Journal of Endocrinology and Metabolism, ISSN 1923-2861 print, 1923-287X online, Open Access
Article copyright, the authors; Journal compilation copyright, J Endocrinol Metab and Elmer Press Inc
Journal website http://www.jofem.org

Case Report

Volume 3, Number 1-2, April 2013, pages 29-37


Pitfalls in the Diagnosis of Ectopic Adrenocorticotropic Hormone Syndrome: A Case Report

Figures

Figure 1.
Figure 1. Octreoscan showing a single nodular lesion in the inferior third of the left hemithorax medial surface.
Figure 2.
Figure 2. Thoracic MRI showing a 1.8 cm of diameter, nodular lesion in the inferior left lobe of the pulmonary parenchyma.
Figure 3.
Figure 3. Atypical carcinoid lung tumour × 200.

Tables

Table 1A. Laboratory Testing on Admission
 
VariableReference Range, AdultsBasal values
Hemogram
  Hemoglobin (g/dL)13.0 - 17.513.8
  Hematocrit (%)40.0 - 50.039.4
  Mean Cell Volume (fL)80.0 - 97.093.1
  White-cell count (per µL)4,000 - 11,0008,900
  Neutrophils (%)57 - 6790
  Lymphocytes (%)25 - 336.5
  Eosinophils (%)1-30.1
  Platelet count (per µL)150,000 - 450,000119,000
Biochemistry
  Glucose (mg/dL)70 - 110288
  Urea nitrogen (mg/dL)10 - 5028
  Creatinine (mg/dL)0.7 - 1.20.6
  Sodium (mmol/L)135-145150
  Potassium (mmol/L)3.5 - 5.12.0
  Chloride (mmol/L)98 - 10796
  Urate (mg/dL)200 - 420136
  Aspartate Transaminase (U/L)0 - 3724
  Alanine Aminotransferase (U/L)10 - 4946
  Gamma-glutamyl transferase (U/L)< 7321
  Alkaline Phosphatase (U/L)45 - 129264
  Bilirubin (mg/dL)0.1 - 1.10.9
  Proteins (g/L)66 - 8763
  Albumin (g/L)34 - 4842
  Lactate dehydrogenase (U/L)208 - 3781,009
  Creatine Kinase (U/L)32 - 29455
  Calcium (mg/dL)8.6 - 10.28.3
  Phosphorus (mg/dL)2.7 - 4.51.5
  Magnesium (mg/dL)1.6 - 2.62.1
  Triglycerides (mg/dL)< 200164
  Total Cholesterol (mg/dL)< 200154
  HDL (mg/dL)< 35 (high risk)44
  C-reactive protein (mg/dL)< 0.50.05

 

Table 1B. Laboratory Testing on Admission
 
VariableReference Range, AdultsBasal Values
Endocrinology
  Insulin (mU/L)3 - 2526.4
  C peptide (ng/mL)0.8 - 3.96.16
  Glycated haemoglobin (%)< 6.0%6.3
  Parathyroid Hormone (pg/mL)14 - 7240.2
  Adrenocorticotropic Hormone (pg/mL)0 - 46212.0
  Cortisol (µg/dL)4.3 - 23 (8 a.m)77.9
  Hydroxyprogesterone (ng/mL)0.3 - 2.04.30
  Dehydroepiandrosteronesulfate (µg/dL)80 - 560375.0
  Delta 4-androstenedione (ng/mL)0.6 - 3.116.90
  11 Desoxycortisol - Compound S (ng/mL)Baseline: < 7.240.30
  Aldosterone (pg/mL)Standing: 40 - 310
Lying: 10 - 160
88.4
  Renin (pg/mL)Standing: 2 - 50
Lying: 1.6 - 15
2.2
  Thyroxin (µg/dL)4.5 - 10.96.6
  Thyroid Stimulating Hormone (µU/mL)0.35 - 5.500.70
  Free Thyroxin (ng/dL)0.89 - 1.801.20
  Triiodothyronine (ng/mL)0.60 - 1.810.68
  Follicle-stimulating hormone (U/L)> 16 years: 1.4 - 18.10.94
  Luteinizing Hormone (U/L)1.5 - 9.32.37
  Prolactin (ng/mL)2.1 - 17.712.8
  Estradiol (pg/mL)Man: < 52< 10.0
  Total Testosterone (ng/dL)241 - 827198.0
  Free Testosterone (pg/mL)8.8 - 2715.30
  Free Androgen Index14.8 - 94.853.8
  Sex-hormone Binding Globulin (nmol/L)13 - 7114.7
  Growth Hormone (ng/mL)0 - 1.00.09
  Insulin-like Growth Factor 1 (ng/mL)117 - 329118.0
Tumoral markers
  CEA (ng/mL)< 5.017.6
  CA 15.3 (U/mL)< 3243.4
  Chromogranin A (µg/L)< 1001473
  Glycoprotein Free alpha-subunit (µg/L)< 0.80.2
  Calcitonin (pg/mL)< 8.4< 5.00
  Human chorionic gonadotropin (ng/mL)0 - 2.5< 0.1
  Somatostatin (µg/L)< 5.61.4
  Serotonin (µg/L)117.5 - 193.3186
  Urinary 5-Hydroxyindoleacetic acid (mg/24h)0.7 - 8.212.8

 

Table 2. Low and High-Dose Dexamethasone Suppression Tests; CRH Stimulation Test
 
Reference Range, AdultsBasal ValuesPost- Low-Dose Dexamethasone
Suppression Test
Post- High-Dose Dexamethasone Suppression Test/Pre-CRHPost-CRH
15’
ACTH (pg/mL)0 - 46197115112
Cortisol (µg/dL)4.3 - 23 a.m.1101075259
Urinary Cortisol (µg/24h)/Urinary Creatinine (g/24h)28.5 - 214/ 0.8 - 2.07711,0221,200

 

Table 3. Inferior Petrosal Sinus Sampling With 1 µg/kg of Endovenous CRH at 0’
 
Inferior Petrosal Sinus Sampling with 1µg/kg endovenous CRH at 0’
Left Inferior Petrosal SinusRight Inferior Petrosal SinusPeripheral blood
ACTH 0’136140126
ACTH 15’143159128