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ENDOCRINE 12TH EDITION

BOARD
REVIEW
S E R G E A . J A B B O U R , M D, P R O G R A M C H A I R

ENDOCRINE
SOCIETY
ENDOCRINE
BOARD
REVIEW
Serge A. Jabbour, MD, Program Chair
Professor of Medicine
Director, Division of Endocrinology,
Diabetes & Metaboiic Diseases
Sidney Kimmei Medical College
Thomas Jefferson University

Frances J. Hayes, MB BCh , BAO Michelle F. Magee, MD

Andrea D. Coviello, MD
Ciinica! Director Director
Associate Professor of Medicine
Division of Endocrinology, Endocrine Division MedStar Diabetes, Research
Metabolism, and Nutrition Massachusetts General Hospital and innovation institutes
Duke University School of Medicine Professor of Medicine
Jacqueline jonklaas, MD, PhD, MPH Georgetown University
Professor School of Medicine
Natalie Cusano, MD, MS
Associate Professor of Medicine Division of Endocrinology
Zucker School of Medicine Georgetown University Medicai Center Kathryn A . Martin, MD
at Hofstra/Northweli
Assistant Professor of Medicine
Director of the Bone Laurence Katznelson, MD Harvard Medical School
Metaboiism Program Professor of Neurosurgery Practicing Clinician
Division of Endocrinology and Medicine Massachusetts General Hospital
at Lenox Hill Hospital Division of Endocrinology Senior Physician Editor,

Stanford University Endocrinology and Diabetes

UpToDate
Tobias Else, MD
Associate Professor
Division of Metabolism, Abbie L. Young, MS, CGC , ELS (D)
Endocrinology, and Diabetes Medical Editor
University of Michigan

Endocrine Society
2055 L Street NW, Suite 600, Washington, DC 20036
ENDOCRINE i
ma

1- 888 - ENDOCRINE © www.endocrine.org

 mm
m1
m
V/ f
SI
4
V

ENDOCRINE
Hormone Stfence ft? Health 4
v

The Endocrine Society is the world’s largest, oldest, and most

active organization working to advance the clinical practice of
endocrinology and hormone research. Founded in 1916, the :
Society now has more than 18,000 global members across a : / / /;/
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range of disciplines The Society has earned an international L'

reputation for excellence in the quality of its peer- reviewed

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improve public health through the practice and science of : ;v V
endocrinology. . '

Visit us at: Other Publications;

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The statements and opinions expressed in this publication are

those of the individual authors and do not necessarily reflect
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the views of the Endocrine Society The Endocrine Society is not
responsible or liable in any way for the currency of the information, %
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the reader is advised to refer to the appropriate medical
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of administration, and other relevant information; In all instances, :
it is the responsibility of the treating physician or other health care
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Library of Congress Control Number; 2019954327

ti Esidocrime Board Review

1
m
 responsibility to submit participant completion information to
OVERVIEW
the ACCME for the purpose of granting ABIM MOC points.
The Endocrine Board Review (EBR ) is a board examination
preparation course designed both for endocrine fellows CME credits and / or MOC points for the activities related to
who have completed or are nearing completion of then- this material must be claimed by the following deadlines.
fellowship and are preparing to sit the board certification
• Endocrine Board Review 2020: December 31, 2022
exam, and for practicing endocrinologists in search of a 0 To claim credits, visit education.endocrine .org / EBR2020
comprehensive self-assessment of endocrinology, either to . ®
Endocrine Board Review Online 2020: October 31, 2022
prepare for recertification or to update their practice. EBR
° To claim credits, visit education.endocrine.org/
'

consists of 220 case-based, American Board oflnternal ‘ EBR 2020Recordings

Medicine ( ABIM ) style, multiple-choice questions, presented « Endocrine Board Review, 12th Edition: October 31, 2022
in a mock exam format. Each section follows the ABIM 0 To claim credits, visit education.endocrine .org/ EBR 12Ed
Endocrinology, Diabetes, and Metabolism Certification
Examination blueprint, covering the breadth and depth For questions about content or obtaining CME credit
of the certification and recertification examinations. Each or MOC points, please contact the Endocrine Society at
case is discussed comprehensively with detailed answer education.endocrine.org/ contact.
explanations and references. A customized score report is
provided to those participating in the online courses. LEARNING OBJECTIVES
Upon completion of this educational activity, learners
ACCREDITATION STATEMENT will be able to demonstrate enhanced medical knowledge
The Endocrine Society is accredited
by the Accreditation Council for
Continuing Medical Education
Pi
tACCREDITED
ACCME?
WITH
COMMENDATION
’
and clinical skills across all major areas of endocrinology;
apply knowledge and skills in diagnosing, managing,
and treating a wide spectrum of endocrine disorders;
( ACCME ) to provide continuing medical and successfully complete the board examination for
education for physicians. The Endocrine Society has certification or recertification in the subspecialty of
achieved Accreditation with Commendation. endocrinology, diabetes, and metabolism.

METHODS OF PARTICIPATION TARGET AUDIENCE

This material is presented in 3 activities, as follows: This CME activity is intended for endocrine
. * Endocrine Board Review 2020: interactive online fellows planning for initial certification, practicing
.
program includes early access to topical on -demand endocrinologists preparing for an MOC assessment, or
presentations and live Q&A sessions with the experts physicians seeking an in- depth review of endocrinology.
held September 16 - 18, 2020. The secondary target audience includes advanced practice
Endocrine Board Review Online 2020: enduring online nurses and physician assistants.
activity
• « Endocrine Board Review, 12th Edition: enduring book activity STATEMENT OF INDEPENDENCE
.
As a provider of CME accredited by the ACCME, the
AMA PRA CATEGORY 1 CREDITS (CME) AND Endocrine Society has a policy of ensuring that the content
and quality of this educational activity are balanced,
MAINTENANCE OF CERTIFICATION (MOC )
The Endocrine Society designates independent, objective, and scientifically rigorous. The
ABIM
scientific content of this activity was developed under
this activity for a maximum of 21 AMA
the supervision of the Endocrine Society's EBR faculty.
PRA Category 1 Credits and 21 points in AzmsDirm

the ABIM's Maintenance of Certification There are no commercial supporters of this activity
( MOC) program. Physicians should claim only the credit and no commercial entities have had influence over the
commensurate with the extent of their participation in the
planning of this CME activity.
activity. Participants will earn MOC points equivalent to the
amount of CME credits claimed for the activity. DISCLOSURE POLICY
The faculty, committee members, and staff who are in
Successful completion of this CME activity includes position to control the content of this activity are required
participation in the activity evaluation. To complete the to disclose to the Endocrine Society and to learners
activity evaluation and claim CME credits and/ or MOC points, any relevant financial relationship (s) of the individual
participants must visit the Endocrine Society's Center or spouse/partner that have occurred within the last
for Learning at education.endocrine.org . After completing 12 months with any commercial interest(s ) whose products
the activity evaluation, participants will be able to save or or services are related to the CME content. Financial
print a CME certificate. It is the CME activity provider s relationships are defined by remuneration in any amount

Wmlocrine Board Review isi

J
 1

1
I

from the commercial interest (s) in the form of grants; Use of professiona! judgment:
research support ; consulting fees; salary; ownership interest The educational content in this activity relates to basic
(eg, stocks, stock options, or ownership interest excluding principles of diagnosis and therapy and does not substitute \
diversified mutual funds); honoraria or other payments for individual patient assessment based on the health care
for participation in speakers bureaus, advisory boards, or provider s examination of the patient and consideration
boards of directors; or other financial benefits. The intent of of laboratory data and other factors unique to the patient.
this disclosure is not to prevent CME planners with relevant Standards in medicine change as new data become available.
financial relationships from planning or delivery of content,
|
but rather to provide learners with information that allows Drugs and dosages: 1

"
them to make their own judgments of whether these When prescribing medications , the physician is advised
financial relationships may have influenced the educational to check the product information sheet accompanying
activity with regard to exposition or conclusion. each drug to verify conditions of use and to identify any
changes in drug dosage schedule or contraindications.
The Endocrine Society has reviewed all disclosures and
resolved or managed all identified conflicts of interest, as
POLICY ON UNLABELED/OFF- LABEL USE
applicable.
The Endocrine Society has determined that disclosure of
The faculty reported the following relevant financial unlabeled/ off -label or investigational use of commercial
relationship( s ) during the content development process for product(s) is informative for audiences and therefore
this activity: requires this information to be disclosed to the learners
Natalie Cusano, MD, MS, has served as a consultant to at the beginning of the presentation. Uses of specific
Shire / Takeda and Radius Pharmaceuticals and has served therapeutic agents, devices, and other products discussed
as a speaker for Shire/ Takeda and Alexion. in this educational activity may not be the same as those
Tobias Else, MD, has served as an advisory board member indicated in product labeling approved by the Food and Drug
to Corcept Therapeutics and HRA Pharma, and his Administration ( FDA). The Endocrine Society requires that
institution has received research support from Corcept any discussions of such “off-label” use be based on scientific
Therapeutics, Merck and Strongbridge Biopharma. research that conforms to generally accepted standards
Serge A, Jabhour, MD, has served as a consultant to of experimental design, data collection, and data analysis.
AstraZeneca and Janssen, and his institution has received Before recommending or prescribing any therapeutic agent
research support from the National Institutes of Health . or device, learners should review the complete prescribing
Laurence Katznelson, MD, has served as a consultant and information, including indications, contraindications,
principal investigator to Chiasma and Camarus, and he has warnings, precautions, and adverse events.
served as an advisory board member to Novo Nordisk .
Michelle F. Magee, MD, receives research support from the PRIVACY AND CONFIDENTIALITY STATEMENT $
NIH Diabetes Prevention Program Observational Study and The Endocrine Society will record learners personal -I
the NIH Grade Study as an investigator on behalf of MedStar information as provided on CME evaluations to allow for
Health Research Institute. She serves as a speaker for the
issuance and tracking of CME certificates. The Endocrine
American Diabetes Association, the American College of
Society may also track aggregate responses to questions
Cardiology, and the Endocrine Society.
in activities and evaluations and use these data to inform
Kathryn A. Martin, MD, has served as a physician editor for
the ongoing evaluation and improvement of its CME
UpToDate.
program. No individual performance data or any other
The following faculty reported no relevant financial personal information collected from evaluations will be
relationships: Andrea D. Coviello , MD; Frances J. Hayes, shared with third parties.
MB BCh, BAO; and Jacqueline Jonklaas, MD, PhD, MPH
ACKNOWLEDGMENT OF COMMERCIAL
The medical editor for this activity reported no relevant SUPPORT
financial relationships: Abbie L. Young, MS, CGC, ELS ( D ) The activity is not supported by educational grant (s ) or
other funds from any commercial supporters.
Endocrine Society staff associated with the development
of content for this activity reported no relevant financial Last Review: August 2020
relationships .
Activity Release: August 2020
DISCLAIMERS Activity Expiration Date: ( date after which this material
The information presented in this activity represents the is no longer certified for credit ): see section titled “ AAIA
opinion of the faculty and is not necessarily the official PIT 4 Category l Credits ( CME ) and Maintenance of
position of the Endocrine Society. Certification ( MGC) ”
sv
 Contents
QUESTIONS ANSWERS

