1
|
Ornaghi S, Fernicola F, Marelli E, Perotti M, Di Gennaro F, Cameroni I, Mariani EM, Pincelli AI, Colciago E, Cetin I, Vergani P. Acute spontaneous non-hemorrhagic adrenal infarction in pregnancy: case-report and literature review. Gynecol Endocrinol 2023; 39:2234492. [PMID: 37486308 DOI: 10.1080/09513590.2023.2234492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023] Open
Abstract
Unilateral non-hemorrhagic adrenal infarction (NHAI) is a very uncommon cause of acute abdomen in pregnancy. Diagnosis is highly challenging due to its rarity, heterogeneity of clinical presentation, and inconclusiveness of the initial workup. Timely recognition is pivotal to ensuring optimal outcomes. Here we describe a case of spontaneous unilateral NHAI diagnosed in a singleton pregnant woman at 32 weeks' gestation at our centre and provide the findings of an extensive literature review on the topic. We identified 22 articles describing 31 NHAI cases in 30 obstetric patients: NHAI occurs more frequently on the right side and in the third trimester, and diagnosis is formulated more than 24 h after clinical presentation in 50% of cases; second-level imaging is always necessary to reach a definitive diagnosis and start appropriate treatment. A high degree of clinical suspicion is needed to promptly recognize NHAI in pregnancy, thus allowing appropriate multidisciplinary management and timely treatment initiation. Promotion of knowledge and awareness of NHAI as a potential cause of acute abdomen in pregnancy is mandatory to improve clinical practice and, ultimately, perinatal outcomes.
Collapse
Affiliation(s)
- Sara Ornaghi
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Federica Fernicola
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Elisabetta Marelli
- Department of Clinical and Biological Sciences, University of Milan, Milan, Italy
- Department of Woman, Mother, and Neonate, Buzzi Children's Hospital-ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Mario Perotti
- Department of Internal Medicine, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Irene Cameroni
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Eloisa M Mariani
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Angela I Pincelli
- Department of Internal Medicine, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Irene Cetin
- Department of Clinical and Biological Sciences, University of Milan, Milan, Italy
- Department of Woman, Mother, and Neonate, Buzzi Children's Hospital-ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Patrizia Vergani
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| |
Collapse
|
2
|
Lee JH, Torpy DJ. Adrenal insufficiency in pregnancy: Physiology, diagnosis, management and areas for future research. Rev Endocr Metab Disord 2023; 24:57-69. [PMID: 35816262 DOI: 10.1007/s11154-022-09745-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 02/01/2023]
Abstract
Adrenal insufficiency requires prompt diagnosis in pregnancy, as untreated, it can lead to serious consequences such as adrenal crisis, intrauterine growth restriction and even foetal demise. Similarities between symptoms of adrenal insufficiency and those of normal pregnancy can complicate diagnosis. Previously diagnosed adrenal insufficiency needs monitoring and, often, adjustment of adrenal hormone replacement. Many physiological changes occur to the hypothalamic-pituitary-adrenal (HPA) axis during pregnancy, often making diagnosis and management of adrenal insufficiency challenging. Pregnancy is a state of sustained physiologic hypercortisolaemia; there are multiple contributing factors including high plasma concentrations of placental derived corticotropin-releasing hormone (CRH), adrenocorticotropin (ACTH) and increased adrenal responsiveness to ACTH. Despite increased circulating concentrations of CRH-binding protein (CRH-BP) and the major cortisol binding protein, corticosteroid binding globulin (CBG), free concentrations of both hormones are increased progressively in pregnancy. In addition, pregnancy leads to activation of the renin-angiotensin-aldosterone system. Most adrenocortical hormone diagnostic thresholds are not applicable or validated in pregnancy. The management of adrenal insufficiency also needs to reflect the physiologic changes of pregnancy, often requiring increased doses of glucocorticoid and at times mineralocorticoid replacement, especially in the last trimester. In this review, we describe pregnancy induced changes in adrenal function, the diagnosis and management of adrenal insufficiency in pregnancy and areas requiring further research.
