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HbA1c 6&#46;3&#37;&#44; creatinine 0&#46;53&#8239;mg&#47;dL&#59; total cholesterol 288&#8239;mg&#47;dL&#44; LDL 201&#8239;mg&#47;dL&#44; HDL 56&#8239;mg&#47;dL&#44; and triglycerides 153&#8239;mg&#47;dL&#46; An AI functionality study was performed with the following results &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#58; erect aldosterone &#40;ALD&#41;&#58; 7&#46;61&#8239;ng&#47;dL&#59; plasma renin activity &#40;PRA&#41; 0&#46;6&#8239;ng&#47;mL&#47;h&#59; ALD&#47;PRA ratio&#58; 12&#46;7&#59; 24&#8239;h catecholamine and metanephrine in urine test&#58; normal&#59; Nugent Test &#40;NT&#41; &#40;cortisol 8&#58;00&#8239;h after dexamethasone &#91;DXT&#93; 1&#8239;mg at 23&#58;00&#8239;h test&#41;&#58; 16&#46;3&#8239;&#181;g&#47;dL&#46; The 17-hydroxyprogesterone determination was normal &#40;1&#46;3&#8239;&#181;g&#47;dL&#44; N&#8239;&#60;&#8239;1&#46;8&#8239;&#181;g&#47;dL&#41;&#46; The patient&#8217;s dehydroepiandrosterone sulphate &#40;DHEA-S&#41; blood levels ruled out the existence of adrenal carcinoma&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Since the patient was being treated with inhaled beclometasone&#44; the NT was repeated to rule out an interaction with the laboratory technique&#44; and the following result was obtained&#58; 15&#46;3&#8239;&#181;g&#47;dL&#46; A 24&#8239;h cortisol in urine test was performed&#58; 29&#46;2&#8239;&#181;g&#47;24&#8239;h &#40;normal up to 120&#8239;&#181;g&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The patient was diagnosed with type 2 diabetes mellitus in the following months as her baseline blood glucose remained above 126&#8239;g&#47;dL&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The decision was made to admit the patient due to the persistent pathological findings from the NT&#46; The following tests were conducted &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#58; 2&#8239;mg dexamethasone suppression test &#40;Liddle test &#91;LT&#93;&#41;&#44; cortisol rhythm&#46; Persistent hypercortisolism in the LT and an altered cortisol rhythm were notable&#44; and late-night cortisol levels remained elevated&#46; The adrenocorticotropic hormone &#40;ACTH&#41; was suppressed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Adrenal cortical scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol was requested&#46; It revealed an increase in radiotracer uptake in the right adrenal with the study being compatible with right adrenal adenoma&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Differential diagnosis</span><p id="par0045" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Functioning adrenal adenoma&#58; Cushing&#8217;s syndrome &#40;CS&#41;&#44; primary hyperaldosteronism and pheochromocytoma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Adrenal carcinoma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Congenital adrenal hyperplasia&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Radiological findings</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Dr&#46; Marcos-Mond&#243;n</span><p id="par0065" class="elsevierStylePara elsevierViewall">An abdominal computerized tomography &#40;CT&#41; scan with adrenal protocol was performed&#44; comprising an exploration with 3 imaging acquisitions&#58; non-contrast&#44; portal venous phase &#40;70&#8239;s&#41; and delayed phase &#40;15&#8239;min&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The exploration revealed the existence of bilateral adrenal nodules&#44; round in shape with well-defined and smooth borders&#44; homogeneous and hypoattenuated with radiological semiology in line with a benign nature&#46; They measured between 23 and 10&#8239;mm in diameter on the right adrenal gland and 11&#8239;mm in diameter on the left adrenal gland&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The baseline density of the largest nodule was 6 Hounsfield units &#40;UH&#41;&#44; a number highly suggestive of a lipid-rich adenoma or a typical adenoma&#46; It presented intense enhancement following contrast administration&#44; reaching 44&#8239;HU in the portal venous phase&#46; After 15&#8239;min&#44; in the delayed phase&#44; the contrast &#8220;washed out&#8221; and reduced the attenuation to 1&#8239;HU&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the cortical adrenal scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol&#44; images were obtained on the 2nd &#40;early&#41; and 5th day &#40;delayed&#41; after intravenous administration of the radiotracer&#46; The early images showed intense focal hyper-uptake in the posterior projection&#44; which corresponds to the cortex of the right adrenal gland &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In the delayed images&#44; persistent intense focal hyper-uptake was observed in cortex of the right adrenal gland&#44; this being more intense and greater in size compared to the previous images&#46; In addition&#44; a discreet increase in radiotracer uptake was observed in the cortex of the left adrenal &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Summary of findings</span><p id="par0085" class="elsevierStylePara elsevierViewall">The described nodules met all the radiological characteristics that suggest it was benign&#58; &#60;4&#8239;cm&#44; round or oval in shape&#44; homogeneous attenuation&#44; and smooth borders&#46; Likewise&#44; its attenuation in the contrast study was &#8804;10&#8239;HU&#44; a parameter with high specificity &#40;96&#37;&#8211;98&#37;&#41; and high-moderate sensitivity &#40;71&#37;&#8722;73&#37;&#41; for the diagnosis of lipid-rich adenomas&#46; By meetings these requirements&#44; was assumed that it corresponds to a typical adenoma and no further evaluations were required<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In this patient&#8217;s case&#44; a contrast scan with portal venous phase and delayed phase was performed&#44; meaning we were also able to evaluate the loss of attenuation due to the early &#8220;washout&#8221; of the contrast&#46; The largest nodule had an absolute washout of 86&#37; and a relative washout of 98&#37;&#44; elevated values that indicate a hypervascular lesion with rapid &#8220;washout&#8221;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The differential diagnosis of the hypervascular adrenal nodules includes the adrenal&#44; but also other less frequent lesions such as metastatic renal cell carcinoma or hepatocarcinoma<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The nuclear medicine scan revealed an increase in radiotracer uptake in the right adrenal&#44; with the study being compatible with right adrenal adenoma&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Concept of incidentaloma</span><p id="par0105" class="elsevierStylePara elsevierViewall">AIs are lesions that are detected in imaging tests conducted for other reasons&#46; Their prevalence is estimated to be around 2&#37; in the general population and up to 7&#37; in the population over 70 years old<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; Their significance is rooted in the importance of determining the presence of carcinoma and demonstrating hormonal overproduction&#46; The prevalence of malignancy is around 2&#37;&#44; though this has reached 12&#37; in some series<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Between 70&#37;&#8211;80&#37; of AIs correspond to nonfunctioning illness&#46; When these are functioning&#44; excess cortisol production tends to be common&#44; resulting in CS<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; CS is associated with an increased presence of metabolic syndrome and osteoporosis&#44; and is related to a decline in quality of life and increased mortality&#46; For that very reason&#44; early detection is important&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Therefore&#44; the initial study of AIs should be based on two pillars&#58; 1&#41; ruling out the presence of malignancy using imaging techniques&#44; and 2&#41; testing for hyperfunctionality<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Benign or malignant incidentaloma</span><p id="par0120" class="elsevierStylePara elsevierViewall">Non-contrast abdominal CT is the primary option