HIV-associated disseminated cryptococcosis-An unusual clinical and diagnostic picture with successful cure by single dose liposomal amphotericin B treatment

BACKGROUND

Cryptococcosis is an invasive, opportunistic fungal infection seen especially in human immunodeficiency virus (HIV) infected patients. Cryptococcal meningitis (CM) is the second leading cause of mortality in HIV patients. We report a case of disseminated cryptococcosis presenting with altered mental status in a newly diagnosed HIV infection.

METHODS AND RESULTS

A 50-year-old with a short history of altered mental sensorium and a history of low-grade fever and weight loss for few months presented at a tertiary care hospital in North India. He was detected positive for HIV-1. Cryptococcal antigen (CRAG) was positive in Cerebrospinal fluid (CSF), and negative in serum. The fungal culture in CSF was sterile while the fungal blood culture grew Cryptococcus neoformans. The patient was treated with single high-dose Liposomal Amphotericin B (LAmB) therapy followed by Fluconazole and Flucytosine for the next two weeks followed by fluconazole daily for consolidation and maintenance therapy. Antiretroviral therapy (ART) was started 4 weeks after induction therapy. After 6 months, the patient is doing fine.

CONCLUSION

Single dose LAmB along with the backbone of fluconazole and flucytosine appears promising in disseminated cryptococcal infection in HIV-infected individuals.

Adrenal Hemorrhage: A Comprehensive Analysis of a Heterogeneous Entity-Etiology, Presentation, Management, and Outcomes

OBJECTIVE

To investigate the etiology, presentation, management, and outcomes of patients with adrenal hemorrhage (AH).

PATIENTS AND METHODS

Longitudinal study of consecutive adult patients with radiologically confirmed AH (January 1, 2017, through December 31, 2021).

RESULTS

Of the 363 patients with AH (median age, 62 years [interquartile range (IQR, 52-70 years]; 128 women [35%]), 338 (93%) had unilateral AH and 25 (7%) had bilateral AH. It was discovered incidentally in 152 patients (42%) and during the evaluation of trauma in 103 (28%), abdominal/back pain in 90 (25%), critical illness in 13 (4%), and symptoms of adrenal insufficiency in 5 (1%). Etiologies included postoperative complications in 150 patients (41%), trauma in 107 (30%), coagulopathy in 22 (6%), anticoagulant/antiplatelet therapy in 39 (11%), adrenal neoplasm in 22 (6%), and sepsis in 11, (3%). Overall, 165 patients (46%) were hospitalized, and no deaths occurred due to AH. Median (IQR) baseline AH size was 34 mm (24-40 mm) on the right and 29 mm (22-37 mm) on the left. Among 246 patients with follow-up imaging, AH resolution was complete in 155 (63%) and incomplete in 74 (30%) at a median of 15 months (IQR, 6-31 months). Patients with bilateral AH were more likely to have underlying coagulopathy (44% vs 3%) and to develop primary adrenal insufficiency (72% vs 0%) than those with unilateral AH (P<.001).

CONCLUSION

Often, AH presents as an incidental unilateral lesion with normal adrenal function, commonly attributed to postoperative complications or trauma. In contrast, bilateral AH is rare and typically linked to underlying coagulopathy, with primary adrenal insufficiency developing in most patients.

Clinical presentation and outcomes in patients with antiphospholipid syndrome-associated adrenal hemorrhage. A multicenter cohort study and systematic literature review

BACKGROUND

Adrenal hemorrhage (AH) can occur in patients with antiphospholipid Syndrome (APS). We aimed to characterize the clinical manifestations, treatments, and outcomes of patients presenting with APS-associated AH (APS-AH) through a retrospective cohort and a systematic literature review (SLR).

METHODS

We performed a mixed-source approach combining a multicenter cohort with an SLR of patients with incident APS-AH. We included patients from Mayo Clinic and published cases with persistent positivity for antiphospholipid antibodies and presenting with AH, demonstrated by imaging or biopsy. We extracted demographics, clinical characteristics, laboratory findings, treatment strategies, and outcomes (primary adrenal insufficiency and mortality). We used Kaplan-Meier and Cox models for survival analysis.

RESULTS

We included 256 patients in total, 61 (24%) from Mayo Clinic and 195 (76%) from the SLR. The mean age was 46.8 (SD 15.2) years, and 45% were female. 69% of patients had bilateral adrenal involvement and 64% presented adrenal insufficiency. The most common symptoms at presentation were abdominal pain in 79%, and nausea and vomiting 46%. Hyponatremia (77%) was the most common electrolyte abnormality. Factors associated with primary adrenal insufficiency were bilateral adrenal involvement at initial imaging (OR 3.73, CI; 95%, 1.47-9.46) and anticardiolipin IgG positivity (OR 3.80, CI; 95%, 1.30-11.09). The survival rate at five years was 82%. History of stroke was associated with 3.6-fold increase in mortality (HR 3.62, 95% CI; 1.33-9.85).

CONCLUSION

AH is a severe manifestation of APS with increased mortality. Most patients developed permanent primary adrenal insufficiency, particularly those positive for anticardiolipin IgG and bilateral adrenal involvement.

Kidney function in patients with adrenal adenomas: A single-center retrospective cohort study

OBJECTIVE

Patients with nonfunctioning adrenal adenomas (NFA) and mild autonomous cortisol secretion (MACS) demonstrate an increased risk of chronic kidney disease (CKD), however factors associated with CKD are unknown. We aimed to identify the factors associated with CKD and assess the impact of adrenalectomy on kidney function in patients with NFA or MACS.

DESIGN

Single-center cohort study of patients with NFA and MACS, 1999-2020.