LABORATORY REFERENCE RANGES 1

COMMON ABBREVIATIONS USED IN

ENDOCRINE BOARD REVIEW 5

ADRENAL BOARD REVIEW 7 93

Tobias Else, MD

CALCIUM & BONE BOARD REVIEW 18 111

Natalie Cusano, MD, MS

DIABETES MELLITUS SECTION 1BOARD REVIEW 29 130

Serge A. Jabbour, MD

DIABETES MELLITUS SECTION 2 BOARD REVIEW 40 149

Michelle F. Magee, MD

FEMALE REPRODUCTION BOARD REVIEW 53 172

Kathryn A. Martin, MD

MALE REPRODUCTION BOARD REVIEW 59 182

Frances J. Hayes, MB BCh, BAO

OBESITY & LIPIDS BOARD REVIEW 66 196

Andrea D. Coviello, MD

PITUITARY BOARD REVIEW 74 218

Laurence Katznelson, MD

THYROID BOARD REVIEW 81 231

Jacqueline Jonklaas, MD, PhD , MPH

For mid volume updates to this book's content, go to endocrine.org/ bookupdates.

-

Ettdserme Ecsttrd Review v

I®
 LABORATORY REFERENCE RANGES
Reference ranges vary among laboratories. Conventional units are listed first with SI units in parentheses.

Lipid Values Thyroid Values

High- density lipoprotein (HDL) cholesterol Thyroglobulin 3 - 42 ng/mL (3 - 42 pg/L) (after surgery and
Optimal >60 mg/dL (>1.55 mmol/L) radioactive iodine treatment: < 1.0 ng/mL [<1.0 pg/L] )
Normal - 40 - 60 mg/dL (1,04- 1.55 mmol/L) Thyroglobulin antibodies —— - <4.0 lU/mL (<4.0 klU/L)
Low — < 40 mg/dL (<1.04 mmol/L) Thyrotropin (T$H ) - —- 0.5 - 5.0 mlU/L
Low - density lipoprotein (LDL) cholesterol Thyrotropin-receptor antibodies ( TRAb) <1.75 IU/ L

Optimal <100 mg/dL (< 2.59 mmol/L) Thyroid -stimulating immunoglobulin — <120% of basal activity
Low — -100- 129 mg/dL (2.59-3.34 mmol/L) Thyroperoxidase ( TPO) antibodies - < 2.0 JU/mL (<2.0 klU/L)
Borderline -high - -130- 159 mg/dL (3.37-4.12 mmol/L) Thyroxine ( TJ (free) — 0.8-1.8 ng/dL (10.30 - 23.17 pmol/L)
High - -160- 189 mg/dL ( 4.14-4.90 mmol/L) Thyroxine ( TJ (total) 5.5-12.5 pg/dL (94.02 - 213.68 nmol/L)
Very high — >190 mg/dL (>4.92 mmol/L) Free thyroxine ( TJ index — 4-12
Non- HDL cholesterol Triiodothyronine ( TJ (free) - 2.3 - 4.2 pg/mL ( 3.53 - 6.45 pmol/L)
Optimal - <130 mg/dL (<3.37 mmol/L) Triiodothyronine ( TJ (total) 70- 200 ng/dL (1.08-3.08 nmol/L)
Borderiine -high - 130- 159 mg/dL (3.37 - 4.12 mmol/L) Triiodothyronine ( TJ, reverse - - 10 - 24 ng/dL (0.15-0.37 nmol/L)
High - > 240 mg/dL (>6.22 mmol/L) Triiodothyronine uptake , resin 25%- 38%
Total cholesterol Radioactive iodine uptake — 3 %-16% {6 hours):
Optimal <200 mg/dL (<5.18 mmol/L) 15% - 30% (24 hours)
Borderline -high - • 200- 239 mg/dL ( 5.18 - 6.19 mmol/L)
High > 240 mg/dL (>6.22 mmol/L) Endocrine Values
Triglycerides Serum
Optimal <150 mg/dL (<1.70 mmol/L) Aldosterone - 4 - 21 ng/dL (111.0- 582.5 pmol/L)
Borderline -high - - 150 -199 mg/dL {1.70 - 2.25 mmol/L) Alkaline phosphatase — — 50-120 U/L (0.84- 2.00 pkat /L)
High 200 - 499 mg/dL ( 2.26 - 5.64 mmol/L) Alkaline phosphatase (bone -specific)
Very high > 500 mg/dL (>5.65 mmol/L) < 20 pg/L (adult male): <14 pg/L (premenopausal female);

Lipoprotein (a ) <30 mg/dL {<1.07 pmol/L) < 22 pg/L (postmenopausal female)

Apolipoprotein B — 50-110 mg/dL (0.5 - 1.1 g/L) Androstenedione
65 - 210 ng/dL ( 2.27 - 7.33 nmol/L) (adult male) ;
Hematologic Values 30 - 200 ng/dL (1.05- 6.98 nmol/L) (adult female)
Erythrocyte sedimentation rate 0- 20 mm/h Antimullerian hormone
Haptoglobin 30 - 200 mg/dL (300 - 2000 mg/L ) 0.7 - 19.0 ng/mL (5.0-135.7 pmol/L) (male, > 12 years);
Hematocrit- - 41% - 50 % (0.41- 0.51) (male) ; 0.9 -9.5 ng/mL (6.4-67.9 pmol/L) (female, 13 - 45 years) ;
35% - 45% (0.35 0.45) (female)
-
<1.0 ng/mL (< 7.1 pmol/L) (female, >45 years)
Hemoglobin Alc 4.0 o/o- 5.6% ( 20 -38 mmol/mol) Calcitonin <16 pg/mL (<4.67 pmol/L) (basal, male);
Hemoglobin — 13.8 - 17.2 g/dL (138-172 g/L) (male); <8 pg/mL (< 2.34 pmol/L) ( basal, female);
12.1-15.1 g/dL (121- 151 g/L) (female) <130 pg/mL (<37.96 pmoi/L) ( peak calcium infusion, male);
International normalized ratio - 0.8 - 1.2 <90 pg/mL (<26.28 pmol/L) (peak calcium infusion, female)

. Mean corouscular volume (MCV) ~ 3

80-100 pm (80 - 100 fL) Carcinoembryonic antigen < 2.5 ng/mL (<2.5 pg/L)
Platelet count 150- 450 x 103/pL ( 150 - 450 x 109/L) Chromogranin A < 93 ng/mL (<93 pg/L)
Protein (total) 6.3 -7.9 g/dL (63 - 79 g/L) Corticosterone --- 53 - 1560 ng/dL (1.53 - 45.08 nmol/L) (>18 years)
Reticulocyte count 0.5%- 1.5% of red blood cells (0.005 - 0.015) Corticotropin (ACTH) -10 -60 pg/mL ( 2.2 - 13.2 pmo!/L)
White blood cell count 4500 -11,000/pL ( 4.5 - 11.0 x 109/L) Cortisol (8 AM) —- 5 - 25 pg/dL (137.9 - 689.7 nmol/L)

Board Review 1
as
1

Cortisol ( 4 PM) - 2- 14 pg/dL (55.2-386.2 nmol/L) 17- Hydroxypregnenolone 29-1S9 ng/dL (0.87 - 5.69 nmol/L)
C - peptide —- — '
0.9 - 43 ng/mL (0.30- 1.42 nmol/L) l7 a -Hydroxyprogesterone
C-reactive protein — - - -—
. r- r
' '
r . 0.8 - 3.1 mg/L (7.62- 29.52 nmol/L) < 220 ng/dL (<6.67 nmol/L) ( adult male);
Cross-linked N-teiopeptide of type 1collagen <80 ng/dL (< 2.42 nmol/L) (follicular, female) ;
5.4-24.2 nmol BCE/mmol creat (male); <285 ng/dL (<8.64 nmol/L) ( luteal, female); '