used to test for AIs&#46; A homogeneous&#44; well-defined lesion with a density less than or equal to 10&#8239;HU is indicative of a high likelihood that the lesion is benign&#46; In indeterminate cases&#44; when the density of the adrenal adenoma is between 10&#8722;30&#8239;HU&#44; a contrast CT can be performed&#46; With adenomas&#44; enhancement and rapid washout are typically observed following administration of the intravenous contrast&#46; An absolute washout greater than or equal to 60&#37; and a relative washout greater than or equal to 40&#37; are typical of adenomas<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging &#40;MRI&#41; tends to be the second diagnostic option for those cases in which CT does not provide a clear diagnosis of whether a lesion is benign&#46; It is the first choice for testing children and pregnant women due to the radiation risk of CT&#46; The capability of MRIs to test for AI malignancy is based on the chemical shift imaging technique&#46; Protons in water vibrate in a slightly different manner than protons in lipids when the magnetic field is applied to them&#46; The lipid-rich adenomas lose signal on out-of-phase images compared with in-phase images&#44; while malignant lesions and pheochromocytomas remain unchanged<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In CT&#44; adrenal carcinoma presents as a heterogeneous mass greater than 4&#8239;cm&#46; When contrast is applied&#44; heterogeneous enhancement appears&#44; predominantly on the periphery with central areas without enhancement secondary to the presence of haemorrhage and necrosis&#46; On MRI&#44; it appears isointense relative to the liver parenchyma on T1-weighted images and hyperintense relative to the liver parenchyma on T2<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Positron emission tomography with 18F-fluorodeoxyglucose associated with CT &#40;PET&#47;CT with <span class="elsevierStyleSup">18</span>FDG&#41; has an elevated negative predictive value and may be useful to rule out malignancy when other imaging techniques have not been helpful&#46; Nevertheless&#44; it is not as valuable for routine testing given the presence of false positives with infections and even pheochromocytoma&#46; Its fundamental indication is for further testing in patients with primary extra-adrenal tumours and in indeterminate AIs&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol associated with SPECT&#47;CT may help in characterising the functionality of AIs&#46; The presence of a lesion on CT and scintigraphy is characteristic of a functioning&#44; benign lesion&#46; Lesions not observed on scintigraphy increase the suspicion that they are nonfunctioning lesions<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Functioning or nonfunctioning incidentaloma</span><p id="par0145" class="elsevierStylePara elsevierViewall">Patients with AIs must be evaluated for the presence of pheochromocytoma and CS<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; In the case of bilateral adenomas&#44; screening for congenital adrenal hyperplasia must also be included<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; The determination of 17-hydroxyprogesterone in the follicular phase of women of childbearing age below 2&#8239;ng&#47;dL rules this out<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Primary hyperaldosteronism testing is reserved for hypertensive patients and&#47;or patients with unexplained hypokalaemia&#46; It is important to determine this due to the elevated cardiovascular morbidity and mortality compared to patients with primary HTN and the same blood pressure grade<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; To screen for primary hyperaldosteronism&#44; the ALD&#47;PRA ratio must be measured after 2&#8239;h of orthostatism&#46; Following a diet with at least 5&#8239;g of salt per day and correcting hypokalemia is imperative&#46; In terms of drugs that may cause a reaction to the test&#44; eplerenone&#44; amiloride&#44; and spironolactone must be suspended at least 4&#8211;6 weeks prior&#46; Initially&#44; other drugs can be continued&#46; Generally&#44; an ALD&#47;PRA ratio higher than 20&#8239;ng&#47;dL&#47;ng&#47;mL&#47;h is suspicious and testing will have to continue<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Pheochromocytoma testing is performed on all subjects with AIs given the elevated morbidity and mortality due to oversecretion of catecholamines<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Prior to hormone testing&#44; medications that directly interfere with laboratory techniques &#40;acetaminophen&#44; mesalamine&#44; sulfadiazine&#41; or with the disposition of catecholamines &#40;such as tricyclic or sympathomimetic antidepressants&#41; must be ruled out&#44; as these can increase the levels of catecholamines and metanephrines&#44; leading to false positives<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">CS is caused by chronic exposure to excess corticosteroids&#46; It is associated with a decline in quality of life and increased mortality&#44; which is why early detection is important&#46; The most common cause of CS is iatrogenic due to chronic corticosteroid administration&#46; CS due to endogenous pathology is uncommon&#44; with an estimated incidence of 2&#8211;3 cases&#47;1&#44;000&#44;000 people&#47;year<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46; CS may be caused by excess ACTH of pituitary or ectopic production&#44; or due to adrenal causes&#46; In about 60&#37; of cases&#44; CS is caused by pituitary adenoma and in 20&#37; by adrenal adenoma<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The NT is widely used as the first test for AIs<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Cortisol levels &#60;1&#46;8&#8239;&#181;g&#47;dL allow CS to be ruled out&#46; Levels higher than 5&#8239;&#181;g&#47;dL enable an increase in the specificity of the test and determine autonomous cortisol secretion&#46; Mid-range levels &#40;1&#46;8&#8722;5&#8239;&#181;g&#47;dL&#41; suggest possible autonomous cortisol secretion&#46; Recently&#44; The Adrenal Pathology Group from the Spanish Endocrinology and Nutrition Society contemplated the need to continue with CS testing in those patients with cortisol higher than 3&#8239;&#181;g&#47;dL or higher than 1&#46;8&#8239;&#181;g&#47;dL who present associated cardiometabolic complications &#40;type 2 diabetes&#44; osteoporosis&#44; obesity&#44; HTN&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">To confirm autonomous cortisol production&#44; at least two determinations from one of the following tests are needed&#58; 24&#8239;h cortisol in urine&#59; NT&#59; LT&#59; late-night salivary cortisol&#59; or late-night plasma cortisol<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Tests measuring total plasma cortisol &#40;NT&#44; LT&#44; late-night plasma cortisol&#41; can give false results if the corticosteroid-binding globulin &#40;CBG&#41; is altered&#46; Women who are being treated with oestrogen have higher concentrations of CBG&#44; and at least 50&#37; of them present false positives in cortisol testing&#46; Therefore&#44; they must suspend treatment for at least six weeks<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">On the other hand&#44; in nephrotic syndrome or critical patients&#44; CBG determinations are reduced&#44; with fewer cases of false negatives<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; In the case of DXT suppression tests&#44; we must take into consideration any medications that interfere with DXT metabolism by inducing or inhibiting its metabolising enzyme &#40;CYP3A4&#41;&#46; Drugs such as anti-seizure drugs &#40;phenytoin&#44; phenobarbital&#44; carbamazepine&#44; primidone&#41; and CYP3A4 inducers increase cortisol metabolism&#44; resulting in false negatives&#46; Conversely&#44; other drugs from varying therapeutic groups &#40;ritonavir&#44; fluoxetine&#44; diltiazem&#44; cimetidine&#41; that are CYP3A4 inhibitors can result in false positives<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The 24&#8239;h cortisol in urine test reveals cortisol secretion over the course of one day&#46; It is not conditioned by CBG alterations as it