METHODS

MACS was diagnosed based on post-dexamethasone cortisol (DST) ≥ 1.8 mcg/dL. Age, sex, dysglycemia, hypertension, therapy with statin, angiotensin converting enzyme inhibitor, or angiotensin II receptor blocker were included in the multivariable analysis. Outcomes included estimated glomerular filtration rate (eGFR) at the time of diagnosis with MACS or NFA and post-adrenalectomy delta eGFR.

RESULTS

Of 972 patients, 429 (44%) had MACS and 543 (56%) had NFA. At the time of diagnosis, patients with MACS had lower eGFR (median 79.6 vs 83.8 ml/min/1.73m2, p < 0.001) than patients with NFA. In a multivariable analysis, factors associated with lower eGFR were older age, hypertension, and higher DST. In 204 patients (MACS: 155, 76% and NFA: 49, 24%) treated with adrenalectomy, post adrenalectomy eGFR improved in both groups starting at 18 months up to 3.5 years of follow up. Factors associated with increased eGFR were younger age, lower pre-adrenalectomy eGFR and longer follow-up period.

CONCLUSION

DST cortisol is an independent risk factor for lower eGFR in patients with adrenal adenomas. Both patients with MACS and NFA demonstrate an increase in eGFR post-adrenalectomy, especially younger patients with lower eGFR pre-adrenalectomy.

High prevalence of frailty in patients with adrenal adenomas and adrenocortical hormone excess: a cross-sectional multi-centre study with prospective enrolment

OBJECTIVE

Frailty, characterized by multi-system decline, increases vulnerability to adverse health outcomes and can be measured using Frailty Index (FI). We aimed to assess the prevalence of frailty in patients with adrenal disorders (based on hormonal sub-type) and examine association between FI and performance-based measures of physical function.

DESIGN

Multi-centre, cross-sectional study (March 2019-August 2022).

METHODS

Adult patients with adrenal disorders (non-functioning adrenal adenomas [NFA], mild autonomous cortisol secretion [MACS], Cushing syndrome [CS], primary aldosteronism [PA]) and referent subjects without adrenal disorders completed a questionnaire encompassing 47 health variables (comorbidities, symptoms, daily living activities). FI was calculated as the average score of all variables and frailty defined as FI ≥ 0.25. Physical function was assessed with hand grip, timed up-and-go test, chair rising test, 6-minute walk test, and gait speed.

RESULTS

Compared to referent subjects (n = 89), patients with adrenal disorders (n = 520) showed increased age, sex, and body mass index-adjusted prevalence of frailty (CS [odds ratio-OR 19.2, 95% confidence interval-CI 6.7-70], MACS [OR 12.5, 95% CI 4.8-42.9], PA [OR 8.4, 95% CI 2.9-30.4], NFA [OR 4.5, 95% CI 1.7-15.9]). Prevalence of frailty was similar to referent subjects when post-dexamethasone cortisol was <28 nmol/L and was higher when post-dexamethasone cortisol was 28-50 nmol/L (OR 4.6, 95% CI 1.7-16.5). FI correlated with all measures of physical function (P < .001).

CONCLUSIONS

Whilst frailty prevalence was highest in patients with adrenocortical hormone excess, even patients with NFA demonstrated an increased prevalence compared to the referent population. Future longitudinal studies are needed to evaluate the impact of various management strategies on frailty.

Primary Aldosteronism: A Pragmatic Approach to Diagnosis and Management

Primary aldosteronism is a prevalent but underdiagnosed cause of hypertension, contributing to increased cardiovascular and cerebrovascular events and end-organ damage independent of blood pressure. Prompt diagnosis and treatment with targeted surgical or medical therapy reduce the risk of complications and improve prognosis. This review outlines a practical approach to diagnosis and management of primary aldosteronism for global practitioners.

Etiology, morphology, and outcomes of adrenal calcifications in 540 adult patients-a retrospective single-center study

Sparse data are available on the etiology, morphology, clinical presentation, and outcomes of adrenal calcification. In this single-center retrospective study of 540 consecutive patients (median age 65 years, 45% women) with adrenal calcification on computed tomography (December 2017 to January 2021), most were discovered incidentally (472, 87%). The commonest etiology was idiopathic (389, 72%), followed by the adrenal tumor (113, 21%), hemorrhage (29, 5%), and infiltrative disease (7, 1%). Calcified adrenal tumors were predominantly benign (92, 81%) and primarily adenomas (63, 69%), whereas the most common calcified adrenal malignancy (16, 18%) was metastasis (12, 67%). Calcification (unilateral 94%, bilateral 6%) morphology varied from punctate (313, 58%) to coarse (165, 30%), linear/curvilinear (46, 9%), and rim-like (16, 3%). In summary, adrenal calcifications are usually incidentally discovered unilateral, punctate, or coarse lesions of unclear etiology. Most calcified adrenal tumors are benign and <20% malignant or pheochromocytomas.

Adrenal and juxta-adrenal schwannomas: A single-centre study

OBJECTIVE

Adrenal schwannomas and juxta-adrenal schwannomas are rare tumours. We aimed to summarise their clinical, biochemical and imaging characteristics.

DESIGN

Single-centre retrospective study of eligible patients between 1995 and 2022.

PATIENTS AND MEASUREMENTS

Patients with a histopathologic diagnosis of adrenal or juxta-adrenal schwannoma.

RESULTS

Twenty-four patients were diagnosed with either primary adrenal schwannoma (8, 33%) or juxta-adrenal schwannoma (16, 67%). Most tumours (21, 88%) were discovered incidentally on imaging. All tumours were unilateral, with 15 (62%) on the left and 9 (38%) on the right. At diagnosis, the median tumour size was 4 cm (range, 2-13 cm). Adrenal schwannomas were smaller when compared to juxta-adrenal schwannomas (median of 3.1 cm [range, 2-9 cm] vs. 4.6 cm [range, 2.3-13.3 cm], p = .037). On imaging, the tumours were round or oval in shape in 16 (70%), lobulated in 7 (30%), solid in 15 (68%), solid-cystic in 7 (32%), heterogeneous in 14 (61%) and homogeneous in 9 (39%). The median unenhanced computed tomography attenuation was 30 Hounsfield units (HU) (range, 12-38 HU). Of the 20 patients who underwent complete hormonal testing, all had nonfunctioning tumours. There was no recurrence or new tumour development in our cohort.

