remission are variable and there is no consensus to define recurrence. Remission is defined as postsurgical hypocortisolemia, but delayed remission may occur. Recurrence is the return of clinical manifestations with biochemical evidence of hypercortisolism. The proper combination of tests and their timing are controversial. Reliable predicting tools may lead to earlier diagnosis upon recurrence. Many factors have been studied independently for prediction with variable performance. Novel artificial intelligence approaches seek to integrate these variables into risk calculators and machine-learning algorithms with an acceptable short-term predictive performance but lack longer-term accuracy. Prospective studies using these approaches are needed. This review summarizes the evidence behind the definitions of remission and recurrence and provide an overview of the available tools to predict and/or diagnose them.
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Affiliation(s)
- José Miguel Hinojosa-Amaya
- Pituitary Clinic, Endocrinology Division and Department of Medicine, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Mexico.
| | - Daniel Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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Ozgen Saydam B, Adiyaman SC, Demir L, Yener S. ADRENOCORTICOTROPIC HORMONE IMMUNOASSAY INTERFERENCE IN A PATIENT WITH SUBCLINICAL HYPERCORTISOLISM. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 16:379-382. [PMID: 33363666 DOI: 10.4183/aeb.2020.379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Context Immunoassays are vulnerable to occasional analytical errors despite their sensitivity and specificity. Adrenocorticotropic hormone (ACTH) is among hormones which are vulnerable to assay interference. Objective In this case report, we aimed to present a case of ACTH interference in a patient with subclinical hypercortisolism. Case report We present a case of subclinical hypercortisolism with unexpectedly elevated levels of ACTH in whom interference was shown by different biochemical methods.It is important for the clinician to keep in mind the possibility of interference when clinical and laboratory results are discordant. The communication between the clinician and laboratory staff is important while interpreting results. This case report shows that ACTH interference should be considered in patients with subclinical hypercortisolism who have unexpectedly high levels of adrenocorticotropic hormone.
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Affiliation(s)
- B Ozgen Saydam
- Dokuz Eylul University Hospital, Division of Endocrinology and Metabolism, Izmir, Turkey
| | - S C Adiyaman
- Dokuz Eylul University Hospital, Division of Endocrinology and Metabolism, Izmir, Turkey
| | - L Demir
- Izmir Katip Celebi University, Ataturk Training and Research Hospital, Department of Biochemistry, Izmir, Turkey
| | - S Yener
- Dokuz Eylul University Hospital, Division of Endocrinology and Metabolism, Izmir, Turkey
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Frara S, Rodriguez-Carnero G, Formenti AM, Martinez-Olmos MA, Giustina A, Casanueva FF. Pituitary Tumors Centers of Excellence. Endocrinol Metab Clin North Am 2020; 49:553-564. [PMID: 32741488 DOI: 10.1016/j.ecl.2020.05.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pituitary tumors are common and require complex and sophisticated procedures for both diagnosis and therapy. To maintain the highest standards of quality, it is proposed to manage patients in pituitary tumors centers of excellence (PTCOEs) with patient-centric organizations, with expert clinical endocrinologists and neurosurgeons forming the core. That core needs to be supported by experts from different disciplines such as neuroradiology, neuropathology, radiation oncology, neuro-ophthalmology, otorhinolaryngology, and trained nursing. To provide high-level medical care to patients with pituitary tumors, PTCOEs further pituitary science through research publication, presentation of results at meetings, and performing clinical trials.
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Affiliation(s)
- Stefano Frara
- Institute of Endocrinology, Università Vita-Salute San Raffaele, Via Olgettina Milano, 58, Milano, Milan 20132, Italy
| | - Gemma Rodriguez-Carnero
- Division of Endocrinology, Complejo Hospitalario Universitario de Santiago (USC/SERGAS), Instituto de Investigacion Sanitaria de Santiago (IDIS), Rúa da Choupana, S/N, Santiago de Compostela, A Coruña 15706, Spain
| | - Ana M Formenti
- Institute of Endocrinology, Università Vita-Salute San Raffaele, Via Olgettina Milano, 58, Milano, Milan 20132, Italy
| | - Miguel A Martinez-Olmos
- Division of Endocrinology, Complejo Hospitalario Universitario de Santiago (USC/SERGAS), Instituto de Investigacion Sanitaria de Santiago (IDIS), Rúa da Choupana, S/N, Santiago de Compostela, A Coruña 15706, Spain; CIBER Fisiopatología de la Obesidad y la Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
| | - Andrea Giustina
- Institute of Endocrinology, Università Vita-Salute San Raffaele, Via Olgettina Milano, 58, Milano, Milan 20132, Italy
| | - Felipe F Casanueva
- Division of Endocrinology, Complejo Hospitalario Universitario de Santiago (USC/SERGAS), Instituto de Investigacion Sanitaria de Santiago (IDIS), Rúa da Choupana, S/N, Santiago de Compostela, A Coruña 15706, Spain; CIBER Fisiopatología de la Obesidad y la Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain.