measures the free cortisol filtered by the kidneys&#46; The recommendation is to consider it positive when it is above the normal range according to the laboratory technique used&#46; In the case of kidney failure&#44; cyclic Cushing&#8217;s syndrome&#44; or early illness&#44; cortisol levels may be normal&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Late-night salivary cortisol is based on cortisol determinations between 23&#58;00 and 24&#58;00&#8239;h&#46; Patients with CS have an altered cortisol rhythm and present elevated levels all 24&#8239;h of the day&#46; This test is valid as long as the patient is not under extreme stress &#40;acute disease&#44; critical patient&#41; or does not work rotating shifts&#46; In addition&#44; the test can be performed on an outpatient basis&#46; Healthy subjects tend to have a late-night salivary cortisol level under 145&#8239;ng&#47;dL&#46; Late-night plasma cortisol is another lab test that can be conducted and is based on the same principle as that mentioned above&#46; It is considered positive for CS when it is above 7&#46;5&#8239;&#181;g&#47;dL in awake patients&#46; The main inconvenience of this test is that the patient must be admitted<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;12</span></a>&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Once a diagnosis of CS has been determined&#44; it is important to identify the origin of the hypercortisolism&#46; The ACTH plasma test is the next step&#46; Low levels of ACTH &#40;less than 10&#8239;pg&#47;mL&#41; suggest an ACTH-independent origin&#44; while elevated levels &#40;more than 20&#8239;pg&#47;mL&#41; are typical of ACTH-dependent Cushing&#8217;s Syndrome<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a>&#46; Within ACTH-dependent Cushing&#8217;s Syndrome&#44; it is necessary to determine whether the origin is pituitary or ectopic&#46; If the 8&#8239;mg strong DXT suppression test obtains at least a 50&#37; decrease in the baseline cortisol level&#44; this suggests pituitary origin&#46; Likewise&#44; in the CRH test&#44; it achieves an increase of at least 50&#37; ACTH&#46; Nevertheless&#44; these responses have been observed in some benign carcinoid tumours&#46; Inferior petrosal sinus sampling continues to be the gold standard for diagnosing pituitary Cushing&#8217;s Syndrome&#46; If the origin is adrenal&#44; an abdominal CT is needed to identify the existence of an adrenal adenoma&#46; Elevated DHEA-S levels together with radiological features indicating malignancy on the CT raise suspicion of the existence of adrenal carcinoma<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Dr&#46; Ma&#241;as-Mart&#237;nez and Dr&#46; Morillo-Vanegas</span><p id="par0200" class="elsevierStylePara elsevierViewall">The unmistakable signs of CS &#40;red striae on the abdomen&#44; proximal myopathy&#44; spontaneous hematomas&#44; osteoporosis with no apparent cause&#44; facial plethora&#41; help adequately diagnose the syndrome&#46; However&#44; these signs are present in patients with established hypercortisolism&#44; meaning it is more difficult to diagnose CS in cases of recent onset or in the case of AIs&#46; It is common for patients to present obesity&#44; depression&#44; type 2 diabetes&#44; HTN or oligomenorrhea&#46; In the presented case&#44; the patient mainly suffered gradual weight gain over the past 5 years as well as HTN&#46; Diabetes did not present initially and appeared later on&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Within IA testing&#44; the normal 24&#8239;h catecholamine and metanephrine in urine levels enabled a diagnosis of pheochromocytoma to be ruled out&#46; Hyperaldosteronism was also ruled out with an ALD&#47;PRA ratio of 20&#8239;g&#47;dL&#47;ng&#47;mL&#47;h&#46; On the other hand&#44; it was possible to confirm that the NT was clearly pathological &#40;&#62;5&#8239;&#181;g&#47;dL&#41;&#44; with 24&#8239;h cortisol in urine always normal&#44; thought the cortisol rhythm was altered&#46; Since ACTH levels were suppressed&#44; the presumptive diagnosis was adrenal CS&#46; The adrenal CT had previously shown the existence of bilateral adrenal adenomas&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In bilateral AIs&#44; it is necessary to rule out the existence of delayed onset congenital adrenal hyperplasia by determining 17-OH-PG levels&#44; which were normal&#46; The normal levels of DHEA-S and the benign features of the adenomas ruled out the presence of carcinoma&#46; The adrenal scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol helped identify the hyperfunctioning gland&#44; which in this case was the right&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Final clinical diagnosis</span><p id="par0215" class="elsevierStylePara elsevierViewall">Adrenal Cushing&#8217;s syndrome&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pathological discussion</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Dr&#46; Berm&#250;dez-Cameo</span><p id="par0220" class="elsevierStylePara elsevierViewall">Upon conducting the macroscopic testing&#44; an adrenalectomy piece was obtained weighing 22&#8239;g and measuring 6&#46;5&#8239;&#215;&#8239;4&#46;5&#8239;cm&#46; On the surface of this there was a nodular mass measuring 3&#46;5&#8239;&#215;&#8239;2&#46;5&#8239;&#215;&#8239;2&#8239;cm which&#44; after serial analysis&#44; turned out to be a single&#44; well-defined&#44; solid brown organ-confined mass&#46; The rest of the glandular parenchyma was thinned&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Microscopically&#44; notably it was formed&#44; in different proportions&#44; by lipid-rich cells and cells similar to the cells in the zona reticularis&#44; with a mixed growth pattern of cords and nets&#46; The nuclei were small in size and uniform&#46; Mitotic activity was minimal&#46; Due to the clear morphological findings&#44; no additional immunohistochemical techniques were applied&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Anatomical diagnosis</span><p id="par0230" class="elsevierStylePara elsevierViewall">Right adrenal gland &#40;adrenalectomy&#41;&#58; cortical adenoma&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0235" class="elsevierStylePara elsevierViewall">This research did not receive any grants or funding from financial agencies in the public&#44; private&#44; or commercial sector&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest&#46;</p></span></span>"
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            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Benign or malignant incidentaloma"
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            1 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Functioning or nonfunctioning incidentaloma"
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        8 => array:3 [
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          "titulo" => "Conclusion"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Dr&#46; Ma&#241;as-Mart&#237;nez and Dr&#46; Morillo-Vanegas"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Final clinical diagnosis"
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          "identificador" => "sec0060"
          "titulo" => "Pathological discussion"
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            0 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Dr&#46; Berm&#250;dez-Cameo"
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        11 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Anatomical diagnosis"
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        12 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Funding"
        ]
        13 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conflicts of interest"
        ]
        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2021-03-19"
    "fechaAceptado" => "2022-02-21"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1569609"
          "palabras" => array:4 [
            0 => "Cushing syndrome"
            1 => "Adrenal incidental imaging finding"
            2 => "Obesity"
            3 => "Metabolic syndrome"
          ]
        ]
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      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1569610"
