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Betti C, Lavagno C, Bianchetti MG, Kottanattu L, Lava SAG, Schera F, Lacalamita MC, Milani GP. Transient secondary pseudo-hypoaldosteronism in infants with urinary tract infections: systematic literature review. Eur J Pediatr 2024:10.1007/s00431-024-05676-3. [PMID: 38985174 DOI: 10.1007/s00431-024-05676-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 06/13/2024] [Accepted: 06/27/2024] [Indexed: 07/11/2024]
Abstract
Infants with a congenital anomaly of the kidney and urinary tract sometimes present with hyponatremia, hyperkalemia, and metabolic acidosis due to under-responsiveness to aldosterone, hereafter referred to as secondary pseudo-hypoaldosteronism. The purpose of this report is to investigate pseudo-hypoaldosteronism in infant urinary tract infection. A systematic review was conducted following PRISMA guidelines after PROSPERO (CRD42022364210) registration. The National Library of Medicine, Excerpta Medica, Web of Science, and Google Scholar without limitations were used. Inclusion criteria involved pediatric cases with documented overt pseudo-hypoaldosteronism linked to urinary tract infection. Data extraction included demographics, clinical features, laboratory parameters, management, and course. Fifty-seven reports were selected, detailing 124 cases: 95 boys and 29 girls, 10 months or less of age (80% of cases were 4 months or less of age). The cases exhibited hyponatremia, hyperkalemia, acidosis, and activated renin-angiotensin II-aldosterone system. An impaired kidney function was found in approximately every third case. Management included antibiotics, fluids, and, occasionally, emergency treatment of hyperkalemia, hyponatremia, or acidosis. The recovery time averaged 1 week for electrolyte, acid-base imbalance, and kidney function. Notably, anomalies of the kidney and urinary tract were identified in 105 (85%) cases. CONCLUSIONS This review expands the understanding of overt transient pseudo-hypoaldosteronism complicating urinary tract infection. Management involves antimicrobials, fluid replacement, and consideration of electrolyte imbalances. Raising awareness of this condition within pediatric hospitalists is desirable. WHAT IS KNOWN • Infants affected by a congenital anomaly of the kidney and urinary tract may present with clinical and laboratory features resembling primary pseudo-hypoaldosteronism. • Identical features occasionally occur in infant urinary tract infection. WHAT IS NEW • Most cases of secondary pseudo-hypoaldosteronism associated with a urinary tract infection are concurrently affected by a congenital anomaly of the kidney and urinary tract. • Treatment with antibiotics and parenteral fluids typically results in the normalization of sodium, potassium, bicarbonate, and creatinine within approximately 1 week.
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Affiliation(s)
- Céline Betti
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
- Pediatric Emergency Department, University Children's Hospital Zurich, Zurich, Switzerland
| | - Camilla Lavagno
- Pediatric Emergency Department, University Children's Hospital Zurich, Zurich, Switzerland
| | - Mario G Bianchetti
- Family Medicine, Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Lisa Kottanattu
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
- Clinical Pharmacology Service, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Federica Schera
- Family Medicine, Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | | | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 9, 20122, Milan, Italy.
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy.
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2
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Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, Husebye ES, Karavitaki N, Prete A, Vaidya A, Yedinak C, Dekkers OM. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab 2024; 109:1657-1683. [PMID: 38724043 PMCID: PMC11180513 DOI: 10.1210/clinem/dgae250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Indexed: 06/18/2024]
Abstract
Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.