Collapse
Affiliation(s)
- Jessica H Lee
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| |
Collapse
|
3
|
Gardella B, Gritti A, Scatigno AL, Gallotti AMC, Perotti F, Dominoni M. Adrenal crisis during pregnancy: Case report and obstetric perspective. Front Med (Lausanne) 2022; 9:891101. [PMID: 36186806 PMCID: PMC9521595 DOI: 10.3389/fmed.2022.891101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Adrenal dysfunction (AD) and, in particular, adrenal crisis are uncommon events in pregnant women, but associated with significant maternal and fetal morbidity and mortality if untreated or undiagnosed. Adrenal crisis may be confused with the common symptoms of pregnancy: the obstetricians should be able to promptly diagnose and treat it in order to avoid the adverse outcomes regarding the mother and the fetus. For this reason, AD must be treated by an expert multidisciplinary team. We presented a case report of a young pregnant woman with adrenal crisis due to tuberculosis, cocaine abuse, and massive bilateral hemorrhage with symptoms of emesis, hypotension, sudden abdominal pain, and leukocytosis. The most common issues of diagnosis and treatment are discussed and analyzed. Finally, we performed a review of the literature regarding adrenal crisis and adrenal insufficiency (AI) in pregnancy in order to clarify the management of these diseases in obstetrics setting.
Collapse
Affiliation(s)
- Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Gritti
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- *Correspondence: Andrea Gritti,
| | - Annachiara Licia Scatigno
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Francesca Perotti
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| |
Collapse
|
4
|
Younes N, Bourdeau I, Lacroix A. Latent Adrenal Insufficiency: From Concept to Diagnosis. Front Endocrinol (Lausanne) 2021; 12:720769. [PMID: 34512551 PMCID: PMC8429826 DOI: 10.3389/fendo.2021.720769] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/09/2021] [Indexed: 11/22/2022] Open
Abstract
Primary adrenal insufficiency (PAI) is a rare disease and potentially fatal if unrecognized. It is characterized by destruction of the adrenal cortex, most frequently of autoimmune origin, resulting in glucocorticoid, mineralocorticoid, and adrenal androgen deficiencies. Initial signs and symptoms can be nonspecific, contributing to late diagnosis. Loss of zona glomerulosa function may precede zona fasciculata and reticularis deficiencies. Patients present with hallmark manifestations including fatigue, weight loss, abdominal pain, melanoderma, hypotension, salt craving, hyponatremia, hyperkalemia, or acute adrenal crisis. Diagnosis is established by unequivocally low morning serum cortisol/aldosterone and elevated ACTH and renin concentrations. A standard dose (250 µg) Cosyntropin stimulation test may be needed to confirm adrenal insufficiency (AI) in partial deficiencies. Glucocorticoid and mineralocorticoid substitution is the hallmark of treatment, alongside patient education regarding dose adjustments in periods of stress and prevention of acute adrenal crisis. Recent studies identified partial residual adrenocortical function in patients with AI and rare cases have recuperated normal hormonal function. Modulating therapies using rituximab or ACTH injections are in early stages of investigation hoping it could maintain glucocorticoid residual function and delay complete destruction of adrenal cortex.
Collapse
Affiliation(s)
| | | | - Andre Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| |
Collapse
|
5
|
Pituitary disease and pregnancy. ENDOCRINOL DIAB NUTR 2021; 68:184-195. [PMID: 34167698 DOI: 10.1016/j.endien.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/07/2020] [Indexed: 11/22/2022]
Abstract
Pregnancy results in a significant change in both pituitary gland size and function. Due to this physiological adaptation, the diagnosis and management of pituitary diseases during pregnancy represents a particularly complex challenge. The presence of a functioning pituitary adenoma may be harmful to the health of the mother and fetus, and scientific evidence regarding the safety of drugs normally used to control hormone excess during pregnancy is scarce. In addition, pregnancy may be associated with the risk of the growth of a pre-existing pituitary adenoma. This review focuses on the diagnostic challenges in pregnant women with adenomas secreting prolactin, growth hormone, or adrenocorticotropic hormone. Some evidence-based recommendations for the treatment of these conditions during pregnancy are provided, and algorithms that could help monitor a pituitary adenoma during pregnancy are examined. Mention is also made of how hormone replacement therapy can be optimised in pregnant women with hypopituitarism. Finally, differential diagnosis between Sheehan's syndrome and lymphocytic hypophysitis, two pituitary disorders that may occur during pregnancy or delivery, is discussed.