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14
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van der Spoel E, Roelfsema F, Akintola AA, Jansen SW, Slagboom PE, Westendorp RGJ, Blauw GJ, Pijl H, van Heemst D. Interrelationships Between Pituitary Hormones as Assessed From 24-hour Serum Concentrations in Healthy Older Subjects. J Clin Endocrinol Metab 2020; 105:5680671. [PMID: 31853555 PMCID: PMC7065845 DOI: 10.1210/clinem/dgz253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 12/17/2019] [Indexed: 12/17/2022]
Abstract
CONTEXT Hormones of the hypothalamic-pituitary-target gland axes are mostly investigated separately, whereas the interplay between hormones might be as important as each separate hormonal axis. OBJECTIVE Our aim is to determine the interrelationships between GH, TSH, ACTH, and cortisol in healthy older individuals. DESIGN We made use of 24-hour hormone serum concentrations assessed with intervals of 10 minutes from 38 healthy older individuals with a mean age (SD) of 65.1 (5.1) years from the Leiden Longevity Study. Cross-correlation analyses were performed to assess the relative strength between 2 24-hour hormone serum concentration series for all possible time shifts. Cross-approximate entropy was used to assess pattern synchronicity between 2 24-hour hormone serum concentration series. RESULTS Within an interlinked hormonal axis, ACTH and cortisol were positively correlated with a mean (95% confidence interval) correlation coefficient of 0.78 (0.74-0.81) with cortisol following ACTH concentrations with a delay of 10 minutes. Between different hormonal axes, we observed a negative correlation coefficient between cortisol and TSH of -0.30 (-0.36 to -0.25) with TSH following cortisol concentrations with a delay of 170 minutes. Furthermore, a positive mean (95% confidence interval) correlation coefficient of 0.29 (0.22-0.37) was found between TSH and GH concentrations without any delay. Moreover, cross-approximate entropy analyses showed that GH and cortisol exhibit synchronous serum concentration patterns. CONCLUSIONS This study demonstrates that interrelations between hormones from interlinked as well as different hypothalamic-pituitary-target gland axes are observed in healthy older individuals. More research is needed to determine the biological meaning and clinical consequences of these observations.
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Affiliation(s)
- Evie van der Spoel
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, RC Leiden, The Netherlands
- Correspondence and Reprint Requests: Evie van der Spoel, Section Gerontology and Geriatrics, Department of Internal, Medicine, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands. E-mail:
| | - Ferdinand Roelfsema
- Section Endocrinology, Department of Internal Medicine, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Abimbola A Akintola
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Steffy W Jansen
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, RC Leiden, The Netherlands
| | - P Eline Slagboom
- Section Molecular Epidemiology, Department of Biomedical Data Sciences, Leiden University Medical Center, RC Leiden The Netherlands
| | - Rudi G J Westendorp
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, RC Leiden, The Netherlands
- Department of Public Health, Center of Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Gerard J Blauw
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Hanno Pijl
- Section Endocrinology, Department of Internal Medicine, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Diana van Heemst
- Section Gerontology and Geriatrics, Department of Internal Medicine, Leiden University Medical Center, RC Leiden, The Netherlands
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15
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Adrenal insufficiency: Physiology, clinical presentation and diagnostic challenges. Clin Chim Acta 2020; 505:78-91. [PMID: 32035851 DOI: 10.1016/j.cca.2020.01.029] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/21/2022]
Abstract
Adrenal insufficiency (AI) is a serious condition, which can arise from pathology affecting the adrenal gland itself (primary adrenal insufficiency, PAI), hypothalamic or pituitary pathology (secondary adrenal insufficiency, SAI), or as a result of suppression of the hypothalamic-pituitaryadrenal (HPA) axis by exogenous glucocorticoid therapy (tertiary adrenal insufficiency, TAI). AI is associated with an increase in morbidity and mortality and a reduction in quality of life. In addition, the most common cause of PAI, autoimmune adrenalitis, may be associated with a variety of other autoimmune disorders. Untreated AI can present with chronic fatigue, weight loss and vulnerability to infection. The inability to cope with acute illness or infection can precipitate life-threatening adrenal crisis. It is therefore a critical diagnosis to make in a timely fashion, in order to institute appropriate management, aimed at reversing chronic ill health, preventing acute crises, and restoring quality of life. In this review, we will describe the normal physiology of the HPA axis and explain how knowledge of the physiology of this axis helps us understand the clinical presentation of AI, and forms the basis for the biochemical investigations which lead to the diagnosis of AI.