          "palabras" => array:4 [
            0 => "S&#237;ndrome de Cushing"
            1 => "Incidentaloma adrenal"
            2 => "Obesidad"
            3 => "S&#237;ndrome metab&#243;lico"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We present the case of a 64-year-old woman from Romania with a medical history of obstructive sleep apnea-hypopnea syndrome&#44; hepatic cirrhosis&#44; COPD&#44; and osteoarthritis&#46; She smokes one pack of cigarettes per day&#46; The patient is referred from the pulmonology department for an outpatient evaluation for an incidental finding of bilateral adrenal adenomas and progressive weight gain over the last five years&#46; Cushing syndrome is detected during study of the adrenal adenomas and obesity&#46; It is important to study recent-onset obesity in multimorbid patients as there could be other secondary causes in addition to the underlying diseases they present with&#46; During the presentation of this clinical case&#44; an essential&#44; practical approach to the adrenal pathology is made&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de una paciente de 64 a&#241;os&#44; natural de Ruman&#237;a&#44; con antecedentes m&#233;dicos de&#58; s&#237;ndrome de apnea-hipopnea&#44; cirrosis hep&#225;tica&#44; EPOC y artrosis&#46; Fumadora activa de 1 paquete cigarrillos&#47;d&#237;a&#46; La paciente es remitida desde la consulta de Neumolog&#237;a para estudio ambulatorio por presentar como hallazgo incidental adenomas suprarrenales bilaterales y aumento progresivo de peso en los &#250;ltimos 5 a&#241;os&#46; En el estudio de adenomas suprarrenales y obesidad se objetiva la presencia de un s&#237;ndrome de Cushing&#46; Es importante estudiar la aparici&#243;n de la obesidad reciente en una paciente pluripatol&#243;gica dado que puede haber otras causas secundarias adem&#225;s de las patolog&#237;as subyacentes que presenta&#46; Durante la presentaci&#243;n del caso cl&#237;nico se realiza un abordaje esencial y pr&#225;ctico de la patolog&#237;a adrenal&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ma&#241;as-Mart&#237;nez AB&#44; Morillo-Vanegas D&#44; Berm&#250;dez-Cameo R&#44; Marcos-Mond&#243;n S&#46; Obesidad secundaria a s&#237;ndrome endocrinol&#243;gico en paciente pluripatol&#243;gica&#46; Rev Clin Esp&#46; 2022&#59;222&#58;543&#8211;548&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ACTH&#58; adrenocorticotropic hormone&#59; DHEA-S&#58; dehydroepiandrosterone sulphate&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Laboratory&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Initial testing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol&#44; Nugent test no&#46; 1&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol&#44; Nugent test no&#46; 2&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DHEA-S&#44; ng&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">720&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal up to 4300 in females&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACTH&#44; pg&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>17-OH progesterone&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Erect aldosterone&#44; pg&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#8722;310&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Plasma renin activity&#44; ng&#47;mL&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6&#8722;4&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hospital admission testing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol&#44; Nugent test&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol&#44; Liddle test&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol&#44; cortisol rhythm&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Baseline cortisol&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#8722;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol 23&#8239;h&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;7&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Metanephrine in 24&#8239;h&#44; &#181;g&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">64&#8722;302&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">29&#46;20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;3&#8722;176&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">176&#46;00&nbsp;\t\t\t\t\t\t\n
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            0 => array:3 [
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                      "titulo" => "Gu&#237;a pr&#225;ctica sobre la evaluaci&#243;n inicial&#44; seguimiento y tratamiento de los incidentalomas adrenales&#46; Grupo de patolog&#237;a adrenal de la Sociedad Espa&#241;ola de Endocrinolog&#237;a y Nutrici&#243;n"
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                          "autores" => array:6 [
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                            2 => "M&#46; Calatayud-Guti&#233;rrez"
                            3 => "P&#46; Parra-Ram&#237;rez"
                            4 => "P&#46; Gracia-Gimeno"
                            5 => "F&#46;A&#46; Hanzu"
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Endocrinol Diabetes Nutr&#46;"
                        "fecha" => "2020"
                        "volumen" => "67"
                        "paginaInicial" => "408"
                        "paginaFinal" => "419"
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                    ]
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of adrenal incidentalomas&#58; European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Fassnacht"
                            1 => "W&#46; Arlt"
                            2 => "I&#46; Bancos"
                            3 => "H&#46; Dralle"
                            4 => "J&#46; Newell-Price"
                            5 => "A&#46; Sahdev"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1530/EJE-16-0467"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Endocrinol&#46;"
                        "fecha" => "2016"
                        "volumen" => "175"
                        "paginaInicial" => "G1"
                        "paginaFinal" => "G34"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27390021"
                            "web" => "Medline"
                          ]
                        ]
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                    ]
                  ]
                ]
              ]
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            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adrenocortical carcinoma"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "T&#46; Else"
                            1 => "A&#46;C&#46; Kim"
                            2 => "A&#46; Sabolch"
                            3 => "V&#46;M&#46; Raymond"
                            4 => "A&#46; Kandathil"
                            5 => "E&#46;M&#46; Caoili"
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1210/er.2013-1029"
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                        "tituloSerie" => "Endocr Rev&#46;"
                        "fecha" => "2014"
                        "volumen" => "35"
                        "paginaInicial" => "282"
                        "paginaFinal" => "326"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24423978"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scintigraphic evaluation of clinically silent adrenal masses"
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                            0 => "M&#46;D&#46; Gross"
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                        "tituloSerie" => "J Nucl Med&#46;"
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                        "paginaInicial" => "1145"
                        "paginaFinal" => "1152"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8014672"
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Clinicopathological Conference
Obesity secondary to endocrinology syndrome in a polymorbid patient
Obesidad secundaria a síndrome endocrinológico en paciente pluripatológica
A.B. Mañas-Martíneza,
Corresponding author
abmannas@salud.aragon.es

Corresponding author.