Collapse
|
6
|
Pituitary disease and pregnancy. ACTA ACUST UNITED AC 2021; 68:184-195. [PMID: 33358152 DOI: 10.1016/j.endinu.2020.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/19/2020] [Accepted: 07/07/2020] [Indexed: 12/30/2022]
Abstract
Pregnancy results in a significant change in both pituitary gland size and function. Due to this physiological adaptation, the diagnosis and management of pituitary diseases during pregnancy represents a particularly complex challenge. The presence of a functioning pituitary adenoma may be harmful to the health of the mother and fetus, and scientific evidence regarding the safety of drugs normally used to control hormone excess during pregnancy is scarce. In addition, pregnancy may be associated with the risk of the growth of a pre-existing pituitary adenoma. This review focuses on the diagnostic challenges in pregnant women with adenomas secreting prolactin, growth hormone, or adrenocorticotropic hormone. Some evidence-based recommendations for the treatment of these conditions during pregnancy are provided, and algorithms that could help monitor a pituitary adenoma during pregnancy are examined. Mention is also made of how hormone replacement therapy can be optimised in pregnant women with hypopituitarism. Finally, differential diagnosis between Sheehan's syndrome and lymphocytic hypophysitis, two pituitary disorders that may occur during pregnancy or delivery, is discussed.
Collapse
|
7
|
Sidibe S, Perazzini C, Cassagnes L, Boyer L, Magnin B. The role of computed tomography in adrenal gland infarction diagnosis during pregnancy: Two case reports. JOURNAL DE MÉDECINE VASCULAIRE 2020; 46:28-31. [PMID: 33546818 DOI: 10.1016/j.jdmv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Seydou Sidibe
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Chiara Perazzini
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France.
| | - Lucie Cassagnes
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Louis Boyer
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Benoit Magnin
- Radiology Department, University Hospital Estaing, Clermont-Ferrand, France
| |
Collapse
|
8
|
Nonhemorrhagic Adrenal Infarction in Pregnancy: Magnetic Resonance Imaging and Computed Tomography Evaluation. J Comput Assist Tomogr 2019; 43:884-886. [PMID: 31268880 DOI: 10.1097/rct.0000000000000887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present the case of unilateral nonhemorrhagic adrenal infarct in a 29-week pregnant 21-year-old woman. The patient presented with right upper quadrant pain, nausea, and vomiting. Ultrasonography of the right upper quadrant and appendix was negative for pathology. Magnetic resonance imaging of the abdomen demonstrated a right nonhemorrhagic adrenal infarct, subsequently confirmed with limited computed tomography of the upper abdomen. This case discusses the clinical presentation and pertinent imaging findings of adrenal infarction in pregnancy.
Collapse
|
9
|
Levin G, Elchalal U, Rottenstreich A. The adrenal cortex: Physiology and diseases in human pregnancy. Eur J Obstet Gynecol Reprod Biol 2019; 240:139-143. [PMID: 31284087 DOI: 10.1016/j.ejogrb.2019.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/18/2019] [Accepted: 06/28/2019] [Indexed: 11/28/2022]
Abstract
Pregnancy is characterized by marked alterations in the hypothalamic-pituitary-adrenal axis and in the function of the adrenal gland. Some of those alterations have clinical characteristics that are similar to those of adrenal gland disorders. While adrenal disorders are rare among pregnant women, they harbor the potential for significant morbidity if they remain unrecognized and untreated. As the majority of patients with adrenal disorders present with clinical features that are typical of normal pregnancy - diagnosis during pregnancy is not uncommonly delayed. A high index of suspicion must be practiced for these disorders as they might carry severe obstetrical negative outcomes. In this review we will survey the normal function of adrenal glands in pregnancy and the role of adrenal hormones in pregnancy. We will outline the adrenal disorders that commonly present during pregnancy and review the literature on treatment modalities.
