Periodic ACTH discharge

Diagnostic challenges in cyclic Cushing's syndrome: a systematic review

Cyclic Cushing's syndrome is a subentity of Cushing's syndrome in which phases of biochemical hypercortisolism (peaks) are followed by spontaneous periods of physiological or even hypocortisolaemic cortisol secretion (troughs). To identify common features of cyclic Cushing's syndrome, we systematically reviewed single case reports and case series in MEDLINE from database inception to Oct 10, 2022, and identified 707 articles, of which 149 articles were assessed for eligibility and 118 articles (covering 212 cases) were included in the analysis. Pituitary tumours accounted for 67% of cases of cyclic Cushing's syndrome (n=143), ectopic tumours for 17% (n=36), and adrenal tumours for 11% (n=23). Occult tumours accounted for 2% of cases (n=4), and 3% of cases were unclassified (n=6). We compared the clinical symptoms and comorbidities of patients with cyclic Cushing's syndrome with those of patients with non-cyclic Cushing's syndrome and observed no major difference. In adrenocorticotropic hormone (ACTH)-dependent cyclic Cushing's syndrome, bilateral inferior petrosal sinus sampling had a positive (ie, true pituitary) and negative (ie, true ectopic) predictive value of 100% when performed during periods of hypercortisolism, versus a positive predictive value of 73% and a negative predictive value of 86% when performed, irrespective of cortisolaemic status. Overall, 6% of patients (n=12) with cyclic Cushing's syndrome had unnecessary surgery due to misclassification. Remission rates were significantly lower and the time to remission significantly longer in patients with cyclic Cushing's syndrome compared with patients with non-cyclic Cushing's syndrome (p<0·001). Variations in biochemical test results due to unpredictable cycle duration and frequency might cause diagnostic challenges resulting in misdiagnoses and missed diagnoses.

Cyclic Vomiting Syndrome in Infants and Children: A Clinical Follow-Up Study

BACKGROUND

Cyclic vomiting syndrome is characterized by recurrent vomiting that is associated with increased adrenocorticotropic hormone and antidiuretic hormone levels during cyclic vomiting syndrome attacks. However, both prognosis and treatment remain unclear. We therefore evaluated the clinical features, prognosis, and effectiveness of the prophylaxis of cyclic vomiting syndrome as well as the relationship between symptoms and adrenocorticotropic hormone/antidiuretic hormone levels.

METHODS

We included 31 patients with cyclic vomiting syndrome who were admitted to Teikyo University between 1996 and 2008. All patients were diagnosed with cyclic vomiting syndrome based on the criteria of the second edition of the International Headache Classification. The patients (25 of 31) were followed until 2013.

RESULTS

The median overall duration of the disorder was 66 (3-179) months. Follow-up was completed for 25 patients with cyclic vomiting syndrome, of whom 44% (n = 11) developed migraine. Valproic acid, valproic acid with phenobarbital, phenobarbital, and amitriptyline were effective in nine, four, three, and one patients, respectively. Abnormally high adrenocorticotropic hormone (n = 17) and antidiuretic hormone (n = 18) levels were found among the 25 patients for whom follow-up data were available. The following correlations were significant: attack duration and adrenocorticotropic hormone levels (correlation coefficient: 0.5153, P = 0.0084) and attack duration and antidiuretic hormone levels (correlation coefficient: 0.5666, P = 0.0031). Antidiuretic hormone levels in patients with bilious vomiting were higher than in those without bilious vomiting (P = 0.048).

CONCLUSIONS

Most patients with cyclic vomiting syndrome recovered completely and benefited from prophylactic therapy, although half of them developed migraines.

Paediatric cyclical Cushing's disease due to corticotroph cell hyperplasia

BACKGROUND

Cushing's disease is very rare in the paediatric population. Although uncommon, corticotroph hyperplasia causing Cushing's syndrome has been described in the adult population, but appears to be extremely rare in children. Likewise, cyclical cortisol hypersecretion, while accounting for 15 % of adult cases of Cushing's disease, has only rarely been described in the paediatric population. Here, we describe a very rare case of a 13-year old boy with cyclical cortisol hypersecretion secondary to corticotroph cell hyperplasia.

CASE PRESENTATION

The case is that of a 13-year old boy, presenting with a long history of symptoms and signs suggestive of hypercortisolism, who was found to have cyclical ACTH-dependent hypercortisolism following dynamic pituitary testing and serial late-night salivary cortisol measurements. The patient underwent endoscopic transsphenoidal resection of the pituitary. Early surgical remission was confirmed by undetectable post-operative morning plasma cortisol levels. Histology and immunocytochemistry of the resected pituitary tissue showed extensive corticotroph cell hyperplasia.

CONCLUSION

This report describes a rare case of cyclical Cushing's disease secondary to corticotroph hyperplasia in a paediatric patient. This highlights the challenging and varied nature of Cushing's disease and its diagnosis, and the need to keep a differential diagnosis in mind during the diagnostic process.

Successful treatment with sumatriptan in a case with cyclic vomiting syndrome combined with 18q- syndrome

The authors present a 14-year-old girl with 18q- syndrome combined with cyclic vomiting syndrome. Since the age of 5 years, she has been admitted to hospital 30 times. Despite trying many prophylactic treatments, no medication has inhibited the vomiting attacks successfully. Intranasal sumatriptan was effective at halting the vomiting attacks. This is the first case of 18q- syndrome combined with cyclic vomiting syndrome successfully treated with sumatriptan. This report may allow us to consider sumatriptan use in patients suffering from misery attack of cyclic vomiting syndrome combined with chromosomal abnormality of 18q- syndrome.