CONCLUSIONS

Adrenal and juxta-adrenal schwannomas are nonfunctioning benign tumours that present with indeterminate radiographic features, including large tumour size and increased unenhanced CT attenuation. We did not find an imaging phenotype that was diagnostic of schwannoma. The diagnosis of this rare tumour is based on biopsy or resection.

Rare benign adrenal lesions

While most benign lesions of the adrenal glands represent either an adrenocortical adenoma or a myelolipoma, the advent and frequent use of high-resolution radiological investigations have led to relatively increased incidental discovery of rare adrenal lesions, specifically benign adrenal cysts, adrenal ganglioneuromas, adrenal schwannomas, adrenal hemorrhage, and adrenal calcifications. Radiological characteristics of the different rare benign adrenal lesions could vary from distinct to indeterminate. Though typically nonfunctional, these rare lesions require evaluation for adrenal hormone excess, as they may phenotypically appear similar to pheochromocytoma or adrenocortical carcinoma and could sometimes be associated with or conceal an underlying functional adrenal tumor. In this review, we discuss the various rare benign adrenal lesions, emphasizing a practical perspective.

Do Gradient Inversion Attacks Make Federated Learning Unsafe?

Federated learning (FL) allows the collaborative training of AI models without needing to share raw data. This capability makes it especially interesting for healthcare applications where patient and data privacy is of utmost concern. However, recent works on the inversion of deep neural networks from model gradients raised concerns about the security of FL in preventing the leakage of training data. In this work, we show that these attacks presented in the literature are impractical in FL use-cases where the clients' training involves updating the Batch Normalization (BN) statistics and provide a new baseline attack that works for such scenarios. Furthermore, we present new ways to measure and visualize potential data leakage in FL. Our work is a step towards establishing reproducible methods of measuring data leakage in FL and could help determine the optimal tradeoffs between privacy-preserving techniques, such as differential privacy, and model accuracy based on quantifiable metrics.

Clinical, imaging and biochemical presentation of cystic pheochromocytomas

OBJECTIVE

Cystic adrenal mass is a rare imaging presentation of pheochromocytoma. We aimed to describe the clinical, biochemical and imaging characteristics of patients with cystic pheochromocytoma.

DESIGN

Single-centre, retrospective study, 2000-2020.

PATIENTS

Consecutive patients with cystic pheochromocytoma were identified from our institutional pathology and adrenal tumour database.

RESULTS

Of the 638 patients with pheochromocytomas, 21 (3.2%) had cystic pheochromocytomas (median age: 57 years, 57% women). Most pheochromocytomas were discovered incidentally (57%) or due to symptoms of catecholamine excess (24%). The median tumour size was 6.4 cm. On imaging, cystic pheochromocytomas were round or oval (90%), heterogeneous lesions (86%) with a thick solid rim (median rim thickness 13.9 mm, unenhanced computed tomography (CT) attenuation 40 Hounsfield units (HU), venous-phase CT attenuation 83 HU), and a median cystic component of 40% (unenhanced CT attenuation 17.6 HU, venous-phase CT attenuation 20.4 HU), and rarely with calcifications (15%). All 20 patients with biochemical testing had functioning tumours (adrenergic in 80%, noradrenergic in 20%). Total urinary metanephrine excretion correlated with the volume of the solid component (R2  = .75, p < .0001) but not the cystic component (R2  = .04, p = .4386). All patients underwent adrenalectomy (48% laparoscopic, 52% open), and the median duration of hospital stay was 4 days.

CONCLUSIONS

Cystic pheochromocytomas are rare, large tumours with a phenotypic appearance that can masquerade as other adrenal cystic lesions. The degree of biochemical abnormality in cystic pheochromocytomas is associated with the volume of the solid component. All patients with adrenal cysts that have a solid component or an unenhanced attenuation >10 HU should undergo biochemical testing for pheochromocytoma.

RF09 | PSUN05 Increased Frailty in Patients With Functioning Adrenal Adenomas

Introduction

Frailty is characterized by multisystem function decline related to aging and can be measured using frailty Index (FI). FI is constructed based on the proportion of deficits present in an individual out of the total number of health variables considered. FI in various populations has been shown to predict adverse health outcomes. We aimed to determine the impact of hormone excess on frailty in a prospective cohort of patients with adrenal adenomas.

Methods

We conducted a multicenter prospective observational study of adult patients with adrenal adenomas and referent subjects without adrenal disorders (Jan 2019-Dec 2021). Adrenal adenomas comprised non-functioning adrenal adenomas (NFA), adenomas with mild autonomous cortisol secretion (MACS), defined as dexamethasone suppression test (DST)&gt;1.8 mcg/dL, Cushing syndrome (CS), and primary aldosteronism (PA). FI was calculated as a sum of 47 variables (20 comorbidities, 13 symptoms, 14 activities of daily living) divided by 47.1 Frailty was defined as FI&gt;0.25. In a subset of patients (n=176), functional measurements (handgrip strength, timed up and go test, gait speed) were performed and compared to FI.

