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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, and alcohol-induced compensated liver cirrhosis as well as COPD and osteoarthritis. She smokes one pack of cigarettes per day. She has not ingested alcohol for the last eight years. She underwent an operation for a gastric ulcer about 15 years ago.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient is receiving treatment with: telmisartan 80 mg/amlodipine 5 mg/day, furosemide 20 mg at breakfast, atorvastatin 20 mg at dinner, omeprazole 20 mg/day, acetylsalicylic acid 100 mg/day, montelukast, inhaled beclometasone, and gabapentin 400 mg TID.</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 (AIs) measuring 10 and 23 mm on the right gland and 11 mm on the left gland. In the medical history, the patient reported progressive weight gain of 30 kg as the only notable datum.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The physical examination found: weight: 76.7 kg, height 151 cm; BMI: 33.6 kg/m<span class="elsevierStyleSup">2</span>. BP: 140/85 mmHg. Distended abdomen with no red striae and cervical kyphosis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lab findings from the first endocrinology consultation assessment were as follows: baseline glucose 126 g/dL, HbA1c 6.3%, creatinine 0.53 mg/dL; total cholesterol 288 mg/dL, LDL 201 mg/dL, HDL 56 mg/dL, and triglycerides 153 mg/dL. An AI functionality study was performed with the following results (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>): erect aldosterone (ALD): 7.61 ng/dL; plasma renin activity (PRA) 0.6 ng/mL/h; ALD/PRA ratio: 12.7; 24 h catecholamine and metanephrine in urine test: normal; Nugent Test (NT) (cortisol 8:00 h after dexamethasone [DXT] 1 mg at 23:00 h test): 16.3 µg/dL. The 17-hydroxyprogesterone determination was normal (1.3 µg/dL, N < 1.8 µg/dL). The patient’s dehydroepiandrosterone sulphate (DHEA-S) blood levels ruled out the existence of adrenal carcinoma.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Since the patient was being treated with inhaled beclometasone, the NT was repeated to rule out an interaction with the laboratory technique, and the following result was obtained: 15.3 µg/dL. A 24 h cortisol in urine test was performed: 29.2 µg/24 h (normal up to 120 µg) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The patient was diagnosed with type 2 diabetes mellitus in the following months as her baseline blood glucose remained above 126 g/dL.</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. The following tests were conducted (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>): 2 mg dexamethasone suppression test (Liddle test [LT]), cortisol rhythm. Persistent hypercortisolism in the LT and an altered cortisol rhythm were notable, and late-night cortisol levels remained elevated. The adrenocorticotropic hormone (ACTH) was suppressed.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Adrenal cortical scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol was requested. It revealed an increase in radiotracer uptake in the right adrenal with the study being compatible with right adrenal adenoma.</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)</span><p id="par0050" class="elsevierStylePara elsevierViewall">Functioning adrenal adenoma: Cushing’s syndrome (CS), primary hyperaldosteronism and pheochromocytoma.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2)</span><p id="par0055" class="elsevierStylePara elsevierViewall">Adrenal carcinoma.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3)</span><p id="par0060" class="elsevierStylePara elsevierViewall">Congenital adrenal hyperplasia.</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. Marcos-Mondón</span><p id="par0065" class="elsevierStylePara elsevierViewall">An abdominal computerized tomography (CT) scan with adrenal protocol was performed, comprising an exploration with 3 imaging acquisitions: non-contrast, portal venous phase (70 s) and delayed phase (15 min) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The exploration revealed the existence of bilateral adrenal nodules, round in shape with well-defined and smooth borders, homogeneous and hypoattenuated with radiological semiology in line with a benign nature. They measured between 23 and 10 mm in diameter on the right adrenal gland and 11 mm in diameter on the left adrenal gland.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The baseline density of the largest nodule was 6 Hounsfield units (UH), a number highly suggestive of a lipid-rich adenoma or a typical adenoma. It presented intense enhancement following contrast administration, reaching 44 HU in the portal venous phase. After 15 min, in the delayed phase, the contrast “washed out” and reduced the attenuation to 1 HU.