Cyclic vomiting syndrome: a brain-gut disorder

Despite the "black box" surrounding CVS, the authors' understanding of this clinical entity has advanced substantially in the last decade as a result of an international interdisciplinary clinical and research effort. Although CVS is now recognized as a unique clinical entity, patients still undergo innumerable hospitalizations and diagnostic tests. Although controlled therapeutic studies are lacking, reasonably effective empiric approaches have been developed by trial and error using anti-migraine, anti-emetic, and anti-epileptic regimens. The ongoing investigations of migraine mechanisms through NMR spectroscopy, mitochondrial DNA mutations and cellular energetics, corticotropin-releasing factor and gastric motility, and brainstem regulation of autonomic function may lead to breakthroughs in the understanding of and new therapies for CVS in the next decade.

[On the subject of the cyclic vomiting syndrome]

The cyclic vomiting syndrome is defined by episodes of vomiting lasting from hours to days with free intervals between episodes. Various symptoms can be associated with vomiting: nausea, abdominal pain, photophobia, fever, pallor, dehydratation, excess salivation, social withdrawal. Some factors often precipitate the crisis: infection, psychological stresses, menstruation. Excluding a medical condition, especially a gastro-intestinal or a neurological disease is compulsory for the diagnostic of cyclic vomiting syndrome. The cyclic vomiting syndrome shares many common features with migraine including treatment. Due to negative paraclinical testing, a psychiatric disease is often suspected in these children. Pathophysiology of cyclic vomiting syndrome is unknown. As for migraine, mitochondrial and ionic channels abnormalities are thought to play a role. Overactivation of hypothalamic-pituitary-adrenal axis and autonomic dysfunction seem to be involved too. Three clinical vignets will illustrate these aspects.

Is cyclic vomiting syndrome related to migraine?

OBJECTIVE

To examine the overlap between cyclic vomiting syndrome (CVS) and migraine by comparing 2 subsets of children with migraine-associated and non-migraine-associated CVS.

METHODS

We studied all children <18 years of age who met the consensus criteria for CVS after presentation to our pediatric gastroenterology service from 1986 to 1998. The clinical patterns and responses to treatment were obtained from a combination of chart reviews and structured interviews.

RESULTS

Among 214 children identified as having CVS, 82% were classified as having migraine-associated CVS based on 1 of 2 criteria either a family history of migraines or subsequent development of migraine headaches. Compared with the non-migraine CVS subgroup, the migraine subset had milder episodes (20.7 27.3 SD vs 39.5 66.5 emeses/episode, P =.006); more symptoms of abdominal pain (83% vs 66%), headache (41% vs 24%), social withdrawal (40% vs 22%), photophobia (36% vs 16%, all P <.05); more frequent triggering events (70% vs 49%, P =.013) including psychologic stress (39% vs 22%), physical exhaustion (23% vs 3%), and motion sickness (10% vs 0%); and a higher positive response rate to anti-migraine therapy (79% vs 36%, P =.002).

CONCLUSIONS

The majority of children with CVS were subclassified as having migraine-associated CVS. The migraine-associated subgroup had less severe vomiting, manifested symptoms typical of migraine headaches, and had higher response rates to anti-migraine therapy. These findings strengthen the relationship between migraine and CVS.

Periodic discharge of adrenocorticotropin and vasopressin associated with focal glomerulosclerosis

We report the first case of the syndrome of periodic adrenocorticotropin (ACTH) and vasopressin (ADH) discharge associated with focal glomerulosclerosis. Approximately 30 cases of this syndrome have so far been reported in Japan, but no cases associated with renal dysfunction have yet been reported. The patient, a 10-year-old Japanese boy, was referred to our hospital because of recurrent attacks of vomiting. He was diagnosed as having this syndrome from clinical and laboratory findings. While various drugs were tried to manage his vomiting attacks, only valproic acid appeared to be effective in reducing the frequency of the attacks. Chronic nephritis was manifested when the patient was 12 years old, which required treatment with continuous ambulatory peritoneal dialysis. Valproic acid was proved to be effective in reducing the number of attacks over 4 months.

Cyclic vomiting and elevation of creatine kinase associated with bitemporal hypoperfusion and EEG abnormalities: a migraine equivalent?

A 13-year-old mentally retarded boy suffered from repeated vomiting attacks since infancy. Each episode lasted 2 to 10 days, and was precipitated by respiratory infection, exercise or stress. During an attack he became irritated, agitated and amnesic, but did not have headaches or seizures. Associated findings were transient elevation of serum creatine kinase (CK) (331-3381 IU/l), and of plasma ACTH and cortisol. The raised CK level was the result of muscle hypertonicity. Ictal EEGs showed delta activity in the front-temporal areas, and inter-ictal IMP-SPECT revealed hypoperfusion in both temporal regions. Unlike the periodic ACTH-ADH discharge syndrome, neither hypertension nor depression developed. These attacks were diagnosed as a migraine equivalent and were suppressed with phenytoin. From the EEG and SPECT findings, we concluded that the vomiting and behavioural changes were related to the paroxysmal vascular abnormality in the temporal regions, but it was not easy to make the distinction between migraine and focal epilepsy. Before a diagnosis of the periodic ACTH-ADH discharge syndrome is made, the possibility of migraine equivalent should be considered.

Vomiting attack with ACTH and ADH discharge improves startle epilepsy

A 15-year-old boy with sequelae of perinatal asphyxia experienced intractable startle-induced epileptic seizures, which were transiently suppressed with episodic vomiting. His vomiting was associated with adrenocorticotropin and antidiuretic hormone discharge, and the alteration of urinary catecholamine excretion, which might modulate epileptic seizures. Because startle-induced epileptic seizures are resistant to conventional antiepileptic therapy, this case is informative for the treatment of startle epilepsy.