Results

Of 233 patients (72.1% women), 71 were diagnosed with NFA (median age 64.5 years), 108 with MACS (median age 60.7 years), 11 with CS (median age 58.0 years), 46 with PA (median age 52.4 years), and 33 were referent subjects (median age 51.3 years). When compared to referent subjects, age- and sex-adjusted frailty prevalence was highest in CS (OR 29, 95%CI 4.3-202), followed by MACS (OR 16, 95%CI 3.5-73.7), and PA (OR 11.7, 95%CI 2.4-56), but not in patients with NFA (OR 5.1, 95%CI 0.99-25.8). Compared to patients with NFA, age- and sex-adjusted frailty prevalence was higher in CS (OR 5.8, 95%CI 1.4-24.4) and in MACS (OR 3.2, 95%CI 1.5-6.7), but not in PA (OR 2.3, 95%CI 0.9-6.1) group. Subgroup-analysis based on DST demonstrated a similar increase in age- and sex-adjusted frailty prevalence in patients with DST&gt;5 mcg/dL (OR 3.1, 95%CI 1.2-8.2) and DST 1.9-5 mcg/dL (OR 3.3, 95%CI 1.5-7.4) when compared to patients with DST&lt;1.8 mcg/dL. Higher FI was associated with lower handgrip measurement (P&lt;0.0001), longer time during timed up and go test (P &lt;0.0001), and decreased gait speed (P&lt;0.0001).

Conclusions

Patients with functional adrenal adenomas are more likely to be frail. In patients with MACS, the prevalence of frailty was not associated with the degree of DST abnormality. FI correlated with currently validated but more cumbersome functional measurements and is a valuable tool that could be easily used in clinical practice and help individualize management decisions in patients with adrenal adenomas.

1 Singh S et al. Frailty in Patients With Mild Autonomous Cortisol Secretion is Higher Than in Patients with Nonfunctioning Adrenal Tumors. JCEM 2020

Presentation: Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

LBSAT141 Bone Health In Patients With Adrenal Disorders

Introduction

Limited data suggest low bone density in patients with adrenal adenomas. However, most studies are retrospective, single-center, and none were conducted in the United States. We aimed to determine the impact of cortisol and aldosterone excess on bone density.

Methods

We conducted a preliminary analysis of data from our multicenter, prospective observational study of adult patients with adrenocortical hormone excess and referent subjects without adrenal disorders (January 2019 - March 2022). Patients were diagnosed with non-functioning adenomas (NFA), adenomas with mild autonomous cortisol secretion, MACS (defined as cortisol following an overnight 1-mg dexamethasone suppression test (DST)&gt;1.8 mcg/dL), adrenal or pituitary Cushing syndrome (CS), primary aldosteronism (PA), and concomitant PA-MACS. Referent subjects were patients undergoing cross-sectional imaging for reasons other than adrenal disease. All participants were interviewed about their bone health, and had bone density measurements at the spine, hips, and/or radius. Bone disease was defined as osteopenia (T-score -1.1 to -2.4), or osteoporosis (T-score &lt; -2.5).

Results

A total of 417 participants included 156 referent subjects (88, 56% women, median age 65, range 2-95 years) and 261 patients (190, 73% women, median age 59, range 21-88 years). Patients were diagnosed with NFA (51, 19%), PA (46, 17%), MACS (122, 47%), PA-MACS (12, 5%), and CS (30,12%). When compared to referent subjects, sex- and age-adjusted analysis demonstrated an increased prevalence of bone disease only in patients with CS (OR 4.8, 95%CI 1.7-13), but not in other adrenal disorders. After excluding patients with CS, those with post-DST cortisol &gt;5 mcg/dL demonstrated a higher prevalence of bone disease when compared to patients with post-DST cortisol between 1.8-5 mcg/dL (OR 2.8, 95%CI 1.2-6.5) and those with post-DST cortisol &lt;1.8 mcg/dL (OR 2.7, 95% CI 1.1-6.7). Patients with MACS and post-DST cortisol between 1.8-5 mcg/dL did not demonstrate increased sex and age-adjusted prevalence of bone disease compared to those with post-DST &lt;1.8 mcg/dL or referent subjects. However, using post-DST cortisol as a continuous variable, we found that after adjusting for sex and age, the risk of bone disease in patients increased by 13% (OR 1.13, 95%CI 1.6-1.2) for every 1 mcg/dL increase in post-DST cortisol.

Conclusions

The prevalence of osteopenia and osteoporosis increases proportional to the increase in post-DST cortisol concentrations. Patients with CS, and those with MACS and post-DST cortisol &gt; 5mcg/dL have the highest prevalence of bone disease.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

OR12-4 Metabolic Profiling in Adrenal Tumors Demonstrates Enhanced Chronic Inflammation, Branched Chain Amino Acids and Ketone Bodies, Biomarkers that Predict High Cardiometabolic Risk

Background

Patients with adrenal hormone excess demonstrate an increased cardiovascular risk and mortality. We aimed to determine the impact of adrenal hormone excess on the metabolic profile that included plasma lipoproteins, total branched-chain amino acids (BCAA), ketone bodies, and GlycA (a proinflammatory glycoprotein biomarker). Method: We conducted a single-center cross-sectional study of consecutive patients with adrenal adenomas, Cushing syndrome (CS), and pheochromocytoma/paragangliomas (PPGL) between January 2015 and May 2021. Adrenal adenomas comprised nonfunctioning adenomas (NFA), adenomas with mild autonomous cortisol secretion (MACS), and primary aldosteronism (PA). Malignant and other benign tumors were excluded. Collected fasting plasma samples were measured using nuclear magnetic resonance spectroscopy for lipoproteins, BCCA, ketone bodies and GlycA. The results were compared to referent subjects from PREVEND (Prevention of Renal and Vascular End-stage Disease) study. Lipoprotein Insulin Resistance Index (LP-IR) which predicts incident diabetes was calculated based on 6 lipoprotein parameters.

