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Mizutani G, Isshiki M, Shimizu E, Saito D, Shimada A. Pheochromocytoma With High Adrenocorticotropic Hormone Production Capacity Without Pigmentation and Cushingoid Symptoms: A Case Report With a Literature Review. Cureus 2024; 16:e53358. [PMID: 38435205 PMCID: PMC10907887 DOI: 10.7759/cureus.53358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Pheochromocytoma or paraganglioma (PPGL) originating from chromaffin cells can produce diverse hormones in addition to catecholamines, including adrenocorticotropic hormone (ACTH). In pheochromocytoma, high levels of ACTH might not result in pigmentation as typically observed in Addison's disease, and patients might not exhibit the symptoms of Cushing's syndrome, despite ACTH-dependent hypercortisolism. A 63-year-old male patient with hypertension was admitted to our facility, and computed tomography (CT) revealed a large right adrenal tumor. Despite high plasma ACTH (700-1300 pg/mL) and serum cortisol (90-100 µg/dL) levels, no physical pigmentation or Cushingoid symptoms were observed. Urinary metanephrine and normetanephrine levels reached as high as 16.0 mg and 3.2 mg, respectively. 123I-metaiodobenzylguanidine (MIBG) scintigraphy was negative. Low-dose dexamethasone paradoxically increased ACTH and cortisol levels, indicating the potential positive feedback regulation of both hormones by glucocorticoids. The patient was diagnosed with an ACTH-producing pheochromocytoma and underwent successful laparoscopic surgery to remove the adrenal tumor under the intravenous administration of a high-dose α-blocker and hydrocortisone. The levels of ACTH, cortisol, and urinary metanephrine/normetanephrine returned close to normal after tumor removal. We report a rare case of pheochromocytoma with extremely high ACTH/cortisol production but without pigmentation or Cushingoid symptoms. We also reviewed previous reports of ACTH-producing PPGL regarding the paradoxical regulation of ACTH/cortisol by glucocorticoids, pigmentation, Cushingoid symptoms, and negativity of 123I-MIBG scintigraphy.
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Affiliation(s)
- Gen Mizutani
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Masashi Isshiki
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Eisuke Shimizu
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Daigo Saito
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
| | - Akira Shimada
- Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, JPN
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Liu S, Liu Z, Chen F, Xu W, Yuan G. Adrenocorticotropic Hormone-Producing Paraganglioma With Low Plasma ACTH Level: A Case Report and Review of the Literature. Front Endocrinol (Lausanne) 2019; 10:936. [PMID: 32038491 PMCID: PMC6985366 DOI: 10.3389/fendo.2019.00936] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/24/2019] [Indexed: 11/13/2022] Open
Abstract
Ectopic adrenocorticotropic hormone (ACTH) syndrome caused by paraganglioma is extremely rare. It usually accompanied by high or normal plasma ACTH level. Here we described a male who presented with ectopic ACTH-producing paraganglioma and a low plasma ACTH level. Immunohistochemistry and immunofluorescence confirmed ACTH production in focal paraganglioma cells. This unusual case expanded the spectrum of ACTH-dependent Cushing's syndrome and revealed a potential mechanism of this unique clinical phenotype. Besides, the literature concerning ACTH-producing paraganglioma is reviewed.
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Iezzi ML, Lasorella S, Varriale G, Zagaroli L, Ambrosi M, Verrotti A. Clitoromegaly in Childhood and Adolescence: Behind One Clinical Sign, a Clinical Sea. Sex Dev 2018; 12:163-174. [PMID: 29804109 DOI: 10.1159/000489385] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2017] [Indexed: 12/28/2022] Open
Abstract
The clitoris is a highly complex organ whose structure has only been clarified in recent years through the use of modern imaging techniques. Clitoromegaly is an abnormal enlargement of this organ. It may be congenital or acquired and is usually due to an excess of androgens in fetal life, infancy, or adolescence. Obvious clitoromegaly in individuals with ambiguous genitalia is easily identifiable, whereas borderline conditions can pass unnoticed. Case reports of clitoromegaly with or without clinical or biochemical hyperandrogenism are quite numerous. In these subjects, a comprehensive physical examination and an accurate personal and family history are needed to investigate the enlargement. We reviewed the literature on the conditions that may be involved in the development of clitoromegaly in childhood and adolescence.