:
6.2 - 19.0 nmol BCE/mmol creat (female) <51.ng/dL (1.55 nmol/L) (postmenopausal, female)
Dehydroepiandrosterone sulfate (DHEA -S) 25 - Hydroxyvitamin D
< 20 ng/mL (<49.9 nmol/L) (deficiency) ;
Patient Age Female Male
21- 29 ng/mL ( 52.4- 72.4 nmoi/L) (insufficiency) ;
18 - 29 years 44-332 pg/dL 89- 457 pg/dL 30-80 ng/mL (74.9-199.7 nmol/L) (optimal levels);
(1.19 - 9.00 pmol/L) ( 2.41- 12.38 pmol/L)
>80 ng/mL (>199.7 nmol/L) (toxicity possible)
30- 39 years 31- 228 pg/dL 65 - 334 pg/dL Inhibin B 15 - 300 pg/mL ( 15- 300 ng/L)
(0.84 -6.78 pmol/L) ( 1.76- 9.05 pmol/L)
Insulinlike growth factor 1 (IGF-1)
40 - 49 years 18- 244 pg/dL 48 - 244 pg/dL
(0.49 - 6.61 pmol/L) (1.30 - 6.61 pmol/L) Patient Age Female Male m
50 - 59 years 15 - 200 pg/dL 35 - 179 pg/dL 18 years 162 - 541 ng/mL 170 - 640 ng/mL
(0.41- 5.42 pmol/L) (0.95- 4.85 pmol/L) :3
( 21.2 - 70.9 nmol/L) ( 223 - 83.8 nmol/L)

>60 years 15 -157 pg/dL 25-131 pg/dL 19 years 138 - 442 ng/mL 147 - 527 ng/mL
(0.41- 4.25 pmol/L) (0.68 - 3.55 pmoi/L) (18.1- 57.9 nmol/L) (193 - 69.0 nmol/L)

20 years 122- 384 ng/mL 132 - 457 ng/mL

(16.0- 503 nmol/L) (173 - 59.9 nmol/L)
Deoxycorticosterone <10 ng/dL (<030 nmol/L) (>18 years)
1,25- Dihydroxyvita min D 3 - — 16- 65 pg/mL ( 41.6-169.0 pmol/L) 21- 25 years 116 - 341 ng/mL 116- 341 ng/mL
(15.2 - 44.7 nmol/L) (15.2- 44.7 nmol/L)
Estradiol 10 - 40 pg/mL (36.7 - 146.8 pmol/L) ( male) ;
10-180 pg/mL (36.7 - 660.8 pmol/L) (follicular, female) ; 26- 30 years 117 - 321 ng/mL 117 - 321 ng/mL
(153 - 42.1 nmol/L) ( 15.3 - 42.1 nmol/L)
100 - 300 pg/mL (367.1- 1101.3 pmol/L) (midcycle, female) ;
40- 200 pg/mL (146.8 - 734.2 pmol/L) (luteal, female); 31- 35 years 113- 297 ng/mL 113- 297 ng/mL
(14.8 - 38.9 nmol/L) (14.8- 38.9 nmol/L)
< 20 pg/mL (<73.4 pmol/L) (postmenopausal, female)
Estrone 10 - 60 pg/mL (37.0 - 221.9 pmol/L) (male); 36 - 40 years 106- 277 ng/mL 106 - 277 ng/mL
( 13.9- 36.3 nmol/L) ( 13.9 - 36.3 nmol/L)
17 - 200 pg/mL (62.9 - 739.6 pmol/L) (premenopausal female);
7 - 40 pg/mL ( 25.9- 147.9 pmol/L) (postmenopausal female) 41- 45 years 98 - 261 ng/mL 98 - 261 ng/mL
(12.8 - 34.2 nmol/L) (12.8- 34.2 nmol/L)
a-Fetoprotein <6 ng/mL (<6 pg/L)
Follicle- stimulating hormone (FSH) — 46- 50 years 91- 246 ng/mL 91- 246 ng/mL
(11.9 - 32,2 nmol/L) ( 11.9 - 32.2 nmol/L)
1.0 - 13.0 mlU/mL (1.0- 13.0 IU/L) (male) ;
<3.0 miU/mL (<3.0 IU/L) (prepuberty, female) ; 51- 55 years 84 - 233 ng/mL 84- 233 ng/mL
( 11.0 - 30.5 nmol/L) (11.0 -30.5 nmol/L)
2.0- 12.0 mlU/mL ( 2.0 - 12.0 IU/L) (follicular, female) ;
4.0 - 36.0 mlU/mL ( 4.0- 36.0 IU/L) (midcycle, female); 56 - 60 years 78 - 220 ng/mL 78 - 220 ng/mL 1

(10.2 - 28.8 nmol/L) (10.2- 28.8 nmol/L)

1.0 - 9.0 mlU/mL (1.0 -9.0 IU/L) (luteal, female) ;
>30.0 mlU/mL (>30.0 IU/ L } (postmenopausal, female) 61- 65 years 72- 207 ng/mL 72 - 207 ng/mL
(9.4- 27.1 nmol/L) (9.4- 27.1 nmol/L)
Free fatty acids 10.6 - 18.0 mg/dL ( 0.4 - 0.7 nmol/L)
Gastrin <100 pg/mL ( <100 ng/L) 66 - 70 years -
67 195 ng/mL 67 -195 ng/mL
(8.8 - 25.5 nmol/L) (8.8- 25.5 nmol/L)
Growth hormone (GH) — 0.01- 0.97 ng/mL (0.01- 0.97 pg/L) ( male);
0.01-3.61 ng/mL (0.01- 3.61 pg/L) (female) 71- 75 years -
62 184 ng/mL 62-184 ng/mL
(8.1- 24.1 nmol/L) (8.1- 24.1 nmol/L)
Homocysteine <1.76 mg/L ( <13 pmol/L)
p-Human chorionic gonadotropin (p- hCG) — — 76 - 80 years -
57 172 ng/mL 57 -172 ng/mL
(7.5 - 22.5 nmol/L) ( 7.5 - 22.5 nmol/L)
<3.0 miU/mL (<3.0 IU/L) (nonpregnant female) ;
> 25 mlU/mL (> 25 IU/ L) indicates a positive pregnancy test >80 years 53 - 162 ng/mL 53 -162 ng/mL
(6.9 - 21.2 nmol/L) ( 6.9 - 21.2 nmol/L)
p-Hydroxybutyrate <3.0 mg/dL (<288.2 pmol/L)
aj
2 Board R &view i

m
m
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irt iiiti' trfT
'
 Insuiinlike growth factor binding protein 3 2.5 - 4.8 mg/L Renin activity, plasma, sodium replete, ambulatory

Insulin - '
1.4 14.0 plU/mL (9.7 97.2 pmol/L)
- - 0.6 - 4.3 ng/mL per h

islet- cell antibody assay — Renin, direct concentration 4- 44 pg/mL (0.1- 1.0 pmol/L)

0 Juvenile Diabetes Foundation units Sex hormone-binding globulin ( SH8 G)

ITT i Luteinizing hormone (LH) — - 1.1- 6.7 pg/mL { 10-60 nmol/L) (male);
T..L: J
yy 1.0 - 9.0 mlU/mL ( 1.0 - 9.0 IU/L) (male) ; 2.2- 14.6 pg/mL ( 20 -130 nmol/L) (female)
;'

f: <1.0 mlU/mL {<1.0 IU/L ) (prepuberty, female) ; a-Subunit of pituitary glycoprotein hormones
4
— —
1.0 - 18.0 mlU/mL ( 1.0 18.0 IU/L) (follicular, female) ;
-
<1.2 ng/mL {<1.2 pg/L)
20.0 - 80.0 mlU/mL ( 20.0 80.0 IU/L) (midcycle , female) ;
-
Testosterone ( bioavailable) -
0.5 - 18.0 mlU/mL (0.5 - 18.0 IU/L) (luteal, female); 0.8 - 4.0 ng/dL (0.03 -0.14 nmol/L)
fT ":
>30.0 mlU/mL (> 30.0 IU/L) (postmenopausal, femcle) ( 20- 50 years, female on oral estrogen) ;

Metanephrines ( plasma fractionated) 0.8 - 10.0 ng/dL (0.03 - 0.35 nmol/L)

Metanephrine — - <99 pg/mL (<0.50 nmol/L) ( 20 - 50 years, female not on oral estrogen);
LTV
Normetanephrine <165 pg/mL (<0.90 nmol/L) 83.0- 257.0 ng/dL ( 2.88-8.92 nmol/L) (male 20- 29 years ) ;
75 g oral glucose tolerance test blood glucose values -
* 72.0 - 235.0 ng/dL ( 2.50-8.15 nmo!/L) (male 30-39 years) ;
60 - 100 mg/dL (3.3 - 5.6 mmol/L) ( fasting) ; 61.0- 213.0 ng/dL ( 2.12- 7.39 nmol/L) (male 40 - 49 years);

& - .. <200 mg/dL {< 11.1 mmoi/L) (1 hour) ; 50.0 - 190.0 ng/dL (1.74- 6.59 nmo!/L) (male 50 - 59 years);
.
tev -r:
K
<140 mg/dL {<7.8 mmol/L) ( 2 hour); 40.0 - 168.0 ng/dL (1.39- 5.83 nmol/L) (male 60 -69 years)
between 140 - 200 mg/dL ( 7.8 - 11.1 mmol/L) is considered Testosterone (free) 9.0 - 30.0 ng/dL (0.31- 1.04 nmol/L) (male) ;
impaired glucose tolerance or prediaoetes. Greater than 0.3 - 1.9 ng/dL (0.01- 0.07 nmol/L) (female)
200 mg/dL ( 11.1 mmol/L) is a sign of diabetes meilitus. Testosterone (total) 300 - 900 ng/dL (10.4- 31.2 nmol/L) (male) ;
50 - g oral glucose tolerance test for gestational diabetes 8-60 ng/dL (0.3 - 2.1 nmol/L) (female)
<140 mg/dL (<7.S mmol/L) (1 hour ) Vitamin B 12 180-914 pg/mL ( 133 - 674 pmol/L)
100- g orcl glucose tolerance test for gestational diaoetes
<95 mg/dL {< 5.3 mmol/L) (fasting ); Chemistry Values
Sfc - < 180 mg/cL ( <10.0 mmol/L) (1 hour ); Alanine aminotransferase — -10- 40 U/L (0.17 - 0.67 pkat/L)
: V\
- • | < 155 mg/dL ( <8.6 mmol/L) ( 2 hour) ; Albumin 3,5 - 5 ,0 g/dL (35 - 50 g/L)

m
c.:;
- <140 mg/dL ( < 7.8 mmoi/L) (3 hour ) Amylase - - 26-102 U/L (0.43 - 1.70 pkat/L)