Results

NFA (n=166, median age 60.1years, 63.3% women), MACS (n=158 (median age 61.8 years, 62. 0% women), CS (n=101, median age 43.8 years, 85.1% women), PA (n=71 (median age 55.8 years, 31. 0% women), PPGL (n=43, median age 55.5 years, 46.5% women) was diagnosed in 539 patients. Referent subjects (n=6540) were younger with a median age of 48.4, 50.2% women. When compared to referent subjects, and after age and sex-adjustment, GlycA was highest in patients with CS (OR 3.3, 95% CI 2.8-3.8), followed by PPGL (OR 2.3, 95%CI 1.8-2.9), MACS (OR 2, 95%CI 1.7-2.3), NFA (OR 1.9, 95%CI 1.7-2.2), and PA (OR 1.5, 95%CI 1.2-1.8). When compared to referent subjects, and after sex- and age adjustment, all patient groups demonstrated increase in BCAA: CS (OR 2.7 (95%CI 2.3-3.2), PPGL (OR 2.3, 95% CI 1.8-2.9), NFA (OR 2.4, 95% CI 2.1-2.7), PA (OR 2. 0, 95%CI 1.7-2.5), MACS (OR 2.2, 95% CI 1.7-2.6). Total ketone bodies were increased in patients with cortisol excess (OR of 1.4, 95%CI 1.2-1.5 in CS, and OR of 1.2, 95%CI 1-1.3 in MACS) and NFA (OR 1.2, 95%CI 1.1-1.3), but not in PA or PPGL. All patient groups except PPGL were more likely to have a higher LP-IR score. When compared to referent subjects, the highest sex- and age-adjusted LP-IR increase was in patients with CS (OR 1.9 (95%CI 1.5-2.2), followed by MACS (OR 1.4, 95% CI 1.2-1.7), PA (OR 1.4, 95%CI 1.1-1.8), and NFA (OR 1.4, 95% CI 1.2-1.7).

Conclusion

Patient with adrenal adenomas and PPGL demonstrate an increase in GlycA, BCAA, and ketone bodies - biomarkers associated with adverse cardiometabolic disorders and mortality. All patients except those with PPGL also demonstrated a higher LP-IR index that was reported to predict incident diabetes. Patients with NFA demonstrated an adverse metabolic profile similar to patients with MACS.

Presentation: Sunday, June 12, 2022 11:45 a.m. - 12:00 p.m.

LBSAT56 Adrenal And Juxta-adrenal Schwannomas: A Single Center Study

Objectives

Adrenal schwannomas and juxta-adrenal schwannomas are rare tumors with limited data on clinical and radiologic features. We aimed to summarize the clinical, biochemical, and imaging characteristics of adrenal and juxta-adrenal schwannomas.

Methods

We performed a single-center retrospective study of patients with a histopathologic diagnosis of adrenal or juxta-adrenal schwannoma between 1995-2022.

Results

A total of 24 patients (18, 75% women) were diagnosed with either primary adrenal schwannoma (8, 33%) or a juxta-adrenal schwannoma (16, 67%) at a median age of 57 years (range, 27 - 77 years). Most tumors (21, 88%) were discovered incidentally on imaging, while 2 were diagnosed because of symptoms of mass effect, and 1 diagnosed incidentally on pathology during nephrectomy performed for renal cell carcinoma. None of the patients had a known genetic syndrome. The median time from identification of schwannoma on imaging to hormonal evaluation was 62 days (range, 0–2076 days). All tumors were unilateral, with 15 (62%) on the left and 9 (38%) on the right. At diagnosis, the median tumor size was 4 cm (range, 2 - 13 cm). Adrenal schwannomas were smaller when compared to juxta-adrenal schwannomas (median of 3.1 cm [range, 2 - 9 cm] vs 4.6 cm [range, 2.3 - 13.3 cm]) (P=0. 037). On imaging, the tumors were round or oval in shape in 16 (70%), lobulated in 7 (30%), solid in 15 (68%), solid-cystic in 7 (32%), heterogeneous in 14 (61%), and homogeneous in 9 (39%). Scattered or peripheral calcifications were seen in 2 cases. In 9 patients with available contrast-enhanced CT, all of the schwannomas demonstrated enhancement. The median unenhanced CT attenuation was 30 Hounsfield units (HU) (range, 12 - 38 HU). In 6 patients with available follow-up imaging of at least 6 months, median growth per year was 0.27 cm (range, 0 - 0.8 cm). Of the 20 patients who underwent complete hormonal testing, all had non-functioning tumors. Biopsy was performed in 5 (20%) patients and all were diagnostic of schwannoma. Adrenalectomy was performed in in 23 (96%) patients (laparoscopic in 16 [70%] and open in 7 [30%]). Open adrenalectomy was more common in patients with larger tumors (median size 7.5 cm; range, 2–13.3 cm) when compared to patients treated laparoscopically (median size 4 cm; range, 2.3–5.4 cm) (P=0. 041). Postoperatively, patients were followed clinically for a median of 1.7 years (range, 0-19 years) or radiographically (n=11) for a median of 2 years (range, 0. 01-11 years), without recurrence or new tumor development.

Conclusions

Adrenal and juxta-adrenal schwannomas are nonfunctioning benign tumors that present with indeterminate radiographic features, including large tumor size and increased unenhanced CT attenuation. We did not find an imaging phenotype that was diagnostic of schwannoma. The diagnosis of this rare tumor is based on biopsy or resection.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

RF33 | PSUN01 Clinical Course of Benign Adrenal Cysts: A Single-Center Experience of 90 Patients

Introduction

Benign adrenal cysts (BACs) comprise 1% of adrenal incidentalomas. Scarce data are available to guide hormonal evaluation and management. We aimed to describe the clinical presentation, imaging characteristics and outcomes of patients with BACs.

Methods

This was a single center retrospective study of patients with histologically or radiologically confirmed BACs evaluated between 1995-2021. Other cystic adrenal lesions (such as cystic pheochromocytoma and adrenocortical cancer) were excluded. Medical records were reviewed for clinical, biochemical, radiological, and surgical information. Subgroup analyses based on surgical versus nonsurgical management was performed.

