The 5% prevalence of heterozygous mutations discovered in our series is higher than initially thought and encourages GR mutation screening in patients with adrenal incidentalomas to unambiguously differentiate from Cushing's states and to optimize personalized follow-up.

A 29-year-old woman was referred for abdominal pain. Results of tests for lupus anticoagulant and antibodies to phosphatidylserine and to P,-glycoprotein I were positive, but the patient had no features of systemic lupus erythematosus (SLE). Abdominal ultrasonography showed a thickening of the gallbladder wall without cholelithiasis. A surgical procedure revealed necrotic areas of the gallbladder wall, and a cholecystectomy was performed. Histologic examination of the gallbladder showed multiple thrombi and no vasculitis. Despite full-dose heparin, the patient developed a catastrophic antiphospholipid syndrome (APS) and subsequently died. Among connective tissue disorders, acute acalculous cholecystitis has been reported in patients with polyarteritis nodosa and/or SLE. APS should be considered as a possible cause of acalculous cholecystitis.The antiphospholipid syndrome (APS) may be responsible for diverse manifestations affecting the liver and/or gut (1,2), but to date, gallbladder involvement has not been described. We describe here a patient who developed acalculous ischemic gallbladder necrosis as a feature of catastrophic APS. CASE REPORTA 29-year-old nulliparous woman was referred for abdominal pain of recent onset. Her medical history was unremarkable. She had been taking an estrogencontaining contraceptive pill for years, and used to smoke 10 cigarettes per day. On cxaniination, she was

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