, D. Morillo-Vanegasb, R. Bermúdez-Cameoc, S. Marcos-Mondónd
a Unidad de Endocrinología y Nutrición, Hospital Ernest Lluch, Calatayud, Zaragoza, Spain
b Unidad de Neumología, Hospital Ernest Lluch, Calatayud, Zaragoza, Spain
c Servicio de Anatomía Patológica, Hospital Ernest Lluch, Calatayud, Zaragoza, Spain
d Servicio de Radiología, Hospital Ernest Lluch, Calatayud, Zaragoza, Spain
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Adrenal cortical scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol&#46; Delayed images&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical case</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 64-year-old female patient from Romania with a medical history of obstructive sleep apnoea-hypopnea syndrome being treated with home CPAP&#44; and alcohol-induced compensated liver cirrhosis as well as COPD and osteoarthritis&#46; She smokes one pack of cigarettes per day&#46; She has not ingested alcohol for the last eight years&#46; She underwent an operation for a gastric ulcer about 15 years ago&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient is receiving treatment with&#58; telmisartan 80&#8239;mg&#47;amlodipine 5&#8239;mg&#47;day&#44; furosemide 20&#8239;mg at breakfast&#44; atorvastatin 20&#8239;mg at dinner&#44; omeprazole 20&#8239;mg&#47;day&#44; acetylsalicylic acid 100&#8239;mg&#47;day&#44; montelukast&#44; inhaled beclometasone&#44; and gabapentin 400&#8239;mg TID&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was referred from the pulmonology department for outpatient evaluation of an incidental finding of bilateral adrenal incidentalomas &#40;AIs&#41; measuring 10 and 23&#8239;mm on the right gland and 11&#8239;mm on the left gland&#46; In the medical history&#44; the patient reported progressive weight gain of 30&#8239;kg as the only notable datum&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The physical examination found&#58; weight&#58; 76&#46;7&#8239;kg&#44; height 151&#8239;cm&#59; BMI&#58; 33&#46;6&#8239;kg&#47;m<span class="elsevierStyleSup">2</span>&#46; BP&#58; 140&#47;85&#8239;mmHg&#46; Distended abdomen with no red striae and cervical kyphosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lab findings from the first endocrinology consultation assessment were as follows&#58; baseline glucose 126&#8239;g&#47;dL&#44; HbA1c 6&#46;3&#37;&#44; creatinine 0&#46;53&#8239;mg&#47;dL&#59; total cholesterol 288&#8239;mg&#47;dL&#44; LDL 201&#8239;mg&#47;dL&#44; HDL 56&#8239;mg&#47;dL&#44; and triglycerides 153&#8239;mg&#47;dL&#46; An AI functionality study was performed with the following results &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#58; erect aldosterone &#40;ALD&#41;&#58; 7&#46;61&#8239;ng&#47;dL&#59; plasma renin activity &#40;PRA&#41; 0&#46;6&#8239;ng&#47;mL&#47;h&#59; ALD&#47;PRA ratio&#58; 12&#46;7&#59; 24&#8239;h catecholamine and metanephrine in urine test&#58; normal&#59; Nugent Test &#40;NT&#41; &#40;cortisol 8&#58;00&#8239;h after dexamethasone &#91;DXT&#93; 1&#8239;mg at 23&#58;00&#8239;h test&#41;&#58; 16&#46;3&#8239;&#181;g&#47;dL&#46; The 17-hydroxyprogesterone determination was normal &#40;1&#46;3&#8239;&#181;g&#47;dL&#44; N&#8239;&#60;&#8239;1&#46;8&#8239;&#181;g&#47;dL&#41;&#46; The patient&#8217;s dehydroepiandrosterone sulphate &#40;DHEA-S&#41; blood levels ruled out the existence of adrenal carcinoma&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Since the patient was being treated with inhaled beclometasone&#44; the NT was repeated to rule out an interaction with the laboratory technique&#44; and the following result was obtained&#58; 15&#46;3&#8239;&#181;g&#47;dL&#46; A 24&#8239;h cortisol in urine test was performed&#58; 29&#46;2&#8239;&#181;g&#47;24&#8239;h &#40;normal up to 120&#8239;&#181;g&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The patient was diagnosed with type 2 diabetes mellitus in the following months as her baseline blood glucose remained above 126&#8239;g&#47;dL&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The decision was made to admit the patient due to the persistent pathological findings from the NT&#46; The following tests were conducted &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#58; 2&#8239;mg dexamethasone suppression test &#40;Liddle test &#91;LT&#93;&#41;&#44; cortisol rhythm&#46; Persistent hypercortisolism in the LT and an altered cortisol rhythm were notable&#44; and late-night cortisol levels remained elevated&#46; The adrenocorticotropic hormone &#40;ACTH&#41; was suppressed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Adrenal cortical scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol was requested&#46; It revealed an increase in radiotracer uptake in the right adrenal with the study being compatible with right adrenal adenoma&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Differential diagnosis</span><p id="par0045" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Functioning adrenal adenoma&#58; Cushing&#8217;s syndrome &#40;CS&#41;&#44; primary hyperaldosteronism and pheochromocytoma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Adrenal carcinoma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Congenital adrenal hyperplasia&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Radiological findings</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Dr&#46; Marcos-Mond&#243;n</span><p id="par0065" class="elsevierStylePara elsevierViewall">An abdominal computerized tomography &#40;CT&#41; scan with adrenal protocol was performed&#44; comprising an exploration with 3 imaging acquisitions&#58; non-contrast&#44; portal venous phase &#40;70&#8239;s&#41; and delayed phase &#40;15&#8239;min&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The exploration revealed the existence of bilateral adrenal nodules&#44; round in shape with well-defined and smooth borders&#44; homogeneous and hypoattenuated with radiological semiology in line with a benign nature&#46; They measured between 23 and 10&#8239;mm in diameter on the right adrenal gland and 11&#8239;mm in diameter on the left adrenal gland&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The baseline density of the largest nodule was 6 Hounsfield units &#40;UH&#41;&#44; a number highly suggestive of a lipid-rich adenoma or a typical adenoma&#46; It presented intense enhancement following contrast administration&#44; reaching 44&#8239;HU in the portal venous phase&#46; After 15&#8239;min&#44; in the delayed phase&#44; the contrast &#8220;washed out&#8221; and reduced the attenuation to 1&#8239;HU&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the cortical adrenal scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol&#44; images were obtained on the 2nd &#40;early&#41; and 5th day &#40;delayed&#41; after intravenous administration of the radiotracer&#46; The early images showed intense focal hyper-uptake in the posterior projection&#44; which corresponds to the cortex of the right adrenal gland &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In the delayed images&#44; persistent intense focal hyper-uptake was observed in cortex of the right adrenal gland&#44; this being more intense and greater in size compared to the previous images&#46; In addition&#44; a discreet increase in radiotracer uptake was observed in the cortex of the left adrenal &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Summary of findings</span><p id="par0085" class="elsevierStylePara elsevierViewall">The described nodules met all the radiological characteristics that suggest it was benign&#58; &#60;4&#8239;cm&#44; round or oval in shape&#44; homogeneous attenuation&#44; and smooth borders&#46; Likewise&#44; its attenuation in the contrast study was &#8804;10&#8239;HU&#44; a parameter with high specificity &#40;96&#37;&#8211;98&#37;&#41; and high-moderate sensitivity &#40;71&#37;&#8722;73&#37;&#41; for the diagnosis