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Affiliation(s)
- Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University of Zürich (USZ) and University of Zürich (UZH), 8091 Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, 81377 Munich, Germany
- The LOOP Zurich Medical Research Center, 8044 Zurich, Switzerland
| | - Tobias Else
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Joint appointment in Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Wuerzburg, Germany
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX 75390-8857, USA
| | - Leonie van Hulsteijn
- European Society of Endocrinology, Bristol BS32 4QW, UK
- Department of Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Christine Yedinak
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, OR 97239-3098, USA
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Endocrinology and Metabolism, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, 8200 Aarhus, Denmark
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3
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Bakare LS, Kamta J. Rapid Refresher on Acute Endocrine Disorders. AACN Adv Crit Care 2024; 35:85-92. [PMID: 38848568 DOI: 10.4037/aacnacc2024140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Affiliation(s)
- Lolade S Bakare
- Lolade S. Bakare is Clinical Pharmacy Specialist, Critical Care, Emory University Hospital, 1364 Clifton Road NE, Room EG22, Atlanta, GA 30322
| | - Jeff Kamta
- Jeff Kamta is Clinical Pharmacist, Emergency Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia
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Fleseriu M, Christ-Crain M, Langlois F, Gadelha M, Melmed S. Hypopituitarism. Lancet 2024; 403:2632-2648. [PMID: 38735295 DOI: 10.1016/s0140-6736(24)00342-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 05/14/2024]
Abstract
Partial or complete deficiency of anterior or posterior pituitary hormone production leads to central hypoadrenalism, central hypothyroidism, hypogonadotropic hypogonadism, growth hormone deficiency, or arginine vasopressin deficiency depending on the hormones affected. Hypopituitarism is rare and likely to be underdiagnosed, with an unknown but rising incidence and prevalence. The most common cause is compressive growth or ablation of a pituitary or hypothalamic mass. Less common causes include genetic mutations, hypophysitis (especially in the context of cancer immunotherapy), infiltrative and infectious disease, and traumatic brain injury. Clinical features vary with timing of onset, cause, and number of pituitary axes disrupted. Diagnosis requires measurement of basal circulating hormone concentrations and confirmatory hormone stimulation testing as needed. Treatment is aimed at replacement of deficient hormones. Increased mortality might persist despite treatment, particularly in younger patients, females, and those with arginine vasopressin deficiency. Patients with complex diagnoses, pregnant patients, and adolescent pituitary-deficient patients transitioning to adulthood should ideally be managed at a pituitary tumour centre of excellence.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health and Science University, Portland, OR, USA; Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, USA; Pituitary Center, Oregon Health and Science University, Portland, OR, USA.
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Fabienne Langlois
- Department of Medicine, Division of Endocrinology, Centre intégré universitaire de santé et de services sociaux de l'Estrie, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Mônica Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Harai N, Hanai S, Hosokawa T, Tsuchiya K, Nakagomi D. Tertiary adrenal insufficiency in a patient with familial Mediterranean fever: Association or coincidence? Arch Rheumatol 2024; 39:314-316. [PMID: 38933730 PMCID: PMC11196229 DOI: 10.46497/archrheumatol.2024.10400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/18/2023] [Indexed: 06/28/2024] Open
Affiliation(s)
- Nozomi Harai
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Chuo-shi, Yamanashi, Japan
| | - Shunichiro Hanai
- Department of Rheumatology, University of Yamanashi Hospital, Chuo-shi, Yamanashi, Japan
| | - Tadatsugu Hosokawa
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Chuo-shi, Yamanashi, Japan
| | - Kyoichiro Tsuchiya
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Chuo-shi, Yamanashi, Japan
| | - Daiki Nakagomi
- Department of Rheumatology, University of Yamanashi Hospital, Chuo-shi, Yamanashi, Japan
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Chakraborty A, Kamat SS. Lysophosphatidylserine: A Signaling Lipid with Implications in Human Diseases. Chem Rev 2024; 124:5470-5504. [PMID: 38607675 DOI: 10.1021/acs.chemrev.3c00701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Lysophosphatidylserine (lyso-PS) has emerged as yet another important signaling lysophospholipid in mammals, and deregulation in its metabolism has been directly linked to an array of human autoimmune and neurological disorders. It has an indispensable role in several biological processes in humans, and therefore, cellular concentrations of lyso-PS are tightly regulated to ensure optimal signaling and functioning in physiological settings. Given its biological importance, the past two decades have seen an explosion in the available literature toward our understanding of diverse aspects of lyso-PS metabolism and signaling and its association with human diseases. In this Review, we aim to comprehensively summarize different aspects of lyso-PS, such as its structure, biodistribution, chemical synthesis, and SAR studies with some synthetic analogs. From a biochemical perspective, we provide an exhaustive coverage of the diverse biological activities modulated by lyso-PSs, such as its metabolism and the receptors that respond to them in humans. We also briefly discuss the human diseases associated with aberrant lyso-PS metabolism and signaling and posit some future directions that may advance our understanding of lyso-PS-mediated mammalian physiology.