Collapse
Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel.
| | - Uriel Elchalal
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
| |
Collapse
|
10
|
Petersenn S, Christ-Crain M, Droste M, Finke R, Flitsch J, Kreitschmann-Andermahr I, Luger A, Schopohl J, Stalla G. Pituitary Disease in Pregnancy: Special Aspects of Diagnosis and Treatment? Geburtshilfe Frauenheilkd 2019; 79:365-374. [PMID: 31000881 PMCID: PMC6461462 DOI: 10.1055/a-0794-7587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/14/2018] [Accepted: 11/10/2018] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and treatment of pituitary disease in pregnancy represents a special clinical challenge. Not least because there is very little data on the treatment of pregnant patients with pituitary disorders. A selective search of the literature was carried out with the aim of compiling evidence about the diagnosis and treatment of pituitary disease in pregnancy. The search covered the databases PubMed/MEDLINE including PubMed Central and also used the Livivo (ZB MED) search engine. Recent studies were evaluated for recommendations about the care of pregnant patients with hormone-inactive and hormone-active pituitary adenomas (prolactinoma, acromegaly and Cushing's disease), pituitary insufficiency, pituitary apoplexy and hypophysitis. The most well-established forms of treatment are for prolactinoma, due to the incidence of this disease and its impact on fertility. When pregnancy has been confirmed, prolactinoma treatment with dopamine agonists should be paused. Although microprolactinomas rarely increase significantly in size after the administration of dopamine agonists is discontinued, symptomatic tumor growth of macroprolactinomas can occur. In such cases, treatment with dopamine agonists can be resumed. If the primary tumor is large and the risk that it will continue to grow is high, it may be necessary to continue medical treatment from the start of pregnancy. If one of the partners has a pituitary disorder, it is often still possible for many couples to achieve their wish of having children if they receive medical support to plan and the pregnancy is carefully monitored. Given the complexity of pituitary disease, pregnant patients with pituitary disorders should be cared for and treated by a multidisciplinary team in centers specializing in the diagnosis and treatment of pituitary disease.
Collapse
Affiliation(s)
- Stephan Petersenn
- ENDOC Praxis für Endokrinologie, Andrologie und medikamentöse Tumortherapie, Hamburg, Germany
| | - Mirjam Christ-Crain
- Endokrinologie, Diabetologie & Metabolismus. Universitätsspital Basel, Basel, Switzerland
| | - Michael Droste
- Endokrinologie, Diabetologie, Hormonanalytik. MEDICOVER MVZ, Oldenburg, Germany
| | - Reinhard Finke
- Praxis an der Kaisereiche (üBAG), Berlin-Friedenau, Germany
| | - Jörg Flitsch
- Klinik und Poliklinik für Neurochirurgie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Anton Luger
- Universitätsklinik für Innere Medizin III, Klinische Abteilung für Endokrinologie & Stoffwechsel, Medizinische Universität Wien, Wien, Austria
| | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Günter Stalla
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.,Medicover Neuroendokrinologie, München, Germany
| |
Collapse
|
11
|
Anand G, Beuschlein F. MANAGEMENT OF ENDOCRINE DISEASE: Fertility, pregnancy and lactation in women with adrenal insufficiency. Eur J Endocrinol 2018; 178:R45-R53. [PMID: 29191934 DOI: 10.1530/eje-17-0975] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 11/30/2017] [Accepted: 11/30/2017] [Indexed: 12/21/2022]
Abstract
With the introduction of hormonal substitution therapy in the 1950s, adrenal insufficiency (AI) has been turned into a manageable disease in pregnant women. In fact, in the light of glucocorticoid replacement therapy and improved obstetric care, it is realistic to expect good maternal and fetal outcomes in patients with AI. However, there are still a number of challenges such as establishing the diagnosis of AI in pregnant women and optimizing the treatment of AI and related comorbidities prior to as well as during pregnancy. Clinical and biochemical diagnoses of a new-onset AI may be challenging because of overlapping symptoms of normal pregnancy as well as pregnancy-induced changes in cortisol values. Physiological changes occurring during pregnancy should be taken into account while adjusting the substitution therapy. The high proportion of reported adrenal crisis in pregnant women with AI highlights persistent problems in this particular clinical situation. Due to the rarity of the disease, there is no prospective data-guiding management of pregnancy in patients with known AI. The aim of this review is to summarize the maternal and fetal outcomes based on recently published case reports in patients with AI and to suggest a practical approach to diagnose and manage AI in pregnancy.