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Chen F, Wang X, Wang Y, Meng H, Hou X, Zhu Y, Gao W, Jiang X, Chen S, Zhang Z, Zou Z, He T, Yang Y, Zhu K, Wang Y, Liu Y, Cui J, Shi B, Yin G. Ectopic Cushing's syndrome due to retroperitoneal ACTH-producing paragangliomas. Can Urol Assoc J 2016; 10:E320-E323. [PMID: 27695589 DOI: 10.5489/cuaj.3153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Extra-adrenal pheochromocytomas, or paragangliomas, are rare tumours that derive from extra-adrenal chromaffin cells. Cushing's syndrome (CS) caused by paragangliomas is extremely rare. We report a 53-year-old man with hypertension, diabetes, and symptoms of hypokalemia. Computer tomography (CT) revealed two retroperitoneal masses and bilateral adrenal hyperplasia. Together with the laboratory examinations, ectopic CS caused by multiple paragangliomas was highly suspected. The patient underwent resections of retroperitoneal tumours, left kidney, and left adrenal; postoperative histopathology confirmed two paragangliomas that were both positively stained for adrenocorticotropic hormone (ACTH). He got clinical and biochemical recoveries without any recurrent evidence at the nine-month followup.
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Affiliation(s)
- Fan Chen
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China;; College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Xiangyu Wang
- Department of Urology, The People's Hospital of Liaocheng, Liaocheng, Shandong, China
| | - Yang Wang
- Department of Urology, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Hui Meng
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Xinguo Hou
- Department of Endocrinology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Yaofeng Zhu
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Wei Gao
- Department of Pathology, Qilu Hospital, Shandong University, Jinan, Shandong, China;; Department of Pathology, Jinan Central Hospital, Shandong University, Jinan, Shandong, China
| | - Xuewen Jiang
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Shouzhen Chen
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Zhaocun Zhang
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Zhichuan Zou
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Tianyi He
- Department of Endocrinology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Yue Yang
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Kejia Zhu
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Yong Wang
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Yaxiao Liu
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Jianfeng Cui
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Benkang Shi
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Gang Yin
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Shandong, China
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Thomas T, Zender S, Terkamp C, Jaeckel E, Manns MP. Hypercortisolaemia due to ectopic adrenocorticotropic hormone secretion by a nasal paraganglioma: a case report and review of the literature. BMC Res Notes 2013; 6:331. [PMID: 23958171 PMCID: PMC3765299 DOI: 10.1186/1756-0500-6-331] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adrenocorticotropic hormone-producing extraadrenal paragangliomas are extremely rare. We present a case of severe hypercortisolemia due to ectopic adrenocorticotropic hormone secretion by a nasal paraganglioma. CASE PRESENTATION A 70-year-old Caucasian woman, was emergently admitted to our department with supraventricular tachycardia, oedema of face and extremities and hypertensive crisis. Initial laboratory evaluation revealed severe hypokalemia and hyperglycemia without ketoacidosis, although no diabetes mellitus was previously known. Computed tomography revealed a large tumor obliterating the left paranasal sinus and a left-sided adrenal mass. After cardiovascular stabilisation, a thorough hormonal assessment was performed revealing marked adrenocorticotropic hormone-dependent hypercortisolism. Due to the presence of a cardiac pacemaker magnetic resonance imaging of the hypophysis was not possible. [68Ga-DOTA]-TATE-Positron-Emission-Tomography was performed, showing somatostatin-receptor expression of the paranasal lesion but not of the adrenal lesion or the hypophysis. The paranasal tumor was resected and found to be an adrenocorticotropic hormone-producing paraganglioma of low-proliferative rate. Postoperatively the patient became normokaliaemic, normoglycemic and normotensive without further need for medication. Genetic testing showed no mutation of the succinatdehydrogenase subunit B- and D genes, thus excluding hereditary paragangliosis. CONCLUSION Detection of the adrenocorticotropic hormone source in Cushing's syndrome can prove extremely challenging, especially when commonly used imaging modalities are unavailable or inconclusive. The present case was further complicated by the simultaneous detection of two tumorous lesions of initially unclear biochemical behaviour. In such cases, novel diagnostic tools - such as somatostatin-receptor imaging - can prove useful in localising hormonally active neuroendocrine tissue. The clinical aspects of the case are discussed and relevant literature is reviewed.