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Affiliation(s)
- Arnab Chakraborty
- Department of Biology, Indian Institute of Science Education and Research, Dr. Homi Bhabha Road, Pashan, Pune 411008, Maharashtra, India
| | - Siddhesh S Kamat
- Department of Biology, Indian Institute of Science Education and Research, Dr. Homi Bhabha Road, Pashan, Pune 411008, Maharashtra, India
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7
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Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, Husebye ES, Karavitaki N, Prete A, Vaidya A, Yedinak C, Dekkers OM. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. Eur J Endocrinol 2024; 190:G25-G51. [PMID: 38714321 DOI: 10.1093/ejendo/lvae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 05/09/2024]
Abstract
Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.
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Affiliation(s)
- Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University of Zürich (USZ) and University of Zürich (UZH), Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, Munich, Germany
- The LOOP Zurich Medical Research Center, Zurich, Switzerland
| | - Tobias Else
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic Rocheste r, MN 55905, US
- Joint appointment in Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, MN 55905, US
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Leonie van Hulsteijn
- European Society of Endocrinology, Bristol, UK
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christine Yedinak
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Kanazawa K, Hijikata M, Koga S, Kuwabara K. Impact of Glucocorticoid Replacement Therapy on Nocturnal Hypoglycemia in Adrenal Insufficiency: An Analysis of Multiple Case Studies. Cureus 2024; 16:e61456. [PMID: 38947638 PMCID: PMC11214865 DOI: 10.7759/cureus.61456] [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: 05/31/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND AND AIM Adrenal insufficiency (AI) is a hormonal disorder characterized by insufficient glucocorticoid production. Nocturnal hypoglycemia (NH) occurs in patients with AI. However, the effect of glucocorticoid replacement therapy (GCRT) on AI and NH remains unclear. This study aimed to investigate the relationship between AI and NH by evaluating the impact of GCRT on NH in patients newly diagnosed with AI. METHODS The present study was conducted between October 2018 and December 2022 at the Department of Diabetes, Metabolism and Endocrinology of the Tokyo Rosai Hospital, Japan. In total, 15 patients aged ≥18 years with newly diagnosed AI or NH were included in this study. The NH frequency was measured using continuous glucose monitoring (CGM). The primary outcome was the change in NH frequency before and after the GCRT intervention. RESULTS GCRT significantly decreased NH frequency. Severe NH frequency and minimum nocturnal glucose levels changed significantly while fasting blood glucose and glycated hemoglobin levels did not change significantly. GCRT intervention improved CGM profiles' time below range, time in range, and average daily risk range. CONCLUSIONS The present study suggests that GCRT can help newly diagnosed patients with AI manage NH. These findings show that CGM can detect NH in patients with newly diagnosed AI, determine the optimal GCRT dosage, and hence prevent an impaired quality of life and even serious adverse effects in these patients. Further large multicenter studies should validate these findings and delve deeper into the mechanistic link between AI and NH.
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Affiliation(s)
- Ken Kanazawa
- Department of Diabetes, Metabolism, and Endocrinology, Japan Labor Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, JPN
| | - Mai Hijikata
- Department of Diabetes, Metabolism, and Endocrinology, Japan Labor Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, JPN
| | - Shinichiro Koga
- Department of Diabetes, Metabolism, and Endocrinology, Japan Labor Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, JPN
| | - Koichiro Kuwabara
- Department of Diabetes, Metabolism, and Endocrinology, Japan Labor Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, JPN
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Kibirige D, Owarwo N, Kyazze AP, Morgan B, Olum R, Bongomin F, Andia-Biraro I. Prevalence, Clinical Features, and Predictors of Adrenal Insufficiency in Adults With Tuberculosis or HIV: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2024; 11:ofae098. [PMID: 38560601 PMCID: PMC10981394 DOI: 10.1093/ofid/ofae098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/19/2024] [Indexed: 04/04/2024] Open
Abstract
Background Despite the high frequency of adrenal insufficiency (AI) in patients with tuberculosis or HIV, its diagnosis is often missed or delayed resulting in increased mortality. This systematic review and meta-analysis aimed to document the prevalence, significant clinical features, and predictors of AI in adult patients with tuberculosis or HIV. Methods We systematically searched databases (Medline, Embase, CINAHL, Cochrane Library, and Africa Journal Online) for published studies on AI in adult patients with tuberculosis or HIV. The pooled prevalence of AI was determined by a random-effect model meta-analysis. A narrative review was used to describe the significant clinical features and predictors of AI in adult patients with tuberculosis or HIV. Results A total of 46 studies involving 4044 adults were included: 1599 with tuberculosis and 2445 with HIV. The pooled prevalence of AI was 33% (95% CI, 22%-45%; I2 = 97.7%, P < .001) in participants with tuberculosis and 28% (95% CI, 18%-38%; I2 = 98.9%, P < .001) in those with HIV. Presentation with multidrug-resistant tuberculosis, abdominal pain, salt craving, myalgia, increased severity and duration of tuberculosis disease, and the absence of nausea predicted AI in participants with tuberculosis in 4 studies. Cytomegalovirus antigenemia positivity, rifampicin therapy, and eosinophilia >3% predicted AI in participants with HIV in 2 studies. Conclusions AI is relatively common in adults with tuberculosis or HIV. Its timely screening, diagnosis, and management in patients with these 2 conditions should be encouraged to avert mortality.