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the cortical adrenal scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol, images were obtained on the 2nd (early) and 5th day (delayed) after intravenous administration of the radiotracer. The early images showed intense focal hyper-uptake in the posterior projection, which corresponds to the cortex of the right adrenal gland (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the delayed images, persistent intense focal hyper-uptake was observed in cortex of the right adrenal gland, this being more intense and greater in size compared to the previous images. In addition, a discreet increase in radiotracer uptake was observed in the cortex of the left adrenal (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</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: <4 cm, round or oval in shape, homogeneous attenuation, and smooth borders. Likewise, its attenuation in the contrast study was ≤10 HU, a parameter with high specificity (96%–98%) and high-moderate sensitivity (71%−73%) for the diagnosis of lipid-rich adenomas. By meetings these requirements, was assumed that it corresponds to a typical adenoma and no further evaluations were required<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In this patient’s case, a contrast scan with portal venous phase and delayed phase was performed, meaning we were also able to evaluate the loss of attenuation due to the early “washout” of the contrast. The largest nodule had an absolute washout of 86% and a relative washout of 98%, elevated values that indicate a hypervascular lesion with rapid “washout”.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The differential diagnosis of the hypervascular adrenal nodules includes the adrenal, but also other less frequent lesions such as metastatic renal cell carcinoma or hepatocarcinoma<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a>.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The nuclear medicine scan revealed an increase in radiotracer uptake in the right adrenal, with the study being compatible with right adrenal adenoma.</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. Their prevalence is estimated to be around 2% in the general population and up to 7% in the population over 70 years old<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Their significance is rooted in the importance of determining the presence of carcinoma and demonstrating hormonal overproduction. The prevalence of malignancy is around 2%, though this has reached 12% in some series<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Between 70%–80% of AIs correspond to nonfunctioning illness. When these are functioning, excess cortisol production tends to be common, resulting in CS<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>. CS is associated with an increased presence of metabolic syndrome and osteoporosis, and is related to a decline in quality of life and increased mortality. For that very reason, early detection is important.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Therefore, the initial study of AIs should be based on two pillars: 1) ruling out the presence of malignancy using imaging techniques, and 2) testing for hyperfunctionality<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>.</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. A homogeneous, well-defined lesion with a density less than or equal to 10 HU is indicative of a high likelihood that the lesion is benign. In indeterminate cases, when the density of the adrenal adenoma is between 10−30 HU, a contrast CT can be performed. With adenomas, enhancement and rapid washout are typically observed following administration of the intravenous contrast. An absolute washout greater than or equal to 60% and a relative washout greater than or equal to 40% are typical of adenomas<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging (MRI) 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. It is the first choice for testing children and pregnant women due to the radiation risk of CT. The capability of MRIs to test for AI malignancy is based on the chemical shift imaging technique. Protons in water vibrate in a slightly different manner than protons in lipids when the magnetic field is applied to them. The lipid-rich adenomas lose signal on out-of-phase images compared with in-phase images, while malignant lesions and pheochromocytomas remain unchanged<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a>.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In CT, adrenal carcinoma presents as a heterogeneous mass greater than 4 cm. When contrast is applied, heterogeneous enhancement appears, predominantly on the periphery with central areas without enhancement secondary to the presence of haemorrhage and necrosis. On MRI, 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>.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Positron emission tomography with 18F-fluorodeoxyglucose associated with CT (PET/CT with <span class="elsevierStyleSup">18</span>FDG) has an elevated negative predictive value and may be useful to rule out malignancy when other imaging techniques have not been helpful. Nevertheless, it is not as valuable for routine testing given the presence of false positives with infections and even pheochromocytoma. Its fundamental indication is for further testing in patients with primary extra-adrenal tumours and in indeterminate AIs.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol associated with SPECT/CT may help in characterising the functionality of AIs. The presence of a lesion on CT and scintigraphy is characteristic of a functioning, benign lesion. Lesions not observed on scintigraphy increase the suspicion that they are nonfunctioning lesions<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>.</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">1,2</span></a>. In the case of bilateral adenomas, screening for congenital adrenal hyperplasia must also be included<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. The determination of 17-hydroxyprogesterone in the follicular phase of women of childbearing age below 2 ng/dL rules this out<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Primary hyperaldosteronism testing is reserved for hypertensive patients and/or patients with unexplained hypokalaemia. 