§.& - Osteocalcin 9.0 - 42.0 ng/mL (9.0 - 42.0 pg/L) Aspartate aminotransferase - — - 20 48 U/L (0.33 -0.80 pkat/L)
-

iT , Parathyroid hormone, intact (PTH) 10 - 65 pg/mL (10-65 ng/L) Bicarbonate — 21- 28 mEq/L ( 21- 28 mmol/L)
NS Parathyroid hormone-related protein (PTHrP) <2.0 pmol/L Bilirubin (total) -0.3 - 1.2 mg/dL ( 5.1- 20.5 pmol/L)
m Progesterone <1.2 ng/mL (<3.8 nmol/L) (male); Blood gases
85 - <1.0 ng/mL (<3.2 nmol/L) ( follicular, female) ; Po2, arterial blood • 80 -100 mm Hg (10.6 - 13.3 kPa )
2.0 - 20.0 ng/mL (6.4 - 63.6 nmol/L) (luteal, female); Pco 2, arterial blood - — 35 - 45 mm Hg (4.7 - 6.0 kPa)
ft: <1.1 ng/mL (<3.5 nmol/L) (postmenopausal, female) ; Blood pH 7.35- 7.45

i > 10.0 ng/mL (>31.8 nmol/L) (evidence of ovulatory adequacy)

Prcinsulin - 26.5-176.4 pg/mL (3.0- 20.0 pmol/L)
Calcium
Calcium (ionized)
8.2 - 10.2 mg/dL (2.1- 2.6 mmol/L)
4.60 - 5.08 mg/dL (1.2 - 1.3 mmol/L)
Prolactin - 4- 23 ng/mL (0.17 - 1.00 nmol/L) ( male); Carbon dioxide 22- 28 mEq/L (22- 28 mmol/L}
4 30 ng/mL (0.17 - 1.30 nmol/L) (nonlcctating female) ;
-
CD 4 ceil count - - 500 - 1400/pL (0.5-1,4 x 109/L}
y J
s#:
,

10 - 200 ng/mL ( 0.43 - 8.70 nmol/L ) (lactcting female) Chloride 96 - 106 mEq/L (96 - 106 mmol/L)
y
; Prostate - specific antigen (PSA ) Creatine kinase - 50 - 200 U/L (0.84- 3.34 pkat /L)
'

< 2.0 ng/mL (< 2.0 pg/L ) (<40 years) ; Creatinine 0.7- 1.3 mg/dL (61.9 - 114.9 pmol/L) (male);
y < 2.8 ng/mL (< 2.8 pg/L) { <50 years); 0.6 - 1.1 mg/dL ( 53.0 - 97.2 pmol/L) (female)
.. .

< 3.8 ng/mL {< 3.8 pg/L) (<60 years); Ferritin 15 - 200 ng/mL (33.7 - 449.4 pmol/L)
HP 1 <5.3 ng/mL { <5.3 pg/L) { <70 years); Folate >4.0 ng/mL (>4.0 pg/L)
yyfy
#y
<7.0 ng/mL (< 7.0 pg/L) { <79 years); Glucose — - 70 - 99 mg/dL (3.9 - 5.5 mmol/L)
yr <7.2 ng/mL (< 7.2 pg/L) (>80 years ) y- Gluta my [ transferase 2 - 30 U/L (0.03 -0.50 pkat /L)

s$ j
IT?" : UmU>ejm& Bosird Review 3
i :
 I

Iron Citrate 320 -1240 mg/24 h (16.7 - 64.5 mmol/d)

50 - 150 |jg/dL (9.0 - 26.8 pmol/L) (male) ; Cortisol - 4- 50 pg/24 h (11-138 nmol/d)
35 -145 |jg/dL (6.3 - 26.0 pmoi/L) (female) Cortisol following dexamethasone suppression test
Lactate dehydrogenase 100 - 200 U/L ( 1.7 - 3.3 pkat/L) (low - dose: 2 day, 2- mg daily ) 10 pg/ 24 h (<27.6 nmol/d )
Lactic acid - - 5.4- 20.7 mg/dL (0.6 - 2.3 mmol/L) Creatinine - 1.0 - 2.0 g/ 24 h (8.8- 17.7 mmol/d )
Lipase — 10- 73 U/L (0.17 - 1.22 pkat /L) Glomerular filtration rate (estimated) >60 mL/min per 1.73 m 2
Magnesium 1.5 - 2.3 mg/dL (0.6 -0.9 mmol/L) 5 ^Hydroxyindole acetic acid 2 - 9 mg/24 h ( 10.5 - 47.1 pmol/d)
Osmolality 275 - 295 mOsm/kg ( 275- 295 mmol/kg) Iodine (random) >100 pjg /L
Phosphate 2.3 - 4.7 mg/dL (0.7 - 1.5 mmol/L) 17 -Ketosteroids 6.0 - 21.0 mg/ 24 h ( 20.8 - 72.9 pmol/d) (male);
Potassium 3.5 - 5.0 mEq/L (3.5- 5.0 mmol/L) 4.0 - 17.0 mg/24 h ( 13.9 - 59.0 pmol/d) (female)
Prothrombin time 8.3 - 10.8 s Metanephrine fractionation
!

Serum urea nitrogen - 8- 23 mg/dL ( 2.9 - 8.2 mmol/L) Normotensive normal ranges:
Sodium 136 - 142 mEq/L (136 - 142 mmol/L) Metanephrine <261 pg/24 h (<1323 nmol/d) (male); i
Transferrin saturation 14% - 50% <180 pg/24 h (<913 nmol/d) (female)
Troponin I <0.6 ng/mL (< 0.6 pg/L) Normetanephrine — age and sex dependent
Tryptase <11.5 ng/mL (<11.5 pg/L) Total metanephrine - age and sex dependent
Uric acid - 3,5 - 7.0 mg/dL ( 208.2 - 416.4 pmol/L) Osmolality 150 -1150 mOsm/kg (150-1150 mmol/kg) 1
Oxalate <40 mg/24 h (<456 mmol/d)
Phosphate - 0.9 - 1.3 g/ 24 h ( 29.1- 42.0 mmol/d) I
Albumin 30-300 pg/mg creat (3.4- 33.9 pg/mol creat ) Potassium 17 - 77 mEq/24 h ( 17 - 77 mmol/d)
!
Albumin -to - creatinine ratio <30 mg/g creat Sodium 40- 217 mEq/ 24 h ( 40 - 217 mmol/d )
Aldosterone 3 - 20 pg/ 24 h (8.3 - 55.4 nmol/d) Uric acid <800 mg/24 h (<4.7 mmol/d )
( should be <12 pg/ 24 h [<33.2 nmol/d] with oral sodium
loading—confirmed with 24- hour urinary sodium >200 mEq)
Calcium - 100 - 300 mg/ 24 h ( 2.5- 7.5 mmol/d) Cortisol (salivary) , midnight <0.13 pg/dL (< 3.6 nmol/L)
Catecholamine fractionation
Normotensive normal ranges: Semen
Dopamine <400 pg/24 h (<2610 nmol/d) Semen analysis > 20 million sperm/mL; >50% motility
Epinephrine — <21 pg/24 h (<115 nmol/d)
Norepinephrine — <80 pg/24 h (< 473 nmoi/d)
*

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fedocnM Boarcf Review

:
 COMMON ABBREVIATIONS USED IN ENDOCRINE BOARD REVIEW

ACTH - corticotropin HMG-CoA reductase inhibitor = 3-hydroxy- 3-methylglutaryl

ACE inhibitor = angiotensin -converting enzyme inhibitor . coenzyme A reductase inhibitor

ALT = alanine aminotransferase IGF-1 - insulinlike growth factor 1

AST = aspartate aminotransferase LDL = low- density lipoprotein
B3VII = body mass index LH - luteinizing hormone
CNS = central nervous system MCV - mean corpuscular volume
CT - computed tomography MIBG - mrta-iodobenzylguanidine
DHEA = dehydroepiandrosterone MRI = magnetic resonance imaging
DHEA-S - dehydroepiandrosterone sulfate NPH insulin - neutral protamine Hagedorn insulin
DNA = deoxyribonucleic acid PCSK 9 inhibitor = proprotein convertase subtilisin /kexin 9
DPP-4 inhibitor = dipeptidyl-peptidase 4 inhibitor inhibitor
DXA = dual- energy x- ray absorptiometry PET = positron emission tomography
FDA = Food and Drug Administration PSA = prostate-specific antigen
FGF- 23 = fibroblast growth factor 23 PTH = parathyroid hormone
FNA = fme-needle aspiration PTHrP ~ parathyroid hormone-related protein
FSH = follicle-stimulating hormone SGLT- 2 inhibitor = sodium-glucose cotransporter 2 inhibitor
GH - growth hormone SHBG = sex hormone-binding globulin
GHRH - growth hormone-releasing hormone T3 = triiodothyronine
GLP-1 receptor agonist = glucagonlike peptide 1 receptor T4 = thyroxine
V agonist TPO antibodies - thyroperoxidase antibodies
GnRH - gonadotropin - releasing hormone -
TRH = thyrotropin releasing hormone
hCG = human chorionic gonadotropin TRAb = thyrotropin -receptor antibodies
HDL = high- density lipoprotein TSH = thyrotropin
HIV = human immunodeficiency virus VLDL = very low- density lipoprotein

E & docrme Bomd Review 5

ENDOCRINE
BOARD
REVIEW

.
"
v:
 Adrenal Board Review
Tobias Else, MD

An endocrine surgery colleague requests a

1 consult to evaluate a 38-year-old woman
who was referred to him for surgery to remove
a possible pheochromocytoma. She has episodic I
5
hypertension with blood pressure values ranging
up to 210/ 110 mm Hg accompanied by headaches, *
s
nausea, lightheadedness, and diaphoresis. These 1
:

episodes started in her early 20s, occur several times

m

per week , and last from hours to days.