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16
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Wissner Greene L, Geer EB, Page-Wilson G, Findling JW, Raff H. Response to Letter to the Editor: "Assay-Specific Spurious ACTH Results Lead to Misdiagnosis, Unnecessary Testing, and Surgical Misadventure-A Case Series". J Endocr Soc 2020; 4:bvz012. [PMID: 32099949 PMCID: PMC7033035 DOI: 10.1210/jendso/bvz012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 11/06/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Loren Wissner Greene
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, US.,Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, US
| | - Eliza B Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, US
| | - Gabrielle Page-Wilson
- Neuroendocrine Unit, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, US
| | - James W Findling
- Endocrinology Center and Clinics, Medical College of Wisconsin, Milwaukee, WI, US.,Department of Community Medicine, Medical College of Wisconsin, Milwaukee, WI, US.,Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, US
| | - Hershel Raff
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, US.,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, US.,Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, US.,Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Aurora Research Institute, Milwaukee, WI, US
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17
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Shi J, Dhaliwal P, Zi Zheng Y, Wong T, Straseski JA, Cervinski MA, Shajani-Yi Z, DeMarco ML. An Intact ACTH LC-MS/MS Assay as an Arbiter of Clinically Discordant Immunoassay Results. Clin Chem 2019; 65:1397-1404. [DOI: 10.1373/clinchem.2019.306365] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/19/2019] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Measurement of plasma adrenocorticotropic hormone (ACTH) is key in the differential diagnosis of hypothalamic-pituitary-adrenal disorders. Two-site sandwich immunoassays dominate clinical testing of ACTH in North America; however, discordant results between manufacturers have been repeatedly reported. To resolve the discrepancy, we developed a liquid chromatography–tandem mass spectrometry (LC-MS/MS) assay for the intended measurand, biologically active intact ACTH (iACTH).
METHODS
The multiple reaction monitoring LC-MS/MS assay was designed to selectively measure full-length iACTH, as well as ACTH analogs and fragments (i.e., ACTH1–24 and ACTH18–39). Epitope assignment of the Roche Elecsys antibodies was performed by MALDI-TOF mass spectrometry. A method comparison between Roche Elecsys and Siemens Immulite ACTH immunoassays was performed and clinically concordant/discordant results identified. In a subset of these samples, the iACTH concentration was determined using the LC-MS/MS method.
RESULTS
The lower limit of the measuring interval of the iACTH LC-MS/MS assay was 9 pg/mL (2 pmol/L). The assay was linear from 9 to 1938 pg/mL (2 to 427 pmol/L). Epitope mapping revealed that the Roche capture and detection antibodies bound residues 9–12 and 36–39 of ACTH, respectively. The iACTH LC-MS/MS analysis demonstrated that for discordant results between 2 immunoassays studied, only the Roche results were highly positively correlated with the iACTH concentration.
CONCLUSIONS
Immunoprecipitation of biologically active ACTH molecules followed by LC-MS/MS analysis enabled selective detection of iACTH and relevant biologically active fragments in plasma. Applied to the investigation of clinically discrepant results, this method can act as an arbiter of the concentration of iACTH present.