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Affiliation(s)
- Davis Kibirige
- Department of Medicine, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
- Non-communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Noela Owarwo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew Peter Kyazze
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Bethan Morgan
- Education and Research Centre, Wythenshawe Hospital, Manchester, UK
| | - Ronald Olum
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Irene Andia-Biraro
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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11
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Tucci L, Fanelli F, Improta I, Bissi V, Lena C, Galante G, Mezzullo M, Magagnoli M, Lalumera AB, Colombin G, Coscia K, Rotolo L, Vicennati V, Pagotto U, Di Dalmazi G. Monitoring adrenal insufficiency through salivary steroids: a pilot study. Eur J Endocrinol 2024; 190:327-337. [PMID: 38571387 DOI: 10.1093/ejendo/lvae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/21/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Various glucocorticoid replacement therapies (GRTs) are available for adrenal insufficiency (AI). However, their effectiveness in restoring glucocorticoid rhythm and exposure lacks adequate biochemical markers. We described the diurnal salivary cortisol (SalF) and cortisone (SalE) rhythm among different GRTs and analysed the associations between saliva-derived parameters and life quality questionnaires. METHODS Control subjects (CSs, n = 28) and AI patients receiving hydrocortisone (HC, n = 9), cortisone acetate (CA, n = 23), and dual-release hydrocortisone once (DRHC-od, n = 10) and twice a day (DRHC-td, n = 6) collected 9 saliva samples from 07:00 to 23:00. Patients compiled Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, and Addison disease-specific quality-of-life questionnaires. SalE and SalF were measured by liquid chromatography-mass spectrometry. Exposure was monitored using SalE for HC and DRHC and SalF for CA. Area under the curve (AUC) was computed. Different GRTs were compared by Z-scores calculated from saliva-derived parameters. Questionnaire results predictors were evaluated with multiple regression analysis. RESULTS Compared with controls, all GRTs resulted in glucocorticoid overexposure in the morning. Hydrocortisone, CA, and DRHC-td caused overexposure also in afternoon and evening. Compared with other treatments, CA determined increased Z-score-07:00 (P < .001), DRHC-td determined increased Z-score-AUC07:00→14:00 (P = .007), and DRHC-od induced lower Z-score-AUC14:00→23:00 (P = .015). Z-scores-AUC14:00→16:00 ≥ .619 best predicted questionnaire scores. CONCLUSIONS None of the GRTs mimics normal glucocorticoid rhythmicity and exposure. SalE, SalF, and Z-score may be useful markers for monitoring and comparing different GRTs. Excess glucocorticoid in early afternoon best associated with depressive symptoms and worse life and sleep quality.