Results

BACs were diagnosed in 92 patients (53, 57% women) at a median age of 45 years. Mode of discovery was incidental on imaging in 81 (88%), symptoms of mass effect in 9 (9.8%), and other in 2 (2.2%). Majority (89, 97%) of patients had unilateral cysts (45 right, 44 left) with a median size of 48 mm (range 4-200) at diagnosis. On imaging, most cysts were round/oval (85.4%), homogenous (83.2%) lesions with calcifications (64.0%) and no vascular enhancement (97.7%). During a median follow-up of 65 months (range 7-288), adrenal cysts demonstrated minimal enlargement (median size change 6 mm, median growth rate 2 mm/year).Age of diagnosis, sex, site and initial size of BAC were not associated with an increase in size during follow up. On hormonal evaluation, 10% (5/50 tested) had an abnormal overnight dexamethasone suppression test, and 9.5% (4/42 tested) had an abnormal case detection testing for primary aldosteronism. Adrenalectomy was performed in 46 (51%) patients. Patients treated with adrenalectomy (46, 50%) were younger (36.9 vs 50.8 years, P=0.0009) and had more rapidly enlarging cysts (median growth rate 5.5 vs 0.4 mm/year, P=0.0002).

Conclusions

BACs are usually incidentally discovered and nonfunctional lesions with excellent prognosis, irrespective of management. On imaging, benign adrenal cysts appear as large, homogenous lesions without vascular enhancement that demonstrate slow growth. Adrenalectomy should be reserved for the minority of patients with abnormal hormonal evaluation or imaging characteristics (heterogenous, vascular enhancement) concerning for an alternate etiology, or those who develop symptoms of mass effect.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:42 p.m. - 12:47 p.m.

PMON151 Long-Term Outcomes in Patients With Adult-Onset Craniopharyngioma

Introduction

Craniopharyngiomas are nonmalignant sellar/parasellar epithelial tumors exhibiting a bimodal age distribution. While the outcomes following the treatment of patients with childhood-onset craniopharyngiomas are well characterized, similar information in adult-onset craniopharyngiomas (AOC) is limited. We aimed to describe the long-term outcomes related to weight changes, obesity prevalence, metabolic comorbidities, and all-cause mortality in patients with AOC following treatment.

Methods

We identified all adults with a newly diagnosed craniopharyngioma who had initial neurosurgical treatment (1993 -2017) and &gt; 6 months of follow-up at our institution. Medical records were reviewed for demographics, anthropometric measurements, biochemical, radiological, pathological investigations, treatment course, and outcomes. Based on body mass index (BMI), patients were categorized as obese (BMI &gt;30 Kg/m2), overweight (BMI 25-29.9 Kg/m2), and normal weight (BMI &lt; 25 Kg/m2).

Results

For the 91 patients with AOC, the mean age at diagnosis was 48.2±18 years, and 44% were women. Over a mean follow-up duration of 100.3±69.5 months, weight was significantly higher at last follow-up than before surgery (mean difference 9.4 ±14.8 kg, P= &lt;0.001), with 65% of patients experiencing &gt;5% weight gain. Postoperative weight gain of &gt;5% was not associated with preoperative BMI; however, those with lower preoperative BMI experienced a higher mean percentage change in weight [normal weight (20.7 +18%) vs. overweight (13.3+18.0%) vs. obese (6.4+15%), P=0.012]. The prevalence of obesity increased significantly by the last follow-up than before the initial treatment (62 vs. 40.5%, P=0.0042). Weight gain of &gt;5% and obesity by the last follow-up were not associated with gender, tumor size, histological subtype, the extent of resection, radiotherapy, postoperative grade of hypothalamic injury, type or number of pituitary hormone deficiencies, including diabetes insipidus.

On follow-up, the proportion of patients who developed hypertension (28 vs. 40% P=0.09) or dyslipidemia (30 vs. 43%, P= 0.06) increased, but this difference was not statistically significant. Whereas the proportion with impaired glucose metabolism (impaired glucose tolerance, impaired fasting glucose, or diabetes mellitus) was significantly increased on follow-up (17.4% vs. 34%, P= 0.017). In a small subset of patients with abdominal imaging, 52% had radiographic evidence of fatty liver disease. At last follow-up, mortality was 12%, with the average age of death 71.9±19.7 years. There was no difference in survival based on BMI &gt;30 kg/m2, ≥3 anterior pituitary hormone deficiencies, diabetes insipidus, the extent of resection, or radiotherapy use.

Conclusion

Patients treated for AOC experience significant long-term consequences of weight gain, obesity, impaired glucose metabolism, and earlier mortality. The mean percentage increase in weight is inversely proportional to the preoperative BMI. The average age of death (71.9 years) for patients with AOC is lower than the average life expectancy in the US (77.7 years, CDC 2020).

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Long-term outcomes in patients with adult-onset craniopharyngioma

PURPOSE

Craniopharyngiomas are nonmalignant sellar and parasellar tumors exhibiting a bimodal age distribution. While the outcomes following treatment in patients with childhood-onset craniopharyngiomas are well characterized, similar information in adult-onset craniopharyngiomas is limited. We aimed to describe the long-term outcomes (weight and metabolic parameters, mortality) in patients with adult-onset craniopharyngioma following treatment.

METHODS

Patients with adult-onset craniopharyngioma with initial treatment (1993-2017) and >6 months of follow-up at our institution were retrospectively identified. Body mass index (BMI) categories included obese (BMI ≥ 30 kg/m2), overweight (BMI 25-29.9 kg/m2), and normal weight (BMI < 25 kg/m2).