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Affiliation(s)
- Theodoros Thomas
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
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Al-Shebail MM, Qureshi VF. Malignancies in Clitoris: A Review of Literature on Etiology, Diagnosis, Pathology and Treatment Strategies. ACTA ACUST UNITED AC 2008. [DOI: 10.3923/ijcr.2008.110.126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Uysal M, Temiz S, Gul N, Yarman S, Tanakol R, Kapran Y. Hypoglycemia due to ectopic release of insulin from a paraganglioma. HORMONE RESEARCH 2007; 67:292-5. [PMID: 17284922 DOI: 10.1159/000099291] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Accepted: 08/09/2006] [Indexed: 11/19/2022]
Abstract
Insulin-secreting pancreatic tumors and insulin-like growth hormone-secreting non-islet cell tumors can cause hypoglycemia. However, insulin-releasing paraganglioma or pheochromocytoma has almost never been reported. A 67-year-old female patient was admitted to our hospital because of headache, palpitation, perspiration, faintness, frequent sense of hunger and absent-mindedness. These intermittent symptoms had begun approximately a year before admission. On physical examination, she had high blood pressure of 150/90 mm Hg. Hormonal studies demonstrated increased urinary norepinephrine levels, and hyperinsulinemic hypoglycemia was confirmed while the patient was symptomatic. Abdominal MRI revealed a retroperitoneal mass measuring 4.5 cm in the pancreatic region. She was treated with an alpha-blocking agent to control blood pressure preceding the removal of the mass. Histopathological diagnosis was paraganglioma, and immunohistochemically insulin staining in the neoplastic cells was demonstrated. Her blood pressure normalized and hypoglycemia relieved after the operation. The patient did not have recurrence of hypoglycemia after a year of follow-up. Paraganglioma is a rare tumor of the neural crest, and co-secretion of insulin and catecholamines has been reported only by a single case report in the literature. The present patient is another case with this co-secretion.
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Affiliation(s)
- M Uysal
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Capa, Istanbul, Turkey.
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Dahir KM, Gonzalez A, Revelo MP, Ahmed SR, Roberts JR, Blevins LS. Ectopic adrenocorticotropic hormone hypersecretion due to a primary pulmonary paraganglioma. Endocr Pract 2005; 10:424-8. [PMID: 15760790 DOI: 10.4158/ep.10.5.424] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present a rare case of primary paraganglioma of the lung, which caused the syndrome of ectopic adrenocorticotropic hormone (ACTH) hypersecretion. METHODS The clinical, biochemical, and imaging findings in this case are described, and the pathologic features of the resected tumor tissue are depicted. In addition, the related literature on paragangliomas is reviewed. RESULTS In a 39-year-old woman with hypertension, weight gain, and easy bruising, laboratory studies showed hypercortisolemia, high plasma ACTH levels, and suppression of cortisol by high-dose dexamethasone. An indium-labeled octreotide whole-body scan disclosed a tumor in the left lower lung field. Thoracoscopic wedge resection of the pulmonary mass was performed. Postoperative microscopic findings and immunohistochemical stains revealed nests of rounded and polyhedral cells and S-100 protein-positive sustentacular (supporting) cells, charac- CONCLUSION This unusual case of Cushing's syndrome was attributable to an ACTH-secreting primary pulmonary paraganglioma.
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Finkenstedt G, Gasser RW, Höfle G, Lhotta K, Kölle D, Gschwendtner A, Janetschek G. Pheochromocytoma and sub-clinical Cushing's syndrome during pregnancy: diagnosis, medical pre-treatment and cure by laparoscopic unilateral adrenalectomy. J Endocrinol Invest 1999; 22:551-7. [PMID: 10475154 DOI: 10.1007/bf03343608] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The coexistence of pheochromocytoma and primary adrenal Cushing's syndrome of the same adrenal gland has rarely been reported. We describe here the case of a female patient presenting with mild Cushing's stigmata, hypertension and diabetes mellitus in whom we diagnosed a pheochromocytoma of the left adrenal gland with coexisting non-ACTH-dependent cortisol hypersecretion. While hormonal work-up was still in progress, the patient became pregnant and wanted to carry her pregnancy to full-term. A laparoscopic adrenalectomy in the 17th week of gestation was decided upon and the patient accordingly prepared for surgery by pre-treatment with phenoxybenzamine. Successful surgery--the first ever reported laparoscopic resection of a pheochromocytoma in pregnancy--without perioperative complications was performed under general anesthesia, with the patient receiving peri- and post-operative hydrocortisone substitution. Pathohistological examination revealed a pheochromocytoma with positive immunostaining for interleukin-6 (IL-6) and negative immunostaining for ACTH, vasoactive intestinal polypeptide (VIP) and cytochrome P450, and with no signs of malignancy. A paracrine stimulation of the ipsilateral adrenal cortex by IL-6 produced by the pheochromocytoma, leading to cortical hyperplasia and subclinical Cushing's syndrome, is suggested by the positive immunostaining for IL-6 and the MRI findings. Post-operatively, secondary adrenal insufficiency ensued, necessitating continuing hydrocortisone replacement over 12 months. Hypertension resolved after surgery, and diabetes after the uncomplicated vaginal delivery at term.