Collapse
Affiliation(s)
- Gurpreet Anand
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| |
Collapse
|
12
|
Peechakara S, Bena J, Clarke NJ, McPhaul MJ, Reitz RE, Weil RJ, Recinos P, Kennedy L, Hamrahian AH. Total and free cortisol levels during 1 μg, 25 μg, and 250 μg cosyntropin stimulation tests compared to insulin tolerance test: results of a randomized, prospective, pilot study. Endocrine 2017; 57:388-393. [PMID: 28730418 DOI: 10.1007/s12020-017-1371-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 07/01/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The appropriate cosyntropin dose during cosyntropin stimulation tests remains uncertain. We conducted a prospective, randomized pilot study to compare 1 μg IV low dose cosyntropin test, 25 μg IM medium dose cosyntropin test, and 250 μg IM standard dose cosyntropin test to evaluate secondary adrenal insufficiency. Insulin tolerance test was used as the gold standard. METHOD The study included patients with hypothalamic/pituitary disease (n = 10) with at least one pituitary axis deficiency other than ACTH deficiency and controls (n = 12). All tests were done in random order. Sensitivity and specificity were calculated for total cortisol and serum free cortisol cut-off levels during cosyntropin stimulation tests. RESULTS The median (range) age and F/M sex ratios for patients and controls were 54 years (23-62), 2/8, and 33 years (21-51), 6/6, respectively. The best total cortisol cut-off during low dose cosyntropin test, medium dose cosyntropin test, 30 min and 60 min standard dose cosyntropin test were 14.6 μg/dL (100% sensitivity & specificity), 18.7 μg/dL (100% sensitivity, 88% specificity), 16.1 (100% sensitivity & specificity), and 19.5 μg/dL (100% sensitivity & specificity), respectively. There was no difference in the ROC curve for cortisol values between the cosyntropin stimulation tests (p > 0.41). Using a cortisol cut-off of 18 μg/dL during cosyntropin stimulation tests, only cortisol level at 30 min during standard dose cosyntropin test provided discrimination similar to insulin tolerance test. The best peak free cortisol cut-off levels were 1 μg/dL for insulin tolerance test, 0.9 μg/dL for low dose cosyntropin test, 0.9 μg/dL for medium dose cosyntropin test, and 0.9 μg/dL and 1.3 μg/dL for 30 min and 60 min standard dose cosyntropin test, respectively. CONCLUSION All cosyntropin stimulation tests had excellent correlations with insulin tolerance test, when appropriate cut-offs were used. This pilot study does not suggest an advantage in using 25 μg cosyntropin dose during the cosyntropin stimulation test. A serum free cortisol cut-off of 0.9 μg/dL may be used as pass criterion during low dose cosyntropin test, standard dose cosyntropin test cosyntropin test, and 30 min standard dose cosyntropin test.
Collapse
Affiliation(s)
- Seenia Peechakara
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA.