RESULTS

For the 91 patients with adult-onset craniopharyngioma (44% women, mean diagnosis age 48.2 ± 18 years) over a mean follow-up of 100.3 ± 69.5 months, weight at last follow-up was significantly higher than before surgery (mean difference 9.5 ± 14.8 kg, P < 0.001) with a higher percentage increase in weight seen in those with lower preoperative BMI (normal weight (20.7 ± 18%) vs. overweight (13.3 ± 18.0%) vs. obese (6.4 ± 15%), P = 0.012). At last follow-up, the prevalence of obesity (62 vs. 40.5%, P = 0.0042) and impaired glucose metabolism (17.4% vs. 34%, P = 0.017) increased significantly. All-cause mortality was 12%, with the average age of death 71.9 ± 19.7 years (average U.S. life expectancy 77.7 years, CDC 2020).

CONCLUSION

Patients with adult-onset craniopharyngioma following treatment may experience weight gain, increased prevalence of obesity, impaired glucose metabolism, and early mortality. Lower preoperative BMI is associated with a greater percentage increase in postoperative weight.

Clinical course and imaging characteristics of benign adrenal cysts: a single-center study of 92 patients

OBJECTIVE

Benign adrenal cysts are rare lesions of the adrenal glands. Limited data are available to guide management. We aimed to describe the presentation and outcomes of patients with benign adrenal cysts.

DESIGN

Retrospective longitudinal cohort study.

METHODS

Consecutive patients with histologically or radiologically confirmed adrenal cysts between 1995 and 2021 were identified. Pheochromocytomas and malignancy were excluded.

RESULTS

Benign adrenal cysts were diagnosed in 92 patients (53, 57% women) at a median age of 45 years. Mode of discovery was incidental on imaging in 81 (88%), symptoms of mass effect in 9 (9.8%), and others in 2 (2.2%). Majority (89, 97%) of patients had unilateral cysts (45 right, 44 left) with a median size of 48 mm (range 4-200) at diagnosis. On imaging, most cysts were round/oval (85.4%), homogenous (83.2%) lesions with calcifications (64.0%) and no vascular enhancement (97.7%). During a median follow-up of 65 months (range 7-288), adrenal cysts demonstrated minimal enlargement (median size change 6 mm, median growth rate 2 mm/year). On hormonal evaluation, 10% (5/50 tested) had an abnormal overnight dexamethasone suppression test, and 9.5% (4/42 tested) had an abnormal case detection testing for primary aldosteronism. Patients treated with adrenalectomy (46, 50%) were younger (36.9 years vs 50.8 years, P = 0.0009) and had more rapidly enlarging cysts (median growth rate 5.5 mm/year vs 0.4 mm/year, P = 0.0002).

CONCLUSION

Benign adrenal cysts are usually incidentally discovered, non-functional, homogenous lesions without vascular enhancement that demonstrate minimal growth. Adrenalectomy should be reserved for patients with heterogeneous lesions, abnormal hormonal evaluation, or those with mass effect symptoms.

Serum Bicarbonate: Reconsidering the Importance of a Neglected Biomarker in Predicting Clinical Outcomes in Sepsis

Background

Despite being an important pathophysiological component, information on the predictive value of serum bicarbonate level in sepsis is limited.

Study design and method

This is a single-centered retrospective study involving 4176 patients admitted to the medical ICU (MICU) with a diagnosis of sepsis. Patients were divided into two groups based on the presence or absence of chronic kidney disease (CKD) on admission: CKD and non-CKD, respectively. Each group was then divided into three sub-groups based on serum bicarbonate level at presentation (in mEq/l)- low (<22), normal (22-28), and high (>28). We compared the clinical outcomes between the sub-groups in each group, with in-hospital mortality as the primary endpoint. Secondary endpoints included vasopressor-free days, ventilator-free days, ICU-free days, and hospital-free days.

Result

In both the CKD and non-CKD groups, low serum bicarbonate was associated with significantly increased in-hospital mortality. There was no difference in the mortality between the sub-groups with normal and high serum bicarbonate. When adjusted for other known predictors of mortality, the association of low serum bicarbonate with increased in-hospital mortality was statistically significant only in the patient group with a Sequential Organ Failure Assessment (SOFA) score of ≥9. Additionally, the SOFA score had a better predictive value for in-hospital mortality, ICU-free days, and ventilator-free days when the serum bicarbonate level was <22.

Interpretation

Serum bicarbonate is a good predictor of clinical outcomes in sepsis and can be used along with other markers of sepsis to predict clinical outcomes.

Low Yield of Thyroid-Function Tests in Adult Hospitalized Patients - A Retrospective Analysis

BACKGROUND

In the US, serum thyroid-stimulating hormone (TSH) and thyroxine measurements are the fourth- and tenth-commonest laboratory tests ordered, respectively. Diagnosis of thyroid disorder requires clinical suspicion supported by laboratory values. However, in the setting of acute illness, both the clinical and laboratory pictures can be confounded.

OBJECTIVE

To study clinical outcomes and derangement patterns of inpatient thyroid-function tests.

DESIGN

This retrospective study was conducted at an academic center on admissions aged ≥18 years and TSH tests performed over a 1-year period. Admissions with active pregnancy and/or prior thyroid-related diagnosis were excluded.

MAIN OUTCOMES

Clinical outcomes were divided based on new diagnosis of thyroid-related disorder, newly prescribed thyroxine replacement, or antithyroid drugs/ endocrinology referrals, or both. In order to analyze the derangement patterns of abnormal TSH, only the results of the first test ordered were considered (as some admissions had multiple TSH tests ordered).