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>. To screen for primary hyperaldosteronism, the ALD/PRA ratio must be measured after 2 h of orthostatism. Following a diet with at least 5 g of salt per day and correcting hypokalemia is imperative. In terms of drugs that may cause a reaction to the test, eplerenone, amiloride, and spironolactone must be suspended at least 4–6 weeks prior. Initially, other drugs can be continued. Generally, an ALD/PRA ratio higher than 20 ng/dL/ng/mL/h is suspicious and testing will have to continue<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</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>. Prior to hormone testing, medications that directly interfere with laboratory techniques (acetaminophen, mesalamine, sulfadiazine) or with the disposition of catecholamines (such as tricyclic or sympathomimetic antidepressants) must be ruled out, as these can increase the levels of catecholamines and metanephrines, leading to false positives<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>.</p><p id="par0160" class="elsevierStylePara elsevierViewall">CS is caused by chronic exposure to excess corticosteroids. It is associated with a decline in quality of life and increased mortality, which is why early detection is important. The most common cause of CS is iatrogenic due to chronic corticosteroid administration. CS due to endogenous pathology is uncommon, with an estimated incidence of 2–3 cases/1,000,000 people/year<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a>. CS may be caused by excess ACTH of pituitary or ectopic production, or due to adrenal causes. In about 60% of cases, CS is caused by pituitary adenoma and in 20% by adrenal adenoma<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>.</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">1,2</span></a>. Cortisol levels <1.8 µg/dL allow CS to be ruled out. Levels higher than 5 µg/dL enable an increase in the specificity of the test and determine autonomous cortisol secretion. Mid-range levels (1.8−5 µg/dL) suggest possible autonomous cortisol secretion. Recently, 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 µg/dL or higher than 1.8 µg/dL who present associated cardiometabolic complications (type 2 diabetes, osteoporosis, obesity, HTN)<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0170" class="elsevierStylePara elsevierViewall">To confirm autonomous cortisol production, at least two determinations from one of the following tests are needed: 24 h cortisol in urine; NT; LT; late-night salivary cortisol; or late-night plasma cortisol<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a>.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Tests measuring total plasma cortisol (NT, LT, late-night plasma cortisol) can give false results if the corticosteroid-binding globulin (CBG) is altered. Women who are being treated with oestrogen have higher concentrations of CBG, and at least 50% of them present false positives in cortisol testing. Therefore, they must suspend treatment for at least six weeks<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>.</p><p id="par0180" class="elsevierStylePara elsevierViewall">On the other hand, in nephrotic syndrome or critical patients, CBG determinations are reduced, with fewer cases of false negatives<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>. In the case of DXT suppression tests, we must take into consideration any medications that interfere with DXT metabolism by inducing or inhibiting its metabolising enzyme (CYP3A4). Drugs such as anti-seizure drugs (phenytoin, phenobarbital, carbamazepine, primidone) and CYP3A4 inducers increase cortisol metabolism, resulting in false negatives. Conversely, other drugs from varying therapeutic groups (ritonavir, fluoxetine, diltiazem, cimetidine) that are CYP3A4 inhibitors can result in false positives<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a>.</p><p id="par0185" class="elsevierStylePara elsevierViewall">The 24 h cortisol in urine test reveals cortisol secretion over the course of one day. It is not conditioned by CBG alterations as it measures the free cortisol filtered by the kidneys. The recommendation is to consider it positive when it is above the normal range according to the laboratory technique used. In the case of kidney failure, cyclic Cushing’s syndrome, or early illness, cortisol levels may be normal.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Late-night salivary cortisol is based on cortisol determinations between 23:00 and 24:00 h. Patients with CS have an altered cortisol rhythm and present elevated levels all 24 h of the day. This test is valid as long as the patient is not under extreme stress (acute disease, critical patient) or does not work rotating shifts. In addition, the test can be performed on an outpatient basis. Healthy subjects tend to have a late-night salivary cortisol level under 145 ng/dL. Late-night plasma cortisol is another lab test that can be conducted and is based on the same principle as that mentioned above. It is considered positive for CS when it is above 7.5 µg/dL in awake patients. The main inconvenience of this test is that the patient must be admitted<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12</span></a>.