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Affiliation(s)
- Junyan Shi
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Pawan Dhaliwal
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Yu Zi Zheng
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Terry Wong
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | | | - Mark A Cervinski
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon NH and The Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Zahra Shajani-Yi
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville, TN
| | - Mari L DeMarco
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital, Providence Health Care, Vancouver, Canada
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18
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Qian S, Smith J, Wijeratne N, Kevat D. ACTH measurements in Cushing's syndrome: the need for caution and communication. Pathology 2019; 51:769-771. [PMID: 31640888 DOI: 10.1016/j.pathol.2019.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 07/14/2019] [Accepted: 08/01/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Sarah Qian
- Department of Endocrinology and Diabetes, Western Health, St Albans, Vic, Australia
| | - Joel Smith
- Department of Biochemistry, Dorevitch Pathology, Heidelberg, Vic, Australia
| | - Nilika Wijeratne
- Department of Biochemistry, Dorevitch Pathology, Heidelberg, Vic, Australia; Department of Medicine, Monash University, Clayton, Vic, Australia
| | - Dev Kevat
- Department of Endocrinology and Diabetes, Western Health, St Albans, Vic, Australia; School of Public Health, Monash University, Melbourne, Vic, Australia.
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19
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Pantiya P, Chairatanapiwong S, Dankai D, Nualkeaw S, Jaiping K, Singboottra P, Pornprasert S. False-positive result of immunochromatographic (IC) strip test for the diagnosis of α-thalassemia in samples with autoantibodies. ACTA ACUST UNITED AC 2019; 58:e44-e46. [DOI: 10.1515/cclm-2019-0827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Patcharapong Pantiya
- Department of Medical Technology, Faculty of Associated Medical Sciences , Chiang Mai University , Chiang Mai , Thailand
| | - Saowanit Chairatanapiwong
- Department of Medical Technology, Faculty of Associated Medical Sciences , Chiang Mai University , Chiang Mai , Thailand
| | - Dararat Dankai
- Immunology Laboratory, Diagnostic Laboratory, Maharajnokorn Chiang Mai Hospital, Faculty of Medicine , Chiang Mai University , Chiang Mai , Thailand
| | - Sarayut Nualkeaw
- Medical Technology Department , Lamphun Hospital , Lamphun , Thailand
| | - Kanokwan Jaiping
- Medical Technology Department , Lamphun Hospital , Lamphun , Thailand
| | - Panthong Singboottra
- Department of Medical Technology, Faculty of Associated Medical Sciences , Chiang Mai University , Chiang Mai , Thailand
| | - Sakorn Pornprasert
- Department of Medical Technology, Faculty of Associated Medical Sciences , Chiang Mai University , Chiang Mai , Thailand
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20
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Morita K, Ogawa M, Kimura M, Okawa Y, Oki Y, Edo N, Tsukamoto K, Ishikawa T. Falsely elevated plasma ACTH levels measured by the Elecsys assay related to heterophilic antibody in a case of secondary adrenocortical insufficiency. Endocr J 2019; 66:563-569. [PMID: 30944263 DOI: 10.1507/endocrj.ej19-0023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 49-year-old woman with membranous nephropathy was referred to our hospital during the tapering of oral prednisolone, because of suspicion of primary adrenal insufficiency based on a plasma ACTH level of 399.1 pg/mL in the Elecsys assay and a serum cortisol level of 3.1 μg/dL. A rapid ACTH stimulation test revealed a suboptimal response, whereas a prolonged ACTH simulation test showed a sufficient increase in her urinary free cortisol. Also, big ACTH was not detected by gel exclusion chromatography. Therefore, we speculated that ACTH levels were falsely elevated due to some interference substances. Pretreatment of her plasma with either polyethylene glycol precipitation or a heterophilic blocking tube substantially reduced her ACTH values. When either the Immulite ACTH II or the TOSOH II ACTH was tried instead of the Elecsys ACTH, her plasma ACTH values turned out to be lower and appropriate for her clinical status. These results indicated that heterophilic antibodies interfered only with the Elecsys ACTH assay presumably by bridging the capture and tracer antibodies. To our knowledge, this is the first case in which the Elecsys ACTH assay yielded falsely elevated results. Regardless of the measurement system used, if there is a discordance between assay results and clinical findings, it should be considered to adopt additional procedures and/or another assay.