of lipid-rich adenomas&#46; By meetings these requirements&#44; was assumed that it corresponds to a typical adenoma and no further evaluations were required<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In this patient&#8217;s case&#44; a contrast scan with portal venous phase and delayed phase was performed&#44; meaning we were also able to evaluate the loss of attenuation due to the early &#8220;washout&#8221; of the contrast&#46; The largest nodule had an absolute washout of 86&#37; and a relative washout of 98&#37;&#44; elevated values that indicate a hypervascular lesion with rapid &#8220;washout&#8221;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The differential diagnosis of the hypervascular adrenal nodules includes the adrenal&#44; but also other less frequent lesions such as metastatic renal cell carcinoma or hepatocarcinoma<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The nuclear medicine scan revealed an increase in radiotracer uptake in the right adrenal&#44; with the study being compatible with right adrenal adenoma&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Concept of incidentaloma</span><p id="par0105" class="elsevierStylePara elsevierViewall">AIs are lesions that are detected in imaging tests conducted for other reasons&#46; Their prevalence is estimated to be around 2&#37; in the general population and up to 7&#37; in the population over 70 years old<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; Their significance is rooted in the importance of determining the presence of carcinoma and demonstrating hormonal overproduction&#46; The prevalence of malignancy is around 2&#37;&#44; though this has reached 12&#37; in some series<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Between 70&#37;&#8211;80&#37; of AIs correspond to nonfunctioning illness&#46; When these are functioning&#44; excess cortisol production tends to be common&#44; resulting in CS<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; CS is associated with an increased presence of metabolic syndrome and osteoporosis&#44; and is related to a decline in quality of life and increased mortality&#46; For that very reason&#44; early detection is important&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Therefore&#44; the initial study of AIs should be based on two pillars&#58; 1&#41; ruling out the presence of malignancy using imaging techniques&#44; and 2&#41; testing for hyperfunctionality<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Benign or malignant incidentaloma</span><p id="par0120" class="elsevierStylePara elsevierViewall">Non-contrast abdominal CT is the primary option used to test for AIs&#46; A homogeneous&#44; well-defined lesion with a density less than or equal to 10&#8239;HU is indicative of a high likelihood that the lesion is benign&#46; In indeterminate cases&#44; when the density of the adrenal adenoma is between 10&#8722;30&#8239;HU&#44; a contrast CT can be performed&#46; With adenomas&#44; enhancement and rapid washout are typically observed following administration of the intravenous contrast&#46; An absolute washout greater than or equal to 60&#37; and a relative washout greater than or equal to 40&#37; are typical of adenomas<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging &#40;MRI&#41; tends to be the second diagnostic option for those cases in which CT does not provide a clear diagnosis of whether a lesion is benign&#46; It is the first choice for testing children and pregnant women due to the radiation risk of CT&#46; The capability of MRIs to test for AI malignancy is based on the chemical shift imaging technique&#46; Protons in water vibrate in a slightly different manner than protons in lipids when the magnetic field is applied to them&#46; The lipid-rich adenomas lose signal on out-of-phase images compared with in-phase images&#44; while malignant lesions and pheochromocytomas remain unchanged<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In CT&#44; adrenal carcinoma presents as a heterogeneous mass greater than 4&#8239;cm&#46; When contrast is applied&#44; heterogeneous enhancement appears&#44; predominantly on the periphery with central areas without enhancement secondary to the presence of haemorrhage and necrosis&#46; On MRI&#44; it appears isointense relative to the liver parenchyma on T1-weighted images and hyperintense relative to the liver parenchyma on T2<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Positron emission tomography with 18F-fluorodeoxyglucose associated with CT &#40;PET&#47;CT with <span class="elsevierStyleSup">18</span>FDG&#41; has an elevated negative predictive value and may be useful to rule out malignancy when other imaging techniques have not been helpful&#46; Nevertheless&#44; it is not as valuable for routine testing given the presence of false positives with infections and even pheochromocytoma&#46; Its fundamental indication is for further testing in patients with primary extra-adrenal tumours and in indeterminate AIs&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol associated with SPECT&#47;CT may help in characterising the functionality of AIs&#46; The presence of a lesion on CT and scintigraphy is characteristic of a functioning&#44; benign lesion&#46; Lesions not observed on scintigraphy increase the suspicion that they are nonfunctioning lesions<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Functioning or nonfunctioning incidentaloma</span><p id="par0145" class="elsevierStylePara elsevierViewall">Patients with AIs must be evaluated for the presence of pheochromocytoma and CS<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; In the case of bilateral adenomas&#44; screening for congenital adrenal hyperplasia must also be included<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; The determination of 17-hydroxyprogesterone in the follicular phase of women of childbearing age below 2&#8239;ng&#47;dL rules this out<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Primary hyperaldosteronism testing is reserved for hypertensive patients and&#47;or patients with unexplained hypokalaemia&#46; It is important to determine this due to the elevated cardiovascular morbidity and mortality compared to patients with primary HTN and the same blood pressure grade<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; To screen for primary hyperaldosteronism&#44; the ALD&#47;PRA ratio must be measured after 2&#8239;h of orthostatism&#46; Following a diet with at least 5&#8239;g of salt per day and correcting hypokalemia is imperative&#46; In terms of drugs that may cause a reaction to the test&#44; eplerenone&#44; amiloride&#44; and spironolactone must be suspended at least 4&#8211;6 weeks prior&#46; Initially&#44; other drugs can be continued&#46; Generally&#44; an ALD&#47;PRA ratio higher than 20&#8239;ng&#47;dL&#47;ng&#47;mL&#47;h is suspicious and testing will have to continue<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Pheochromocytoma testing is performed on all subjects with AIs given the elevated morbidity and mortality due to oversecretion of catecholamines<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Prior to hormone testing&#44; medications that directly interfere with laboratory techniques &#40;acetaminophen&#44; mesalamine&#44; sulfadiazine&#41; or with the disposition of catecholamines &#40;such as tricyclic or sympathomimetic antidepressants&#41; must be ruled out&#44; as these can increase the levels of catecholamines and metanephrines&#44; leading to false positives<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">CS is caused by chronic exposure to excess corticosteroids&#46; It is associated with a decline in quality of life and increased mortality&#44; which is why early detection is important&#46; The most common cause of CS is iatrogenic due to chronic corticosteroid administration&#46; CS