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Once a diagnosis of CS has been determined, it is important to identify the origin of the hypercortisolism. The ACTH plasma test is the next step. Low levels of ACTH (less than 10 pg/mL) suggest an ACTH-independent origin, while elevated levels (more than 20 pg/mL) are typical of ACTH-dependent Cushing’s Syndrome<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a>. Within ACTH-dependent Cushing’s Syndrome, it is necessary to determine whether the origin is pituitary or ectopic. If the 8 mg strong DXT suppression test obtains at least a 50% decrease in the baseline cortisol level, this suggests pituitary origin. Likewise, in the CRH test, it achieves an increase of at least 50% ACTH. Nevertheless, these responses have been observed in some benign carcinoid tumours. Inferior petrosal sinus sampling continues to be the gold standard for diagnosing pituitary Cushing’s Syndrome. If the origin is adrenal, an abdominal CT is needed to identify the existence of an adrenal adenoma. 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">1–3</span></a>.</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. Mañas-Martínez and Dr. Morillo-Vanegas</span><p id="par0200" class="elsevierStylePara elsevierViewall">The unmistakable signs of CS (red striae on the abdomen, proximal myopathy, spontaneous hematomas, osteoporosis with no apparent cause, facial plethora) help adequately diagnose the syndrome. However, these signs are present in patients with established hypercortisolism, meaning it is more difficult to diagnose CS in cases of recent onset or in the case of AIs. It is common for patients to present obesity, depression, type 2 diabetes, HTN or oligomenorrhea. In the presented case, the patient mainly suffered gradual weight gain over the past 5 years as well as HTN. Diabetes did not present initially and appeared later on.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Within IA testing, the normal 24 h catecholamine and metanephrine in urine levels enabled a diagnosis of pheochromocytoma to be ruled out. Hyperaldosteronism was also ruled out with an ALD/PRA ratio of 20 g/dL/ng/mL/h. On the other hand, it was possible to confirm that the NT was clearly pathological (>5 µg/dL), with 24 h cortisol in urine always normal, thought the cortisol rhythm was altered. Since ACTH levels were suppressed, the presumptive diagnosis was adrenal CS. The adrenal CT had previously shown the existence of bilateral adrenal adenomas.</p><p id="par0210" class="elsevierStylePara elsevierViewall">In bilateral AIs, it is necessary to rule out the existence of delayed onset congenital adrenal hyperplasia by determining 17-OH-PG levels, which were normal. The normal levels of DHEA-S and the benign features of the adenomas ruled out the presence of carcinoma. The adrenal scintigraphy with I<span class="elsevierStyleSup">131</span>-cholesterol helped identify the hyperfunctioning gland, which in this case was the right.</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’s syndrome.</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. Bermúdez-Cameo</span><p id="par0220" class="elsevierStylePara elsevierViewall">Upon conducting the macroscopic testing, an adrenalectomy piece was obtained weighing 22 g and measuring 6.5 × 4.5 cm. On the surface of this there was a nodular mass measuring 3.5 × 2.5 × 2 cm which, after serial analysis, turned out to be a single, well-defined, solid brown organ-confined mass. The rest of the glandular parenchyma was thinned.</p><p id="par0225" class="elsevierStylePara elsevierViewall">Microscopically, notably it was formed, in different proportions, by lipid-rich cells and cells similar to the cells in the zona reticularis, with a mixed growth pattern of cords and nets. The nuclei were small in size and uniform. Mitotic activity was minimal. Due to the clear morphological findings, no additional immunohistochemical techniques were applied.</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 (adrenalectomy): cortical adenoma.</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, private, or commercial sector.</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.</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, hepatic cirrhosis, COPD, and osteoarthritis. She smokes one pack of cigarettes per day. 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. Cushing syndrome is detected during study of the adrenal adenomas and obesity. 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. During the presentation of this clinical case, an essential, practical approach to the adrenal pathology is made.</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 años, natural de Rumanía, con antecedentes médicos de: síndrome de apnea-hipopnea, cirrosis hepática, EPOC y artrosis. Fumadora activa de 1 paquete cigarrillos/día. La paciente es remitida desde la consulta de Neumología para estudio ambulatorio por presentar como hallazgo incidental adenomas suprarrenales bilaterales y aumento progresivo de peso en los últimos 5 años. En el estudio de adenomas suprarrenales y obesidad se objetiva la presencia de un síndrome de Cushing. Es importante estudiar la aparición de la obesidad reciente en una paciente pluripatológica dado que puede haber otras causas secundarias además de las patologías subyacentes que presenta. Durante la presentación del caso clínico se realiza un abordaje esencial y práctico de la patología adrenal.</p></span>"