She has a PhD degree in engineering and l
works as an executive for a local company. She i
brings a detailed log listing up to 20 blood pressure tl
measurements per day. Her family history is
negative for paraganglioma , pheochromocytoma ,
or cancers. At todays visit , her blood pressure is Laboratory test results:
:
Sfffr 132 / 81 mm Hg and pulse rate is 78 beats/ min . Plasma normetanephrine = 205.1 pg/ mL
The laboratory workup and imaging that her ( <164.8 pg/ mL) (SI: 1.12 nmol/ L [ <0.90 nmol/ L] )
primary care physician ordered are available for Plasma metanephrine = 39.4 pg / mL ( < 98.6 pg/ mL )
:T ;
review. The CT shows a thickened left adrenal ( SI: 0.20 nmol / L [ < 0.50 nmol / L ] )
gland with a probable central 1 -cm nodule ( see Sodium = 140 mEq/ L (136-142 mEq / L)
images, arrows). (SI: 140 mmol/ L [ 136 -142 mmol / Lj )
Potassium = 4.2 mEq / L ( 3.5-5.0 mEq / L )
(SI: 4.2 mmol/ L [ 3.5- 5.0 mmol/ L] )
I
Serum aldosterone = 6 ng / dL ( 4- 21 ng / dL)
(SI: 166.4 pmol / L [ 111.0-582 , 5 pmol/ L ] )
Plasma renin activity = < 0.6 ng / mL per h
( 0.6- 4.3 ng / mL per h )

Which of the following is the best next step in this

patient's care?
The 123I - MIBG -SPECT /CT shows avidity of the A. Obtain a 24 -hour urine collection for
left adrenal gland , presence of a cardiac silhouette, metanephrine and normetanephrine
and no other MIBG-avid lesion ( see image ) . B. Perform a 68Ga-DOTATATE PET -CT
C. Discuss the diagnosis of
pseudopheochromocytoma
D. Proceed with left adrenalectomy
E. Perform MRI with in - phase/ out-of- phase
imaging

Adrenal Board Review - QUESTIOMS 7

 I

A 55-year-old. man is referred for endocrine Which of the following is the best next step in this
Am consultation after a recent emergency patient's evaluation?
department visit for hypertensive urgency. He has A. 24 -Hour urine collection for cortisol
a 20-year history of hypertension controlled measurement
with hydrochlorothiazide. However, he has B. Sleep study
recently been experiencing headaches and has C. 68
Ga - DOTATATE PET- CT
measured his blood pressure more often. These D. 123
I - MIBG SPECT- CT i
measurements document values ranging between E. Repeated measurement of plasma metanephrine
160 and 190 mm Hg systolic and between 95 and levels after holding doxazosin
y8

110 mm Hg diastolic. His primary care physician j

:#
intensified his antihypertensive regimen to include ;f A general surgeon requests a consult to
amlodipine, losartan, and doxazosin. mS evaluate a 68-year- old woman for adrenal
He describes worsening headaches, loss of insufficiency. The patient had a left hemicolectomy
libido, tiredness, and fatigue over the last few for colon cancer with construction of a transient |
months. He has gained more than 40 lb ( > 18.1 kg ) colostomy the night before. Overnight she had I
over the last 5 years, and his current BM1 is episodes of hypotension with blood pressure as
37 kg / m 2. low as 90/ 50 mm Hg ( baseline blood pressure I
On physical examination, he is a well- is 130 / 80 mm Hg) , mild fever, tachycardia of
developed, obese patient with typical fat 110 beats/ min, and increased output through her
distribution and no striae, bruising, or skin colostomy. She was treated with intravenous
atrophy. His blood pressure is 142 /92 mm Hg. fluids and 50 mg of tramadol. She developed mild
hyponati’emia, and a morning cortisol concentration
Laboratory test results after the emergency was documented to be 0.9 pg / dL ( 24.8 nmol/ L).
department visit: She does not smoke cigarettes and was healthy I
Urinary metanephrine = 66 pg / 24 h ( < 261 pg / 24 h) before her surgery. She has a diagnosis of mild %
Urinary normetanephrine = 920 pg / 24 h hypertension and diet-controlled diabetes (most
( < 484 pg / 24 h ) recent hemoglobin Alc = 6.8 % [51 mmol/ mol] ) . 1
i
Plasma metanephrine = 39.4 pg/ mL ( < 98.6 pg / mL ) She is resting comfortably and does not have M
(SI: 0.2 nmol / L [ <0.50 nmol / L] ) any nausea. She would like to eat. On physical
m
Plasma normetanephrine = 183.2 pg/ mL examination, she is obese ( BMI = 32 kg / m 2)
S//A

( < 164.8 pg / mL ) (SI: 1.0 nmol / L [ < 0 90 nmol/ L ] )

, and does not appear ill. Her blood pressure is !
. "vS
Sodium = 140 mEq / L ( 136-142 mEq/ L ) 124/ 85 mm Pig, and pulse rate is 90 beats/ min. m
(SI: 140 mmol/ L [ 136 - 142 mmol / L] ) 3
Potassium = 3.5 mEq / L ( 3.5-5.0 mEq/ L ) Her most recent basic metabolic profile shows the V

(SI: 3.5 mmol / L [3.5 - 5.0 mmol/ Lj ) following results: mm

Serum aldosterone = 18 ng/ dL ( 4- 21 ng / dL ) Sodium = 133 mEq/ L ( 136-142 mEq/ L ) m
(SI: 499.3 pmol/ L [ 111 0-582.5 pmol / L] )
, (SI: 133 mmol/ L [ 136 - 142 mmol/ L] ) I
Plasma renin activity = 1.0 ng/ mL per h Potassium = 3.8 mEq / L ( 3.5-5.0 mEq/ L) ml
(0.6-4.3 ng/ mL per h ) (SI: 3.8 mmol/ L [ 3.5-5.0 mmol/ L ] ) 1
I
Serum testosterone = 240 ng/ dL ( 300- 900 ng / dL ) Glucose = 168 mg / dL (70 -99 mg / dL ) 1
m
(SI: 8.3 nmol/ L [ 10.4 - 31.2 nmol/ L] ) (SI: 9.3 mmol/ L [ 3.9- 5.5 mmol/ L ] )
Serum creatinine = 0.7 mg/ dL ( 0.6-1.1 mg / dL)
( SI: 6 L 9 pmol/ L [ 53.0- 97.2 pmol / L ] )
t
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8 Emfocrlrie Board Review

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me of the following is the most likely cause for the On physical examination; the patient appears
Sift Which
cortisol level? chronically ill and thin . His blood pressure
'»0
low
S
ra?
''
A. Medication given as a prophylaxis for is 98 / 50 mm Hg (sitting) and 75/ 45 mm Hg
TP postoperative nausea (standing) , He can move all extremities but has

mIS '
B.
C.
Overnight use of tramadol
Primary autoimmune adrenal insufficiency
generalized weakness. Lungs are clear, and no skin
lesions are appreciated.
WOK As part of the initial workup, he had an
D. Metastasis from the colon cancer
Ofe
jjjjlsr 7
E. Delayed effect of inhaled anesthetics abdominal CT ( see image ) , which documented
bilateral adrenal masses, and a chest CT, which
A 48-year old man has recently showed no abnormalities . The following laboratory
§fe been diagnosed with adrenocortical test results were documented:
vnr
Mp# ; carcinoma. He reports no history of malignancy ; Sodium = 129 mEq /L ( 136 -142 mEq/ L )
lie but states that his brother had colon cancer at age
38 years and that his mother died of uterine cancer
(SI: 129 mmol/ L [ 136 -142 mmol/ L] )
Potassium = 5.4 mEq/ L ( 3.5-5.0 mEq/ L )
Sir at age 51 years. His mother had 5 siblings: a brother (SI: 5.4 mmol/ L [3.5-5.0 mmol/ L] )
with colon cancer in his late 50s , a sister with Serum aldosterone = < 2 ng/dL ( 4- 21 ng/ dL )
stomach cancer in her 40s , and 3 brothers who (SI: 55.5 pmol / L [111.0- 582.5 pmol/ Lj )
are alive and well in their 60s without any cancer Plasma renin activity = 64 ng/ mL per h
diagnosis. The patients maternal grandfather had (0, 6 - 4.3 ng / mL per h)
prostate cancer in his 60s and his maternal Plasma ACTH = 252 pg / mL (10- 60 pg/ mL )
grandmother had colon cancer at age 47 years. (SI: 55.4 pmol/ L [ 2.2-13.2 pmol / L] )
There are no family members with adrenal tumors. Serum cortisol ( 8 AM ) = 1.2 pg / dL ( 5 -25 pg/ dL )
The patient’s family is wondering whether they (SI: 106.1 nmol / L [ 137.9-689.7 nmol / L] )
could have a familial cancer syndrome. Serum DHEA-S = 23 pg/ dL ( 35-179 pg / dL)
(SI: 0.62 pmol/ L [0.95 - 4.85 pmol / L] )
Which hereditary syndrome is most likely in this
patient's family?
A. Li - Fraumeni syndrome
B. Lynch syndrome ( hereditary nonpolyposis colon
cancer )
age C. Familial adenomatous polyposis
gflir
UP D. Carney complex
E. Multiple endocrine neoplasia type 1
§§i
m mm;-
“•2r2 A 52-year- old man is referred for evaluation
of bilateral adrenal masses. Over the Which of the following is the most likely diagnosis
m- last 6 months, he has lost 30 lb ( 13.6 kg ) and underlying this patient's presentation?
ip developed night sweats. He has been increasingly- A. Congenital adrenal hyperplasia
isife fatigued and has had dizziness and nausea . He B. Autoimmune adrenalitis
im
It lives in a northern state and has not traveled C. Melanoma metastatic to the adrenal gland
outside the United States. He is a lifelong D. Adrenal lymphoma
nonsmoker. He has had no sick contacts and works
m
iltr in an office setting.
E. Histoplasmosis