| | - James Bena
- Quantitative Health Sciences, Lerner Research Institute, Cleveland, OH, 44195, USA
| | - Nigel J Clarke
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 92675, USA
| | - Michael J McPhaul
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 92675, USA
| | - Richard E Reitz
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 92675, USA
| | - Robert J Weil
- Brain Tumor and Neuro-Oncology Center and Department of Neurosurgery, The Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Pablo Recinos
- Brain Tumor and Neuro-Oncology Center and Department of Neurosurgery, The Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Laurence Kennedy
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Amir H Hamrahian
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
- Department of Endocrinology, Medical Subspecialty Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| |
Collapse
|
13
|
Rafii DC, Park P, Resta CA. Autoimmune Polyglandular Syndrome Type 2 In A Patient With Peripartum Cardiomyopathy. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161326.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
14
|
Gasco V, Berton A, Caprino MP, Karamouzis I, Maccario M, Ghigo E, Grottoli S. Acylated ghrelin as provocative test for the diagnosis of ACTH deficiency in patients with hypothalamus-pituitary disease. Endocrine 2015; 50:474-82. [PMID: 25487034 DOI: 10.1007/s12020-014-0494-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 11/25/2014] [Indexed: 01/03/2023]
Abstract
The insulin tolerance test (ITT) is the gold standard to evaluate adrenocorticotropic hormone (ACTH) insufficiency. However, alternative tests have been proposed such as metyrapone, glucagon, and ACTH stimulation test. We determined the diagnostic reliability of testing with ghrelin, the natural GH secretagogue that is a potent stimulus exploring the integrity of hypothalamic-pituitary-adrenal axis. We studied the ACTH and cortisol response to acylated ghrelin in 49 patients with history of pituitary disease. The best cortisol and ACTH cut offs to ghrelin test, defined as those with the best sensitivity (SE) and specificity (SP), were identified using the ROC analysis. We also compared accuracy of ghrelin test with that of a simple and cheap test like basal cortisol and ACTH levels. The best cortisol and ACTH cut offs to ghrelin test were ≤11.6 µg/dl (SE 86.4%, SP 77.8%) and ≤32.5 pg/ml (SE 72.7%, SP 51.9%), respectively; the best basal cortisol and ACTH cut offs were ≤10.7 µg/dl (SE 90.9%, SP 70.4%) and ≤25.0 pg/ml (SE 85%, SP 37%), respectively. The diagnostic accuracy was 81.6, 60.9, 79.6, and 57.4%, respectively. A comparison between ROC AUC showed a great diagnostic power for cortisol, both stimulated and basal, versus ACTH, both stimulated and basal, but no difference between stimulated and basal cortisol evaluation. Our data show that testing with acylated ghrelin is not a useful diagnostic tool for the diagnosis of central hypocortisolism; particularly ghrelin test adds no more information that basal cortisol evaluation in the diagnosis of ACTH deficiency in patients with hypothalamus-pituitary disease.
Collapse
Affiliation(s)
- Valentina Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Alessandro Berton
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Mirko Parasiliti Caprino
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Ioannis Karamouzis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Mauro Maccario
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Silvia Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy.
| |
Collapse
|
15
|
Abstract
Adrenal insufficiency is the clinical manifestation of deficient production or action of glucocorticoids, with or without deficiency also in mineralocorticoids and adrenal androgens. It is a life-threatening disorder that can result from primary adrenal failure or secondary adrenal disease due to impairment of the hypothalamic-pituitary axis. Prompt diagnosis and management are essential. The clinical manifestations of primary adrenal insufficiency result from deficiency of all adrenocortical hormones, but they can also include signs of other concurrent autoimmune conditions. In secondary or tertiary adrenal insufficiency, the clinical picture results from glucocorticoid deficiency only, but manifestations of the primary pathological disorder can also be present. The diagnostic investigation, although well established, can be challenging, especially in patients with secondary or tertiary adrenal insufficiency. We summarise knowledge at this time on the epidemiology, causal mechanisms, pathophysiology, clinical manifestations, diagnosis, and management of this disorder.
Collapse
Affiliation(s)
- Evangelia Charmandari
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.
| | - Nicolas C Nicolaides
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - George P Chrousos
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| |
Collapse
|
16
|
Abstract
A 25-year-old pregnant woman at 28 weeks gestational age presented with increasing abdominal pain and was found to have a unilateral adrenal infarction on a CT scan of the abdomen. Her medical history was unremarkable. There was no evidence of adrenal insufficiency with normal cortisol and adenocorticotropic hormone levels for pregnancy. Evaluation of thrombophilia disorders established the patient to be heterozygous for methylenetetrahydrofolatereductase C677T gene mutation as the only finding. The patient was anticoagulated to prevent contralateral thrombosis. At 32 weeks she experienced spontaneous rupture of membranes. One week later she delivered vaginally and remained anticoagulated for the puerperium.
Collapse
Affiliation(s)
- Paul-Ann D Green
- Department of OB-GYN and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Ivan M Ngai
- Department of OB-GYN and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Tony T Lee
- Department of Radiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - David J Garry
- Department of OB-GYN and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| |
Collapse
|