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\t\t\t\t" scope="col" style="border-bottom: 2px solid black">Value \t\t\t\t\t\t\n
\t\t\t\t\t\t</th><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">Reference range \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> \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"> \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"> \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, Nugent test no. 1, µg/dL \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">16.3 \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"><1.8 \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, Nugent test no. 2, µg/dL \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">15.3 \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"><1.8 \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, ng/mL \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 \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 \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, pg/mL \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 \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"><46 \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, µg/dL \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">1.3 \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"><1.8 \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, pg/mL \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">76.09 \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">40−310 \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, ng/mL/h \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 \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">0.6−4.18 \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> \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"> \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"> \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, Nugent test, µg/dL \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">16.22 \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"><1.8 \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, Liddle test, µg/dL \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">20.6 \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"><1.8 \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, cortisol rhythm, µg/dL \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"> \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"> \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, µg/dL \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">17.9 \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">5−25 \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 23 h, µg/dL \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">17.7 \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"><7.5 \t\t\t\t\t\t\n
\t\t\t\t</td></tr></tbody></table>
"""
]
]
]
]
"descripcion" => array:1 [
"en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hormone blood levels.</p>"
]
]
4 => array:8 [
"identificador" => "tbl0010"
"etiqueta" => "Table 2"
"tipo" => "MULTIMEDIATABLA"
"mostrarFloat" => true
"mostrarDisplay" => false
"detalles" => array:1 [
0 => array:3 [
"identificador" => "at0025"
"detalle" => "Table "
"rol" => "short"
]
]
"tabla" => array:1 [
"tablatextoimagen" => array:1 [
0 => array:1 [
"tabla" => array:1 [
0 => """
<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 \t\t\t\t\t\t\n
\t\t\t\t\t\t</th><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"> \t\t\t\t\t\t\n
\t\t\t\t\t\t</th><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">Value \t\t\t\t\t\t\n
\t\t\t\t\t\t</th><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">Reference range \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">Pheochromocytoma test \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">Normetanephrine in 24 h, µg \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">409.46 \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">162−527 \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"> \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">Metanephrine in 24 h, µg \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">146.33 \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">64−302 \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"> \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">Vanillylmandelic acid in 24 h, mg \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">7.18 \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">0.5−6 \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"> \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">Vanillylmandelic acid \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">2.98 \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">1−7 \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">Cushing’s testing \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">24 h cortisol in urine no. 1, µg \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">29.20 \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">4.3−176 \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"> \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">24 h cortisol in urine no. 2, µg \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">176.00 \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">4.3−176 \t\t\t\t\t\t\n
\t\t\t\t</td></tr></tbody></table>
"""
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