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Aarersol Board Review - QUESTIONS
 ill
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PP; A 37-year-old woman with primary adrenal pA 32-year-old woman is referred for i
%s0 insufficiency presents for routine follow- A evaluation of an incidental adrenal mass
up . She describes worsening anorexia and nausea. that was identified on CT performed as part of
She has been on steady dosages of hydrocortisone, the workup for an episode of painless hematuria i
15 mg in the morning upon awakening and 5 mg 4 weeks ago. In taking a history, you elicit a 14-lb
in the afternoon, and fludrocortisone, 0.1 mg . (6.5-kg ) weight gain over the past year associated
daily. Adrenal insufficiency was initially diagnosed with the onset of irregular menses, hirsutism, and
at age 24 years. She follows "sick day rules” and has '
poor sleep. She takes no medications.
injectable hydrocortisone at home. She has always On physical examination, her blood pressure
been slightly hyperpigmented since diagnosis, but is 140/88 mm Hg. She has mild to moderate
she has noticed worsening hyperpigmentatioil over . facial fullness and plethora and supraclavicular fat
the last 6 months. accumulation.
Over the last year, she started the following CT demonstrates a 1.4-cm left adrenal mass
medications: combined oral contraceptives; biotin ( see image; right and left adrenal glands are identified
supplement ( for subjective hair loss); omeprazole, by arrows ) .
40 mg daily; and cholestyramine, 8 g daily ( for Right Adrenaf Left Adrenal
postcholecytectomy diarrhea ) . Diarrhea improved
slightly, but still persists. Over the course of the
last 6 weeks, she has lost 13.2 lb (6 kg) , Her current W
W
weight is 127.9 lb (58 kg ). | m
3®

On physical examination, she appears less healthy

than you remember from prior visits. She is generally A
Ml
pale and has hyperpigmentation. Her blood pressure I Wm if
is 110/ 78 mm Hg, and pulse rate is 89 beats/ min . Mmtm

Laboratory test results: Laboratory test results:

Sodium = 130 mEq / L ( 136-142 mEq/ L ) Sodium = 138 mEq/ L ( 136-142 mEq/ L )
(SI: 130 mmol / L [ 136-142 mmol/ L ] ) (SI: 138 mmol / L [ 136 -142 mmol/ L] ) 1
i
Potassium = 5.4 mEq / L ( 3.5 - 5.0 mEq/ L ) Potassium = 3.7 mEq / L ( 3.5 - 5.0 mEq/ L)
(SI: 5.4 mmol/ L [ 3.5-5.0 mmol / L] ) (SI: 3.7 mmol/ L [ 3.5- 5.0 mmol / L] ) ;
1
Plasma renin activity = 60 ng / mL per h Late-night salivary cortisol ( 2 measurements) =
(0.6- 4.3 ng / ml per h ) 0.43 pg / dL (SI: 11.9 nmol/ L)
Plasma ACTH = 644 pg / mL (10-60 pg / mL ) Serum cortisol after overnight 1-mg dexamethasone
(SI: pmol/ L [ 2.2-13.2 pmol/ L] ) = 8.2 gg/ dL ( SI: 226.2 nmol / L)
TSH = 5.2 mlU / L (0.5-5.0 mlU/ L) Serum aldosterone = 4 ng / dL ( 4- 21 ng / dL)
Free T 4 = 1.0 ng/ dL ( 0.8-1.8 ng / dL) (SI: 111.0 pmol/ L [ 111.0- 582.5 pmol/ L ] )
(SI: 12.9 pmol/ L [ 10.30 - 23, 17 pmol / L ] ) Pregnancy test, negative

Which of the following is the most likely cause of this Which of the following studies should be ordered next?
patient's concerns? A. Plasma renin activity
A. Cholestyramine B. Adrenal MRI
B. Omeprazole C. Dexamethasone corticotropin -
C. Hashimoto disease releasing hormone test
D . Combined oral contraceptive D . Biopsy of the adrenal tumor
E. Atrophic gastritis E. Plasma ACTH measurement

I
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EHi docr\n & BOQRCI Review ]

 %\
m

#% A primary care physician refers a 32 - year - g% A 59 -year -old woman is referred for a second
tl old man because of an elevated plasma »* #M opinion regarding primary aldosteronism.
« *

WjtjCTH concentration. He has a 10- year history of She developed resistant hypertension in her early
primary adrenal insufficiency due to autoimmune 50s and was found to be hypokalemic 6 months ago
adrenalitis. He also has primary hypothyroidism on routine blood testing.
due to Hashimoto thyroiditis. The patient feels
ell and has no concerns. His medications
• Screening laboratory test results:
gjinclude hydrocortisone, 12.5 mg every morning • Sodium = 142 mEq/ L ( 136 - 142 mEq / L )
jfejjd5 mg every afternoon ; fludrocortisone , 50 meg (SI: 142 mmol/ L [136- 142 mmol/ L] )
jgdaily; and levothyroxine, 125 meg daily , Potassium = 3.2 mEq / L ( 3.5-5.0 mEq / L )
til On physical examination , he is a healthy (SI: 3.2 mmol / L [ 3.5-5.0 mmol/ L] }
appearing man with a blood pressure of Serum aldosterone = 22 ng/dL ( 4- 21 ng/dL)
| 122 /76 mm Hg, a regular pulse rate of 70 beats/ min ,
f (SI: 610.3 pmoI / L [ 111.0- 582.5 pmol/ L ] )
If
and a BMI of 24 kg / m . His skin is well pigmented
2
Plasma renin activity = < 0.6 ng/ mL per h
(0.6 - 4.3 ng/ mL per h )
in sun -exposed areas . Examination findings are
otherwise normal .
On the third day of a high -salt diet, the 24-hour
Laboratory test results: urine collection documents a sodium excretion of
Electrolytes, normal
>• Vi 240 mEq/ 24 h ( 240 mmol/ d ) and an aldosterone
Nil Plasma renin activity = 2.1 ng / mL per h excretion of 24 pg / 24 h ( 66.6 nmol/ d ) . CT with
(0.6 - 4.3 ng / mL per h ) fine cuts of the adrenals shows normal glands .
HI Serum TSH = 2.8 mlU / L (0.5- 5.0 mlU / L ) She undergoes adrenal venous sampling with
: "

<
:N
Plasma ACTH = 312 pg / mL ( 10- 60 pg / mL)
T
'
continuous infusion of cosyntropin at 50 meg
m
7N
(SI: 68.6 pmol / L [ 2.2 - 13.2 pmol / L. ) per h. The results are shown ( see table ) .
She is told that the source is the left adrenal
jjjj /n addition to reviewing sick - day corticosteroid gland on the basis of the high left adrenal vein
jjjmanagement, which of the following should you aldosterone concentration and the aldosterone -to-
jjt recommend?
saga
cortisol ratio.
i§LA. Discontinue hydrocortisone and substitute
prednisone , 5 mg in the morning and 2.5 mg How should the results of the adrenal venous sampling
in the afternoon study be interpreted?
B. Add dexamethasone, 0.75 mg orally at bedtime A. Unable to localize
C. Increase the hydrocortisone dosage to 20 mg in B. Left adrenal gland is the source (left adenoma)
:
£N; - the morning and 10 mg in the afternoon
.
C. Both adrenal glands are sources ( bilateral,
ifife
i; D. Increase the fludrocortisone dosage to idiopathic hyperaldosteronism )
100 meg daily D. Insufficient information to interpret whether
|§ Make no changes in his corticosteroid
* the study was successful
dosages E. Right adrenal gland is the source ( right adenoma)
0C
is
CSrsv -
ft -

H&; Measurement Right Adrenal Vein Left Adrenal Vein inferior Vena Cava
!|
|| § fgg . .

Aldosterone 36 ng/dL 6400 ng/dL 34 ng/dL

INN: (SI: 998.6 pmol/L) (Si: 177, 536 pmol/L) (SI: 943.2 pmol/L)

. £N - Cortisol 21 pg/dL 2000 pg/dL 19 pg/dL

SI: 579.4 nmol/L} (SI: 55,176 nmoi/L) (Si: 524.2 nmol/L)
A!dosterone - to - Corti$ ol Ratio 1.7 3.2 1.8

r- 1
Adrssusi Board Review - QUESTIONS 11
h- r .
-K ,, ...
R
: 1
m
:
m
Hi 1
.