due to endogenous pathology is uncommon&#44; with an estimated incidence of 2&#8211;3 cases&#47;1&#44;000&#44;000 people&#47;year<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46; CS may be caused by excess ACTH of pituitary or ectopic production&#44; or due to adrenal causes&#46; In about 60&#37; of cases&#44; CS is caused by pituitary adenoma and in 20&#37; by adrenal adenoma<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The NT is widely used as the first test for AIs<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Cortisol levels &#60;1&#46;8&#8239;&#181;g&#47;dL allow CS to be ruled out&#46; Levels higher than 5&#8239;&#181;g&#47;dL enable an increase in the specificity of the test and determine autonomous cortisol secretion&#46; Mid-range levels &#40;1&#46;8&#8722;5&#8239;&#181;g&#47;dL&#41; suggest possible autonomous cortisol secretion&#46; Recently&#44; The Adrenal Pathology Group from the Spanish Endocrinology and Nutrition Society contemplated the need to continue with CS testing in those patients with cortisol higher than 3&#8239;&#181;g&#47;dL or higher than 1&#46;8&#8239;&#181;g&#47;dL who present associated cardiometabolic complications &#40;type 2 diabetes&#44; osteoporosis&#44; obesity&#44; HTN&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">To confirm autonomous cortisol production&#44; at least two determinations from one of the following tests are needed&#58; 24&#8239;h cortisol in urine&#59; NT&#59; LT&#59; late-night salivary cortisol&#59; or late-night plasma cortisol<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Tests measuring total plasma cortisol &#40;NT&#44; LT&#44; late-night plasma cortisol&#41; can give false results if the corticosteroid-binding globulin &#40;CBG&#41; is altered&#46; Women who are being treated with oestrogen have higher concentrations of CBG&#44; and at least 50&#37; of them present false positives in cortisol testing&#46; Therefore&#44; they must suspend treatment for at least six weeks<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">On the other hand&#44; in nephrotic syndrome or critical patients&#44; CBG determinations are reduced&#44; with fewer cases of false negatives<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; In the case of DXT suppression tests&#44; we must take into consideration any medications that interfere with DXT metabolism by inducing or inhibiting its metabolising enzyme &#40;CYP3A4&#41;&#46; Drugs such as anti-seizure drugs &#40;phenytoin&#44; phenobarbital&#44; carbamazepine&#44; primidone&#41; and CYP3A4 inducers increase cortisol metabolism&#44; resulting in false negatives&#46; Conversely&#44; other drugs from varying therapeutic groups &#40;ritonavir&#44; fluoxetine&#44; diltiazem&#44; cimetidine&#41; that are CYP3A4 inhibitors can result in false positives<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The 24&#8239;h cortisol in urine test reveals cortisol secretion over the course of one day&#46; It is not conditioned by CBG alterations as it measures the free cortisol filtered by the kidneys&#46; The recommendation is to consider it positive when it is above the normal range according to the laboratory technique used&#46; In the case of kidney failure&#44; cyclic Cushing&#8217;s syndrome&#44; or early illness&#44; cortisol levels may be normal&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Late-night salivary cortisol is based on cortisol determinations between 23&#58;00 and 24&#58;00&#8239;h&#46; Patients with CS have an altered cortisol rhythm and present elevated levels all 24&#8239;h of the day&#46; This test is valid as long as the patient is not under extreme stress &#40;acute disease&#44; critical patient&#41; or does not work rotating shifts&#46; In addition&#44; the test can be performed on an outpatient basis&#46; Healthy subjects tend to have a late-night salivary cortisol level under 145&#8239;ng&#47;dL&#46; Late-night plasma cortisol is another lab test that can be conducted and is based on the same principle as that mentioned above&#46; It is considered positive for CS when it is above 7&#46;5&#8239;&#181;g&#47;dL in awake patients&#46; The main inconvenience of this test is that the patient must be admitted<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;12</span></a>&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Once a diagnosis of CS has been determined&#44; it is important to identify the origin of the hypercortisolism&#46; The ACTH plasma test is the next step&#46; Low levels of ACTH &#40;less than 10&#8239;pg&#47;mL&#41; suggest an ACTH-independent origin&#44; while elevated levels &#40;more than 20&#8239;pg&#47;mL&#41; are typical of ACTH-dependent Cushing&#8217;s Syndrome<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a>&#46; Within ACTH-dependent Cushing&#8217;s Syndrome&#44; it is necessary to determine whether the origin is pituitary or ectopic&#46; If the 8&#8239;mg strong DXT suppression test obtains at least a 50&#37; decrease in the baseline cortisol level&#44; this suggests pituitary origin&#46; Likewise&#44; in the CRH test&#44; it achieves an increase of at least 50&#37; ACTH&#46; Nevertheless&#44; these responses have been observed in some benign carcinoid tumours&#46; Inferior petrosal sinus sampling continues to be the gold standard for diagnosing pituitary Cushing&#8217;s Syndrome&#46; If the origin is adrenal&#44; an abdominal CT is needed to identify the existence of an adrenal adenoma&#46; Elevated DHEA-S levels together with radiological features indicating malignancy on the CT raise suspicion of the existence of adrenal carcinoma<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Dr&#46; Ma&#241;as-Mart&#237;nez and Dr&#46; Morillo-Vanegas</span><p id="par0200" class="elsevierStylePara elsevierViewall">The unmistakable signs of CS &#40;red striae on the abdomen&#44; proximal myopathy&#44; spontaneous hematomas&#44; osteoporosis with no apparent cause&#44; facial plethora&#41; help adequately diagnose the syndrome&#46; However&#44; these signs are present in patients with established hypercortisolism&#44; meaning it is more difficult to diagnose CS in cases of recent onset or in the case of AIs&#46; It is common for patients to present obesity&#44; depression&#44; type 2 diabetes&#44; HTN or oligomenorrhea&#46; In the presented case&#44; the patient mainly suffered gradual weight gain over the past 5 years as well as HTN&#46; Diabetes did not present initially and appeared later on&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Within IA testing&#44; the normal 24&#8239;h catecholamine and metanephrine in urine levels enabled a diagnosis of pheochromocytoma to be ruled out&#46; Hyperaldosteronism was also ruled out with an ALD&#47;PRA ratio of 20&#8239;g&#47;dL&#47;ng&#47;mL&#47;h&#46; On the other hand&#44; it was possible to confirm that the NT was clearly pathological &#40;&#62;5&#8239;&#181;g&#47;dL&#41;&#44; with 24&#8239;h cortisol in urine always normal&#44; thought the cortisol rhythm was altered&#46; Since ACTH levels were suppressed&#44; the presumptive diagnosis was adrenal CS&#46; The adrenal CT had previously shown the existence of bilateral adrenal adenomas&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In bilateral AIs&#44; it is necessary to rule out the existence of delayed onset congenital adrenal hyperplasia by determining 17-OH-PG levels&#44; which were normal&#46; The normal levels of DHEA-S and the benign features of the adenomas ruled out the presence of carcinoma&#46; The adrenal scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol helped identify the hyperfunctioning gland&#44; which in this case was the right&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Final clinical diagnosis</span><p id="par0215" class="elsevierStylePara elsevierViewall">Adrenal Cushing&#8217;s syndrome&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pathological