AACE Adrenal

  • Cortical
  • Adernomedullary
Metabolic diseases

Cushing's Disease 

Diagnostic Tests Limitations 
1. Mid Night Salivary Cortisol: Excitement can cause increase in midnight salivary level although not on all the patients. 
3. Cyclic CS may give normal UFC results. Cyclic CS can occur at all age. 
4. LDDST (1 mg Dex ST) Upto 30 % false positive rate. 5 % false negative rate on patient who metabolize dexamethasone slowly.
5. Drugs may interfere with DST: Dexamethasone metabolized through CEP3A4 pathway.  
6. ACTH level may overlap between different cause of Cushing's syndrome 
7. Only 1/2 patient with CD have no tumors on conventional T1 MRI. False negative MRI of brain is possible. Not all pituitary MRI are the same. Field of view and TR/TE ratio matters. 
8. IPSS : 95 % sensitivity and specificity of the tests. False negative IPSS can occur. 4/501 patients with surgically proved cushiness had false-negative IPSS. Likewise, cyclic CS may be missed. 
9. IPSS insufficient suppression of ACTH is a concern. 
10. No single imaging study can identify and localize every ectopic adrenal tumor. Gated (EKG based gating) Imaging may be of help at times. 
11. Surgical technique affects results. If any cells are left behind tumor will recur. 
12. Ensure gastric acidity when using Ketokinazole. 

1. < 10 HU = more lipid content. Adrenal gland use cholesterol for making hormones, and is stored as cholesterol ester, which is lipid. More likely it is adrenal adenoma. > 10 HU, could be anything. 
2. Ald/ PRA > 30 AND Plasa Aldo > 12
3. Sex steroid tumor are never incidental. They will have symptoms. Female: Hirsutitism, Cliteromegaly, amernorrhea, acne, 
Male: Gynecomastic. DHEAS: > 8000 ng / ml (Not DHEA). DHEAS is adrenal. 
4. Pheochormocytoma: Plasma metanephrines and Plasma normetanephrines (for incidental findings you do not want it as it has 99 % sensitivity). For symptomatic patients use. 

Adrenal Crisis in ICU
1. Patient with SIRS in ICU have more cortisol than patient without SIRS
2. Such increased cortisol in ICU patient is due to decreased metabolism. 
3. Tests of adrenal insufficiency in ICU
1. Random Cortisol (10-34 ug/dL is a cutoff) . Others have used the cutoff of 15 ug/dL . Other have used the cutoff of 8 or 18. But they ignore the binding protein in these studies. Hence, free cortisol is really not assessed. 
2. Cosyntropin Stimulation Test