•
ii •

-
> r

: I 1 A 25-year -old woman with congenital

«1 m A 56 -year - old man is referred for I
|
|
adrenal hyperplasia due to 21-hydroxylase I m&Im
sate evaluation of an incidentally discovered I
I
deficiency diagnosed at birth is transitioning to adrenal mass. He had not seen a physician in
adult care from her pediatric endocrinologist . Her 10 years, and he sought medical attention for l:
current treatment consists of hydrocortisone, postprandial abdominal pain. Abdominal CT 7
10 mg 3 times daily with meals, and fludrocortisone without contrast was obtained ( see image ). The I

acetate, 0.2 mg every evening . She has regular official interpretation is "1.2-cm left adrenal mass, 1
m
menses, is not sexually active, and is not attempting MRI can further characterize. ” His abdominal 1
i
to become pregnant. pain has since resolved with a 6- week course of
On physical examination, she has no acne omeprazole. His medical history is unremarkable.
i
or unwanted facial hair , purple striae, or skin On physical examination, he has no Cushingoid l
i
thinning. Her BMI is 25 kg / m2. Her blood stigmata. Blood pressure measurements obtained i
pressure is 117/ 74 mm Hg. She feels well and has in the clinic since he first presented have ranged %
7
no concerns . as follows: systolic 144-162 mm Hg and diastolic
She took her hydrocortisone today at 6 AM and 92-98 mm Hg ( even after resolution of his
12 PM, and her blood is drawn at 5:30 PM . abdominal pain ). 1
i

Laboratory test results ( 5:30 PM blood draw):

Sodium = 138 mEq / L (136-142 mEq/ L )
(SI: 138 mmol/ L [ 136 -142 mmol/ Lj ) 3
a

Potassium = 4.2 mEq / L ( 3.5-5.0 mEq / L ) 1•

(SI: 4.2 mmol / L [ 3.5 - 5.0 mmol/ L] )

Serum DHEA -S = < 15 pg/ dL ( 44 -332 pg / dL)
( SI: < 0.4 pmol/ L [ 1.19-9.00 pmol/ L] )
Serum testosterone = 40 ng/ dL ( 8-60 ng / dL)
( SI: L 4 nmol/ L [0.3- 2.1 nmol/ L] ) m
Plasma renin activity = 2.4 ng/ mL per h
(0.6- 4.3 ng / mL per h ) yS

Serum androstenedione = 90 ng / dL ( 80- 240 ng/ dL ) Laboratory test results:

(SI: 3.0 nmol/ L [ 2.79-8.38 nmol/ L] ) Potassium = 3.8 mEq/ L ( 3.5-5.0 mEq / L )
Serum 17 -hydroxyprogesterone = 4500 ng/ dL (SI: 3.8 mmol/ L [ 3.5 -5.0 mmol/ L] )
( < 80 ng/ dL) (SI: 136.4 nmol / L [ 2.42 nmol / L ] ) Plasma normetanephrine = 150 pg/ mL %

( < 165 pg / mL ) ( SI: 0.82 nmol/ L [ < 0.90 nmol/ L] )

Which of the following changes to her management Plasma metanephrine = 40 pg / mL { <99 pg/ mL)
should be recommended? (SI: 0.20 nmol/ L [ < 0.50 nmol/ L] )
A. No changes Serum cortisol (8 AM ) after overnight 1-mg
I
B. Increase the second dose of hydrocortisone to dexamethasone-suppression M
15 mg test = 0.4 pg / dL (SI: 11.0 nmol / L )
I
C. Switch hydrocortisone to dexamethasone, Fasting glucose = 80 mg/ dL ( 70- 99 mg / dL ) I
1 mg at bedtime (SI: 4.4 mmol/ L [ 3.9-5.5 mmol/ L] ) 'i

D. Divide hydrocortisone as 7.5 mg 4 times daily

E. Stop fludrocortisone acetate
1
1

m
I
Endocdne Hoard! n%vmw
m
 Which of the following is the best next step in this i
f vjl A 43-year-old woman is seen for follow-
patient's management? JLi . up of Cushing disease. She initially
A. Obtain 24 - hour urine collection to measure presented with hypertension, hypokalemia, muscle
metanephrines weakness, hirsutism, oligomenorrhea, and weight
B. Perform adrenal MRI gain over the last 2 years.
C. Measure serum DHEA -S and plasma ACTH
D. Repeat adrenal CT in 1 year Preoperative laboratory test results:
E . Measure serum aldosterone and plasma renin Late-night salivary cortisol = 0.82 pg / dL

jp:-
w- '
activity ( < 0.13 pg / dL ) (SI: 22.6 nmol/L [ < 3.6 nmol/ L] )
Urinary free cortisol = 850 pg/ 24 h ( 4-50 pg / 24 h )
r ?
m - I
JL
You are asked to evaluate for ( SI: 2346 nmol / d [ 11-138 nmol/ d ] )
Cushing syndrome in a 49-year- Basal plasma ACTH = 102 pg / mL (10- 60 pg / mL)
IS, oid man in the intensive care unit. Over the (SI: 22.4 pmol/ L [ 2.2 -13.2 pmol/ L] )

|
S?y
Ss : preceding 8 weeks, he experienced rapid onset
of hyperglycemia, hypertension , muscle weakness, Inferior petrosal sinus sampling and MRI
and psychosis. He was taken to the emergency confirmed a pituitary tumor, and she underwent
department by ambulance, where he was confused transsphenoidal surgery 6 weeks ago.
sr and hypoxic. Chest CT shows a 3-cm upper right Postoperatively, serial morning cortisol values
were less than 0.5 pg /dL ( < 13.8 nmol/ L) , and she
lung mass and hilar Iymphadenopathy. Both
ON" adrenal glands are uniformly enlarged to double was discharged on the third postoperative day and
m1
§
normal size. instructed to take hydrocortisone, 25 mg on arising
ST2 and 10 mg in the early afternoon (without her
tr ?
Laboratory test results: antihypertensive medications).
-
m .
Plasma ACTH = 420 pg/ mL ( 10-60 pg / mL )
(SI: 92.4 pmol / L [ 2.2 - 13.2 pmol / L; )
Her blood pressure has normalized, and she has
lost 8 lb (3.6 kg) . She describes diffuse muscle aches,
Serum cortisol = 180 pg / dL ( 5 - 25 pg / dL ) fatigue, and anorexia. She states, " 1 am sleeping all
(SI: 4966 nmol / L [ 137.9 -689.7 nmol / L ] ) day and feel worse than when I had Cushing s.”
*i*. . :
- Serum potassium = 2.4 mEq / L ( 3.5- 5.0 mEq / L ) On physical examination, her blood pressure
'
.
A
;
/
(SI: 2.4 mmol / L [ 3.5- 5.0 mmol / L ] ) is 120/80 mm Hg and pulse i ate is 70 beats/ min
*

ALT = 150 U / L ( 10- 40 U / L ) (SI: 2.5 pkat / L without orthostatic changes. Her Cushingoid
m
& A- .
[0.17-0.67 pkat / L ] ) features are beginning to resolve.
Ifo
In the emergency department, he was intubated Laboratory test results:
and ventilated before transfer to the intensive care Serum sodium = 136 mEq/ L ( 136 -142 mEq / L)
cv - •
. •'
•

\ unit. You suspect ectopic ACTH syndrome, but the ( SI: 136 mmol/ L [136-142 mmol/ L] )
. ..
patient is too ill for further evaluation. Serum potassium = 4.4 mEq / L ( 3.5-5.0 mEq/ L )
ig?£ . '
( SI: 4.4 mmol / L [ 3.5 -5.0 mmol/ L ] )
/T
:
Which of the following medications should be Fasting glucose = 80 mg /dL ( 70-99 mg/dL)
..
recommended immediately to treat his ( SI: 4.4 mmol / L [ 3.9- 5.5 mmol/ L ] )
hypercortisolemia? Serum cortisol ( 8 AM ) before first dose
A. Mitotane of hydrocortisone = < 0.5 pg/ dL ( 5 - 25 pg / dL )
- .
B. Pasireotide (SI: < 13.8 nmol / L [ 137.9 -689.7 nmol / L] )
C. Etomidate DHEA-S = <15 pg / dL (18-244 pg / dL )
D. Ketoconazole ( SI: < 0.41 pmol / L [ 0.49-6.61 pmol / L] )
E. Mifepristone Basal plasma ACTH = < 4 pg/ mL ( 10-60 pg/ mL)
( SI: < 0.9 pmol/ L [ 2.2 -13.2 pmol / L] )

Ac!renal Board Review - QUESTIONS

 I
. : :Is-

Which of the following should be done next to 5 mg daily. He remains intubated and has been
address her symptoms? treated with pressors and saline boluses for
A. Perform another pituitary MRI 3 days. His systolic blood pressure is 85 mm Hg,
B. Add fludrocortisone, 0.1 mg daily and pulse rate is 1.18 beats/ min. The team has
C Measure late-night salivary cortisol performed a cosyntropin-stimulation test and asks I
D. Increase the hydrocortisone dosage to 40 mg on . for assistance with interpretation of the results.

arising and 20 mg in the early afternoon

E. Add DHEA, 25 mg daily ‘
Results of cosyntropin-stimulation testing:
_
mM. | j
J8T it
A 42-year-old woman with
Basal serum cortisol = 15 pg / dL ( 5-25 pg / dL)
(SI: 413.8 nmol/ L [137.9-689.7 nmol/ L] )
JibTs recurrent Cushing disease is Stimulated serum cortisol = 16 pg / dL
commencing mifepristone therapy, 300 mg (SI: 441.4 nmol/ L )
daily. Her comorbidities from Cushing disease Serum glucose = 134 mg/ dL (70 - 99 mg/ dL)
include hypertension and diabetes mellitus for (SI: 7.4 mmol / L [ 3.9 -5.5 mmol/ L] )
which she takes amlodipine, 5 mg daily, and Serum albumin = 2.3 g /dL ( 3.5-5.0 g / dL )
metformin, 1500 mg daily. Her blood pressure is (SI: 23 g/ L [ 35- 50 g / L] )
135/ 85 mm Hg. Her menses have been irregular.
VCrfiich ofthe following do you recommend as the best
Laboratory test results: next step in this patient's evaluation and management?
Fasting glucose = 185 mg/ dL ( 70-99 mg/ dL ) A. Insulin tolerance test
(SI: 10.3 mmol/ L [3.9-5.5 mmol/ L] ) B. Serum DHEA-S measurement
Potassium = 3.7 mEq/ L ( 3.5-5.0 mEq/L ) C. Plasma ACTH measurement m
(SI: 3.7 mmol/ L [ 3.5- 5.0 mmol/ L ] ) D. Low-dose cosyntropin -stimulation test I