RESULTS

A total of 7,204 admissions aged ≥18 years had TSH tests done. Of these, 1,912 were excluded. Of the 5,292 admissions with no prior thyroid disorder or active pregnancy, 183 (3.46%) were assigned a new diagnosis of thyroid-related disorder, 54 (1.02%) received treatment/referral, and 46 (0.87%) received both a new diagnosis and treatment/referral. Based on the TSH results (reference range 0.42-4.0 mIU/L) of the 5,292 admissions, 4,312 (81.5%) and 980 (18.5%) admissions were flagged normal and abnormal, respectively. Of the 980 admissions with one or more abnormal TSH results, 21 (2.14%) had first ordered TSH <0.05 mIU/L, 855 (87.25%) admissions had first TSH result between 0.05-10 mIU/L, and lastly 104 (10.61%) were >10 mIU/L.

CONCLUSION

There is low value in testing inpatients for thyroid disorders, and testing comes at significant expense to the health-care system.

Alternatives to Transfusion

OBJECTIVES

We discuss two main categories of blood substitutes: perfluorocarbons and hemoglobin-based oxygen carriers.

METHODS

We provide a review of the notable products developed in both categories and include their attributes as well as their setbacks.

RESULTS

We contribute a case report tothe growing literature of the successful use of Sanguinate.

CONCLUSIONS

We find that artificial oxygen carriers are an attractive field of research because of the practical limitations and the multitude of potential complications that surround human blood transfusions.

Procalcitonin: A promising tool or just another overhyped test?

Sepsis is the leading cause of death worldwide. Timely administration of antibiotics is recognized as the cornerstone in the management of sepsis. However, inappropriate use of antibiotics may lead to adverse effects and the selection of drug-resistant pathogens. Microbiological cultures remain the gold standard to diagnose infection despite their low sensitivity and the intrinsic delay to obtain the results. Certain biomarkers have the benefit of rapid turnover, potentially providing an advantage in timely diagnosis leading to accurate treatment. Over the last few decades, there is an ongoing quest for the ideal biomarker in sepsis. Procalcitonin (PCT), when used alone or alongside additional clinical information, has shown to be a promising tool to aid in the diagnosis and management of patients with sepsis. In February 2017, the Food and Drug Administration (FDA) approved the use of PCT to guide antibiotic treatment in lower respiratory tract infections and sepsis. Despite a good negative predictive value for bacterial infection, the utility of PCT-guided antibiotic initiation is conflicting at best. On the other hand, the use of PCT-guided antibiotic discontinuation has shown to reduce the duration of antibiotic use, the associated adverse effects, and to decrease the overall mortality. The current review discusses the history and pathophysiology of procalcitonin, synthesizes its utility in the diagnosis and management of sepsis, highlights its limitations and compares it with other biomarkers in sepsis.

SAT-623 Acute Bradycardia Secondary to Worsening of Hypothyroidism Post-Iodine Contrast

BACKGROUNDPatient with history or risk of developing thyroid disorder can develop worsening of overt hypothyroidism after exposure to iodine containing contrast. We report a case of bradycardia requiring CCU treatment due to worsening of hypothyroidism due to iodine contrast.CASE DETAILSA 68 years old female with history of heart failure, coronary artery disease, hypertension, diabetes mellitus and hypothyroidism presented to ED for chest pain and dyspnea. She was taking L-thyroxine 100mcg with other medications at home. CT angiography was negative and coronary angiogram was unremarkable. Her symptoms were alleviated and she was discharged home next day. Her discharge vitals included heart rate within normal limit. After 3 days she presented to ED for dizziness and weakness. Her vitals included heart rate of 51 and BP of 105/50. EKG showed sinus bradycardia. She was not taking medications that could potentially cause bradycardia, including beta-blockers. She was discharged next day without change in medications. She again presented to the hospital next day due to dizziness, fatigue and bradycardia. Vitals signs showed BP of 91/48 with heart rate of 37. She was admitted to CCU and treated with dopamine drip. Her TSH was 11.90(0.35-5.5 uIU/ml) and free T4 0.69(0.76-1.46ng/dl). She was started on 125mcg of L-thyroxine and was discharged home on this dose. After 2 days of discharge patient again presented to ED for the 4^th time for dizziness and bradycardia. EMS details regarding vitals and EKG were not available but document did include atropine given en route, suggesting likely bradycardia of <40. On arrival to ED, Heart rate was 52 with BP 120/59. TSH done this visit was reported 26.40. Patient confided not taking 125mcg of L-thyroxine but continuing 100mcg, the dose she was on before first admission. Patient was again started on 125mcg of levothyroxine in hospital and observed for 3 days. Patient’s symptoms were resolved, and her heart rate was >60/min on the day of discharge.DISCUSSION Association of iodine contrast with hypothyroidism has been less studied compared to that with hyperthyroidism. Risk factors such as pre-existing sub-clinical hypothyroidism and hashimoto thyroiditis has been identified in some studies. It is postulated that in presence of excess iodine, iodine internalization into the thyrocyte and iodine organification is suppressed, also known as Wolff-Chaikoff effect. In most of the reported cases and studies, transient changes in thyroid function after exposure to iodine contrast rarely resulted change in management. Our case is unique in the sense that patient needed treatment in cardiac critical care including chronotropic agent. As use of iodine contrast in acute care setting has been on rise since last few decades, a hospital clinician needs to be vigilant about this phenomenon.

Back Pain: An Ominous Harbinger of Aortitis

Isolated aortitis is a rare entity and was recently included in the 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides under the single organ vasculitis group. Isolated aortitis represents a challenging situation due to the lack of reliable diagnostic methodology. Here, we describe the case of a 46-year-old woman who presented with severe upper back pain. She tested negative for pulmonary embolism, myocardial infarction, and other usual causes of back pain. The case highlights the clinical presentation of a rare disease with a usual symptom.

A Hematological Menace: Multiple Venous Thrombosis Complicated by Acquired Factor VIII Deficiency

Patient: Male, 21

Final Diagnosis: Acquired Factor VIII Deficiency

Symptoms: Abdominal hematoma • DVT • life threatening bleeding

Medication: —

Clinical Procedure: Life saving medical therapy

Specialty: Hematology