discussion</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Dr&#46; Berm&#250;dez-Cameo</span><p id="par0220" class="elsevierStylePara elsevierViewall">Upon conducting the macroscopic testing&#44; an adrenalectomy piece was obtained weighing 22&#8239;g and measuring 6&#46;5&#8239;&#215;&#8239;4&#46;5&#8239;cm&#46; On the surface of this there was a nodular mass measuring 3&#46;5&#8239;&#215;&#8239;2&#46;5&#8239;&#215;&#8239;2&#8239;cm which&#44; after serial analysis&#44; turned out to be a single&#44; well-defined&#44; solid brown organ-confined mass&#46; The rest of the glandular parenchyma was thinned&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Microscopically&#44; notably it was formed&#44; in different proportions&#44; by lipid-rich cells and cells similar to the cells in the zona reticularis&#44; with a mixed growth pattern of cords and nets&#46; The nuclei were small in size and uniform&#46; Mitotic activity was minimal&#46; Due to the clear morphological findings&#44; no additional immunohistochemical techniques were applied&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Anatomical diagnosis</span><p id="par0230" class="elsevierStylePara elsevierViewall">Right adrenal gland &#40;adrenalectomy&#41;&#58; cortical adenoma&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0235" class="elsevierStylePara elsevierViewall">This research did not receive any grants or funding from financial agencies in the public&#44; private&#44; or commercial sector&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We present the case of a 64-year-old woman from Romania with a medical history of obstructive sleep apnea-hypopnea syndrome&#44; hepatic cirrhosis&#44; COPD&#44; and osteoarthritis&#46; She smokes one pack of cigarettes per day&#46; The patient is referred from the pulmonology department for an outpatient evaluation for an incidental finding of bilateral adrenal adenomas and progressive weight gain over the last five years&#46; Cushing syndrome is detected during study of the adrenal adenomas and obesity&#46; It is important to study recent-onset obesity in multimorbid patients as there could be other secondary causes in addition to the underlying diseases they present with&#46; During the presentation of this clinical case&#44; an essential&#44; practical approach to the adrenal pathology is made&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de una paciente de 64 a&#241;os&#44; natural de Ruman&#237;a&#44; con antecedentes m&#233;dicos de&#58; s&#237;ndrome de apnea-hipopnea&#44; cirrosis hep&#225;tica&#44; EPOC y artrosis&#46; Fumadora activa de 1 paquete cigarrillos&#47;d&#237;a&#46; La paciente es remitida desde la consulta de Neumolog&#237;a para estudio ambulatorio por presentar como hallazgo incidental adenomas suprarrenales bilaterales y aumento progresivo de peso en los &#250;ltimos 5 a&#241;os&#46; En el estudio de adenomas suprarrenales y obesidad se objetiva la presencia de un s&#237;ndrome de Cushing&#46; Es importante estudiar la aparici&#243;n de la obesidad reciente en una paciente pluripatol&#243;gica dado que puede haber otras causas secundarias adem&#225;s de las patolog&#237;as subyacentes que presenta&#46; Durante la presentaci&#243;n del caso cl&#237;nico se realiza un abordaje esencial y pr&#225;ctico de la patolog&#237;a adrenal&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ma&#241;as-Mart&#237;nez AB&#44; Morillo-Vanegas D&#44; Berm&#250;dez-Cameo R&#44; Marcos-Mond&#243;n S&#46; Obesidad secundaria a s&#237;ndrome endocrinol&#243;gico en paciente pluripatol&#243;gica&#46; Rev Clin Esp&#46; 2022&#59;222&#58;543&#8211;548&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Initial testing</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol&#44; Nugent test no&#46; 1&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol&#44; Nugent test no&#46; 2&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DHEA-S&#44; ng&#47;mL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">720&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Normal up to 4300 in females&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACTH&#44; pg&#47;mL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>17-OH progesterone&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Erect aldosterone&#44; pg&#47;mL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">76&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&#8722;310&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Plasma renin activity&#44; ng&#47;mL&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;6&#8722;4&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hospital admission testing</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol&#44; Nugent test&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16&#46;22&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;1&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol&#44; Liddle test&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Baseline cortisol&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&#8722;25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cortisol 23&#8239;h&#44; &#181;g&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;7&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Vanillylmandelic acid in 24&#8239;h&#44; mg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;98&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cushing&#8217;s testing&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">29&#46;20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#46;3&#8722;176&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">24&#8239;h cortisol in urine no&#46; 2&#44; &#181;g&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">176&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;3&#8722;176&nbsp;\t\t\t\t\t\t\n
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                            3 => "P&#46; Parra-Ram&#237;rez"
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                            5 => "F&#46;A&#46; Hanzu"
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                    0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Pheochromocytoma and paraganglioma&#58; an endocrine society clinical practice guideline"
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                    0 => array:2 [
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                        "tituloSerie" => "J Clin Endocrinol Metab&#46;"
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                        "volumen" => "99"
                        "paginaInicial" => "1915"
                        "paginaFinal" => "1942"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24893135"
                            "web" => "Medline"
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                ]
              ]
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                        "paginaFinal" => "927"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26004339"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "The diagnosis of Cushing&#8217;s syndrome&#58; an endocrine society clinical practice guidelines"
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                        "paginaFinal" => "1540"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18334580"
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                ]
              ]
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                      "titulo" => "Diagnosis of endocrine disease&#58; differentiation of pathologic&#47;neoplastic hypercortisolism &#40;Cushing&#8217;s syndrome&#41; from physiologic&#47;non-neoplastic hypercortisolism &#40;formerly known as pseudo-Cushing&#8217;s syndrome&#41;"
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Original language: English
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