When to Intervene for Subclinical Cushing's Syndrome

Association of chronic central serous chorioretinopathy with subclinical Cushing's syndrome

Purpose

To report the clinical course of a patient with central serous chorioretinopathy (CSCR) secondary to subclinical hypercortisolism before and after adrenalectomy.

Observations

A 50-year-old female patient with multifocal, chronic CSCR was found to have an adrenal incidentaloma and was diagnosed with subclinical hypercortisolism. Patient elected to undergo minimally-invasive adrenalectomy and presented at 3 months after surgery without subretinal fluid.

Conclusions and Importance

Subclinical Cushing's Syndrome (SCS) may present an underrecognized risk factor for developing chronic CSCR. Further investigation is needed to determine the threshold of visual comorbidity that may influence surgical management.

Hormonal Evaluation of Incidental Adrenal Masses: The Exception, Not the Rule

BACKGROUND

Incidental adrenal masses (IAMs) occur in approximately 4% of patients undergoing abdominal CT scans for any indication. Hormonal evaluation is recommended for all IAMs. The purpose of this study was to identify the rate of IAMs in a screening population and to determine the adequacy of endocrine evaluation of newly identified IAMs based on established guidelines.

METHODS

This was a retrospective analysis of 6913 patients undergoing a non-contrast screening CT colonography at a single academic medical center between June 2004 and July 2012.

RESULTS

The prevalence of IAMs in this asymptomatic screening population was 2.1% (n = 148). Of those patients, 8.8% (n = 11) underwent some form of hormonal evaluation and only 6.4% (n = 8) patients had a "complete" workup. Cortisol, metanephrines, and an aldosterone-renin ratio were evaluated in 8.0%, 7.2%, and 4.0% of patients, respectively. Of the patients (n = 11) who underwent hormonal evaluation, 27.3% had functional masses and 36.4% underwent surgery. Of those who did not have hormonal evaluation, 42.1% (n = 48) had comorbidities that should have prompted hormonal evaluation based on established guidelines. Hormonal evaluation was not performed in 89.4% of patients with hypertension and 21.1% of patients with diabetes. 88.9% of patients on three or more antihypertensive medications did not undergo any hormonal evaluation.

CONCLUSIONS

Compliance with IAM workup guidelines is poor, which may result in missed diagnosis of functional adrenal masses. Establishment of a robust protocol and education on appropriate workup for IAMs is necessary for adequate hormonal evaluation.