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Affiliation(s)
- G Finkenstedt
- Department of Internal Medicine, University of Innsbruck, Austria.
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Silistreli E, Acikel U, Oto O, Catalyurek H, Sariosmanoglu N, Narin C, Sagol O, Kargi A, Ucan ES. Primary Pulmonary Paraganglioma. Asian Cardiovasc Thorac Ann 1998. [DOI: 10.1177/021849239800600421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 2-cm nodular mass was detected by thoracic computed tomography in the peripheral region of the right middle lobe of the lung in a 60-year-old female with a 5-year history of cough and respiratory distress. The resected tumor was diagnosed as a primary paraganglioma on pathologic examination.
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Affiliation(s)
| | | | | | | | | | | | - Ozgul Sagol
- Department of Pathology Dokuz Eylul Medical Faculty İzmir, Turkey
| | - Aydanur Kargi
- Department of Pathology Dokuz Eylul Medical Faculty İzmir, Turkey
| | - Eyup Sabri Ucan
- Department of Pulmonary Medicine Dokuz Eylul Medical Faculty İzmir, Turkey
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Weber A, Trainer PJ, Grossman AB, Afshar F, Medbak S, Perry LA, Plowman PN, Rees LH, Besser GM, Savage MO. Investigation, management and therapeutic outcome in 12 cases of childhood and adolescent Cushing's syndrome. Clin Endocrinol (Oxf) 1995; 43:19-28. [PMID: 7641408 DOI: 10.1111/j.1365-2265.1995.tb01888.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Cushing's syndrome in childhood and adolescence is rare. We analysed the clinical presentation, investigation, management and therapeutic outcome in 12 paediatric patients with Cushing's syndrome. DESIGN Retrospective review of case notes. PATIENTS Twelve patients, 7 males and 5 females, aged 7.6-17.8 years with Cushing's syndrome who were admitted to St Bartholomew's Hospital between 1978 and 1993, were studied. Aetiologies of the Cushing's syndrome patients were: Cushing's disease (9), adrenal adenoma (1), nodular adrenocortical dysplasia (1) and ectopic ACTH syndrome (1). One further male patient, aged 17.8 years who presented with Nelson's syndrome after bilateral adrenalectomy for Cushing's disease in 1978, is described. MEASUREMENTS Presenting symptoms, endocrine tests for hypercortisolism, imaging studies, simultaneous bilateral inferior petrosal sinus sampling and therapeutic strategies are discussed. RESULTS The dominant clinical features were obesity, short stature, virilization, headaches, fatigue and emotional lability. Investigations confirmed Cushing's syndrome by demonstrating absent cortisol circadian rhythm and impaired suppression on low dose dexamethasone test and differentiated Cushing's disease from other aetiologies by high dose dexamethasone and hCRH tests. In Cushing's disease, pituitary CT scan identified a microadenoma in 4 out of 9 subjects. In 5 of the 9 patients (3 with a normal pituitary CT, 2 with a suggested microadenoma), a pituitary MRI scan was performed and confirmed the CT findings. Inferior petrosal sinus catheterization for ACTH in 4 patients confirmed excess pituitary ACTH secretion, correctly lateralizing the tumour in all cases. Cushing's disease was treated by transsphenoidal surgery alone in 6 patients and combined with pituitary irradiation in 3 patients. Of these 9 patients, 7 are cured and 2 are in remission. The patient with Nelson's syndrome is cured after total hypophysectomy. CONCLUSIONS This series describes the clinical features, aetiologies and management of juvenile Cushing's syndrome. Investigation with low and high-dose dexamethasone suppression tests and hCRH test identified the aetiology in each case. Collaboration between paediatric and adult endocrine units together with an experienced neurosurgeon and a radiotherapist contributed to the successful therapeutic outcome of these patients.
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Affiliation(s)
- A Weber
- Division of Paediatric Endocrinology, St Bartholomew's Hospital, London, UK
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