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Affiliation(s)
- Koji Morita
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
| | - Masumi Ogawa
- Division of Metabolism, Department of Internal Medicine, Self-Defense Forces Central Hospital, Tokyo 154-8532, Japan
| | - Michiko Kimura
- Department of Laboratory Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
| | - Yuta Okawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Yutaka Oki
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Naoki Edo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
| | - Kazuhisa Tsukamoto
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
| | - Toshio Ishikawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
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21
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Greene LW, Geer EB, Page-Wilson G, Findling JW, Raff H. Assay-Specific Spurious ACTH Results Lead to Misdiagnosis, Unnecessary Testing, and Surgical Misadventure-A Case Series. J Endocr Soc 2019; 3:763-772. [PMID: 30963134 PMCID: PMC6446888 DOI: 10.1210/js.2019-00027] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 02/15/2019] [Indexed: 11/19/2022] Open
Abstract
The proper clinical evaluation of pituitary and adrenal disorders depends on the accurate measurement of plasma ACTH. The modern two-site sandwich ACTH immunoassay is a great improvement compared with older methods but still has the potential for interferences such as heterophile antibodies and pro-opiomelanocortin (POMC) and ACTH fragments. We report the cases of five patients in whom the diagnosis or differential diagnosis of Cushing syndrome was confounded by erroneously elevated results from the Siemens ACTH Immulite assay [ACTH(Immulite)] that were resolved using the Roche Cobas or Tosoh AIA [ACTH(Cobas) and ACTH(AIA), respectively]. In one case, falsely elevated ACTH(Immulite) results owing to interfering antibodies resulted in several invasive differential diagnostic procedures (including inferior petrosal sinus sampling), MRI, and unnecessary pituitary surgery. ACTH(Cobas) measurements were normal, and further studies excluded the diagnosis of Cushing syndrome. In three cases, either Cushing disease or occult ectopic ACTH were suspected owing to elevated ACTH(Immulite) results. However, adrenal (ACTH-independent) Cushing syndrome was established using ACTH(AIA) or ACTH(Cobas) and proved surgically. In one case, ectopic ACTH was suspected owing to elevated ACTH(Immulite) results; however, the ACTH(Cobas) findings led to the diagnosis of alcohol-induced hypercortisolism that resolved with abstinence. We have concluded that ACTH(Immulite) results can be falsely increased and alternate ACTH assays should be used in the diagnosis or differential diagnosis of clinical disorders of the hypothalamic-pituitary-adrenal axis.
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Affiliation(s)
- Loren Wissner Greene
- Department of Medicine, New York University School of Medicine, New York, New York.,Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York
| | - Eliza B Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gabrielle Page-Wilson
- Neuroendocrine Unit, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
| | - James W Findling
- Endocrinology Center and Clinics, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hershel Raff
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Aurora Research Institute, Milwaukee, Wisconsin
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22
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Hinojosa-Amaya JM, Varlamov EV, McCartney S, Fleseriu M. Hypercortisolemia Recurrence in Cushing's Disease; a Diagnostic Challenge. Front Endocrinol (Lausanne) 2019; 10:740. [PMID: 31787930 PMCID: PMC6856050 DOI: 10.3389/fendo.2019.00740] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/14/2019] [Indexed: 12/30/2022] Open
Abstract
Cushing's disease recurrence following successful pituitary surgery is common and merits prompt and careful diagnosis, as untreated hypercortisolism leads to increased morbidity and mortality. However, an established recurrence definition has not been forthcoming. This poses a diagnostic challenge especially early in the course of returning hypercortisolemia and/or in the presence of non-neoplastic hypercortisolemia. A late-night salivary cortisol (LNSC) test is the first test to reveal abnormal results, however, has limitations related to assay performance as well as individual patient variability. Dexamethasone suppression tests and 24-h urinary free cortisol (UFC) results are next to reveal abnormal results. Other tests including, corticotropin-releasing hormone (CRH) stimulation test and combined CRH-dexamethasone test, as well as desmopressin stimulation test with/without dexamethasone are also used, although, none have proven to be the preeminent diagnostic test for recurrence determination. There is a possible role for these tests in predicting recurrence in patients who have experienced remission, though, this also remains challenging due to lack of established cutoff values. This article details and summarizes evidence about different diagnostic tests currently used to diagnose and predict Cushing's disease recurrence.
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Affiliation(s)
- José Miguel Hinojosa-Amaya
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Endocrinology Division, Department of Medicine, Hospital Universitario “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elena V. Varlamov
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Shirley McCartney
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
- *Correspondence: Maria Fleseriu
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