Serum cortisol = 22 pg / dL ( 5-25 pg/ dL ) E. No further testing

(SI: 606.9 nmol / L [137.9 - 689.7 nmol/ L ] )
Hemoglobin Alc = 8.5% ( 4.0%- 5.6% ) m c* A 33-year- old woman presents
( 69 mmol/ mol [ 20- 38 mmol/ mol] ) tia for evaluation of weight gain,
Plasma ACTH = 65 pg/ mL (10-60 pg / mL) depression, hirsutism, irregular menses,
( SI: 14.3 pmol / L [ 2.2-13.2 pmol/ L] ) and hypertension . Her symptoms began 2 i
Urinary free cortisol = 360 pg / 24 h ( 4- 50 pg / 24 h ) years ago and have been gradually progressive.
( SI: 993.6 nmol / d [11 -138 nmol/ d ] ) Her medications are an oral contraceptive i
( ethinylestradiol and drospirenone ) ; sertraline,
Which of the following parameters should be used to 100 mg daily; and omeprazole, 20 mg daily.
titrate the mifepristone dosage in this patient? On physical examination, she has facial
A. Urinary free cortisol excretion plethora, disproportionate supraclavicular fat
B. Return of regular monthly menses pads, 1- to 2 -cm nonblanching purple striae on
C. Plasma ACTH level the abdomen and upper arms, central obesity, and
D. Blood pressure proximal muscle weakness.
1
E. Fasting serum glucose level
Laboratory test results: i

> # I/; An endocrine consult is requested

"
Serum cortisol after 1 mg dexamethasone =
AS,: for a 72 -year -old man who is in the 25 pg/ dL (SI: 690 nmol/ L )
medical intensive care unit for hypovolemic Plasma ACTH = 188 pg/ mL ( 10- 60 pg / mL )
shock from sepsis. Before hospital admission , his (SI: 41.4 pmol/ L [ 2.2-13.2 pmol / L] )
?
only medications were metformin, 1000 mg Late- night salivary cortisol = 0.42 pg / dL
daily; lisinopril, 20 mg daily; and atorvastatin, ( <0.13 pg / dL ) ( SI: 11.6 nmol/ L [ < 3.6 nmol/ L ] )

j
14 Endocrine Board Review
 Repeat late- night salivary cortisol = 0.48 pg/ dL Which of the following is the most likely diagnosis?
( <0.13 pg / dL) ( SI: 13.2 nmol/ L [ < 3.6 nmol/ L ] ) A. Macronodular adrenocortical hyperplasia
-
Serum glucose = 125 mg / dL (70 99 mg/ dL ) B. Nonclassic 1 Ip - hydroxylase deficiency
(SI: 6.9 mmol/ L [ 3.9-5.5 mmol/ L ] ) C. Adrenocortical carcinoma
D. Ovarian hyperthecosis
MRI of the sella without and with contrast shows an E. Anabolic steroid abuse
irregular 2- mm area of delayed contrast enhancement
: ;

on the right side of the pituitary gland found only % lOl A 22-year -old woman is referred for
1
on the dynamic scans, which the radiology report * K
H0 evaluation of severe hypertension and
describes as ' consistent with pituitary adenoma.” adrenal masses. She has new -onset hypertension
and mild hyperglycemia. Her mother and a
Which of the following is the best next step in this maternal uncle also developed severe hypertension
.
patient' s management? before age 40 years. The uncle died of a myocardial
A. Stop the contraceptive for 6 weeks and repeat infarction, and the patient’s mother underwent
the dexamethasone-suppression test adrenalectomy for bilateral pheochromocytoma
B. Refer for pituitary surgery and ultimately died of metastatic renal cell cancer.
C. Measure 24-hour urinary free cortisol excretion
; D. Start mifepristone, 600 mg daily Laboratory test results:
E. Refer for inferior petrosal sinus sampling Sodium = 138 mEq/ L (136-142 mEq / L )
(SI: 138 mmol / L [136-142 mmol/ L] )
A 34-year-old woman presents Potassium = 3.8 mEq / L ( 3.5 -5.0 mEq / L )
17 with rapidly progressive hirsutism ,
secondary amenorrhea, balding, voice deepening,
(SI: 3.8 mmol/ L [ 3.5- 5.0 mmol / L ] )
Plasma normetanephrine = 1502 pg/ mL
and hypertension over the last 6 months. Her ( < 165 pg/ mL) (SI : 8.2 nmol / L [ < 0.90 nmol/ L] )
primary care physician has obtained some initial Plasma metanephrine = 60 pg/ mL ( < 99 pg / mL )
laboratory test results: (SI: 0.30 nmol/ L [ <0.50 nmol/ L] )
Sodium = 143 mEq/ L ( 136 -142 mEq/ L ) Serum aldosterone = 5 ng / dL ( 4-21 ng / dL )
( SI: 143 mmol/ L [ 136-142 mmol/ L ] ) (SI: 138.7 pmol/ L [111.0-582.5 pmol/ L ] )
Potassium = 3.1 mEq / L ( 3.5 - 5.0 mEq/ L ) Plasma renin activity = 2.4 ng / mL per h ( 0.6 -
( SI: 3.1 mmol/ L [ 3.5- 5.0 mmol/ L] ) 4.3 ng/ mL per h )
Serum aldosterone = < 4 ng / dL ( 4- 21 ng / dL )
( SI: <111.0 pmol/ L [ 111.0- 582.5 pmol/ L ] ) CT scan after intravenous contrast is shown
Plasma renin activity = < 0.6 ng / mL per h ( see image ).
(0.6 -4.3 ng / mL per h )
Plasma ACTH = 11 pg /mL (10 -60 pg/ mL )
( SI: 2.4 pmol/ L [ 2.2 -13.2 pmol/ L ] )
Serum cortisol ( 8 AM ) = 14 pg / dL ( 5-25 pg/ dL )
(SI: 386.2 nmol / L [ 137.9- 689.7 nmol/ L] )
Serum DHEA -S = 2833 pg/ dL ( 44-352 pg / dL)
( SI: 76.8 pmol / L [1.2-9.5 pmol/ L ] )
Serum 11- deoxycortisol = 282 ng / dL (10 - 79 ng / dL)
( SI: 8.5 nmol/ L [0.30- 2.39 nmol / L] )
Serum total testosterone = 310 ng/ dL ( 8-60 ng / dL)
( SI: 10.8 nmol / L [0.3- 2.1 nmol/ L] )
SHBG = 1.0 pg / mL ( 2.2-14.6 pg / mL)
( SI: 8.9 nmol/ L [ 20-130 nmol / L] )

A differ? of Board Review - QUESTIONS 15

.
 A pathogenic variant in which of the following genes is Repeated laboratory test results:
most likely responsible for pheochromocytoma in this Plasma ACTH ( 8 AM ) = 8 pg/ mL (SI: 1.8 pmol/ L )
kindred? Repeated plasma ACTH = 6 pg/ mL (SI: 1.3 pmol/ L )
A. RET Serum DHEArS = < 15 pg / dL (SI: < 0.41 pmol / L )
B. MEN 1 •Serum cortisol after 1 mg dexamethasone =
C. VHL 4.1 pg / dL tSI: 113.1 nmol/ L )
•

D. SDHD Urinary free cortisol = 28 pg/ 24 h (SI: 77.3 nmol/ d ) I

E. TMEM 127
Which of the following is the best recommendation for
L 1 v v A 55- year- old woman is referred for this patient's care?
| §
mevaluation of an incidentally discovered A. Delay medical or surgical therapy until urinary
right adrenal mass. The mass measures 3.4 cm free cortisol is clearly elevated
in diameter, the precontrast attenuation value B. Refer for petrosal sinus sampling
is -5 Hounsfield units, and there is more than C. Start medical treatment with mifepristone,
60% contrast medium 15 minutes after contrast 300 mg daily
administration. The left adrenal gland has no D. Refer for laparoscopic right adrenalectomy
nodularity. Her only medication is alendronate E. Perform fiuorodeoxyglucose- PET scan to
for osteoporosis. evaluate for malignant transformation
On physical examination, she has
borderline hypertension ( 144 / 92 mm Hg). Her '

LA 55-year - old woman presents

"
v :
weight is 169 lb ( 76.8 kg ) ( BMI - 29 kg / m 2). Sm for follow- up of adrenocortical
She has no facial plethora, dermal atrophy, cancer. She initially presented with ACTH -
bruising, or supraclavicular fat pads. independent hypercortisolism and androgen
excess, and a 9-cm adrenocortical cancer was
Initial laboratory test results: excised by open resection 12 weeks ago. She
Plasma ACTH ( 8 AM ) = 7 pg / mL (10-60 pg / mL ) developed adrenal insufficiency postoperatively.
(SI: 1.5 pmol / L [ 2.2 -13.2 pmol/ L] ) Due to aggressive histologic features, she
Repeated plasma ACTH = 8 pg / mL ( SI: 1.8 pmol / L ) was treated with mitotane 3 months ago and
Serum DHEA-S = 58 pg / dL (15-200 pg / dL ) advanced to a dosage of 1 g 6 times daily. Her last
( SI: 1.57 pmol/ L [0.41- 5.42 pmol / L] ) serum mitotane measurement was therapeutic
Serum cortisol after 1 mg dexamethasone = at 16 mg/ L. During the mitotane titration, she
4.2 pg / dL ( SI: 115.9 nmol/ L) experienced fatigue and anorexia, and based on
Repeated serum cortisol = 4.2 pg/ dL information she learned in an Internet chat group,
( SI: 115.9 nmol/ L ) she experimented with raising her hydrocortisone
Urinary free cortisol = 22 pg/ 24 h ( 4 -50 pg/ 24 h ) dosage to 60 mg on arising and 20 mg with lunch
( SI: 60.7 nmol/ d [ 11-138 nmol/ d ] ) and supper. At todays appointment, she reports 1
-
feeling much better taking the higher dosage
Two years later, the patient has gained of hydrocortisone. A senim cortisol value 3 hours
32 lb (14.5 kg ) ( BMI - 34 kg / m 2 ) . She has no after the morning hydrocortisone dose is 12 pg / dL
facial plethora, dermal atrophy, bruising, or ( 331.1 nmol/ L) .
supraclavicular fat pads. Hypertension is controlled
!
i
\
on amlodipine and losartan ( 132 / 80 mm Hg ) .
1
She is still taking alendronate and has started
,

l
metformin to treat diabetes (hemoglobin Alc = 6.9%
[ 52 mmol/ mol ] ) .
mi
: :y
|
:
it
i
!
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