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Affiliation(s)
- Lorenzo Tucci
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Flaminia Fanelli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Ilaria Improta
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Bissi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Claudia Lena
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Greta Galante
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Marco Mezzullo
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Matteo Magagnoli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Anna Bianca Lalumera
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Giacomo Colombin
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Kimberly Coscia
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Laura Rotolo
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Vicennati
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Guido Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
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12
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Lee SE, Choi Y, Oh Y, Lee D, Kim J, Hong S. Black Phosphorus-Based Reusable Biosensor Platforms for the Ultrasensitive Detection of Cortisol in Saliva. ACS APPLIED MATERIALS & INTERFACES 2024; 16:11305-11314. [PMID: 38406866 DOI: 10.1021/acsami.3c18605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
A black phosphorus (BP)-based reusable biosensor platform is developed for the repeated and real-time detection of cortisol using antibody-conjugated magnetic particle (MP) structures as a refreshable receptor. Here, we took advantage of the low-noise characteristics of a mechanically exfoliated BP-based field-effect transistor (FET) and hybridized it with anti-cortisol antibody-functionalized MPs to build a highly sensitive cortisol sensor. This strategy allowed us to detect cortisol down to 1 aM in real time and discriminate cortisol from other hormones. In this case, we could easily remove MPs with used antibodies from the surface of a BP-FET and reuse the chip for up to eight repeated sensing operations. Moreover, since our platform could be fabricated using conventional photolithography techniques and the sensor can be reused multiple times, one should be able to significantly reduce operation costs for practical applications. Furthermore, this method could be utilized to detect different hormones with high sensitivity and selectivity in complex environments such as artificial saliva solutions. In this respect, our reusable BP-FET biosensing platform can be a powerful tool for versatile applications such as clinical diagnosis and basic biological analysis by conjugating various antibodies.
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Affiliation(s)
- Sang-Eun Lee
- Department of Physics and Astronomy, and Institute of Applied Physics, Seoul National University, Seoul 08826, Republic of Korea
| | - Yoonji Choi
- Department of Physics and Astronomy, and Institute of Applied Physics, Seoul National University, Seoul 08826, Republic of Korea
| | - Yuhyeon Oh
- Department of Physics and Astronomy, and Institute of Applied Physics, Seoul National University, Seoul 08826, Republic of Korea
| | - Dongryul Lee
- Department of Chemical and Biological Engineering, Korea University, Seoul 02841, Republic of Korea
| | - Jihyun Kim
- Department of Chemical and Biological Engineering, Seoul National University, Seoul 08826, Republic of Korea
| | - Seunghun Hong
- Department of Physics and Astronomy, and Institute of Applied Physics, Seoul National University, Seoul 08826, Republic of Korea
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13
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Charoensri S, Auchus RJ. A Contemporary Approach to the Diagnosis and Management of Adrenal Insufficiency. Endocrinol Metab (Seoul) 2024; 39:73-82. [PMID: 38253474 PMCID: PMC10901672 DOI: 10.3803/enm.2024.1894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
Adrenal insufficiency (AI) can be classified into three distinct categories based on its underlying causes: primary adrenal disorders, secondary deficiencies in adrenocorticotropin, or hypothalamic suppression from external factors, most commonly glucocorticoid medications used for anti-inflammatory therapy. The hallmark clinical features of AI include fatigue, appetite loss, unintentional weight loss, low blood pressure, and hyponatremia. Individuals with primary AI additionally manifest skin hyperpigmentation, hyperkalemia, and salt craving. The diagnosis of AI is frequently delayed due to the non-specific symptoms and signs early in the disease course, which poses a significant challenge to its early detection prior to an adrenal crisis. Despite the widespread availability of lifesaving glucocorticoid medications for decades, notable challenges persist, particularly in the domains of timely diagnosis while simultaneously avoiding misdiagnosis, patient education for averting adrenal crises, and the determination of optimal replacement therapies. This article reviews recent advancements in the contemporary diagnostic strategy and approaches to optimal treatment for AI.
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Affiliation(s)
- Suranut Charoensri
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Richard J. Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
- Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
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14
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Wäscher H, Knauerhase A, Klar B, Postrach T, Weber MA, Willenberg HS. On Primary Adrenal Insufficiency with Normal Concentrations of Cortisol - Early Manifestation of Addison's Disease. Horm Metab Res 2024; 56:16-19. [PMID: 37918821 DOI: 10.1055/a-2180-7108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Primary adrenal insufficiency (AI) is an endocrine disorder in which hormones of the adrenal cortex are produced to an insufficient extent. Since receptors for adrenal steroids have a wide distribution, initial symptoms may be nonspecific. In particular, the lack of glucocorticoids can quickly lead to a life-threatening adrenal crisis. Therefore, current guidelines suggest applying a low threshold for testing and to rule out AI not before serum cortisol concentrations are higher than 500 nmol/l (18 μg/dl). To ease the diagnostic, determination of morning cortisol concentrations is increasingly used for making a diagnosis whereby values of>350 nmol/l are considered to safely rule out Addison's disease. Also, elevated corticotropin concentrations (>300 pg/ml) are indicative of primary AI when cortisol levels are below 140 nmol/l (5 μg/dl). However, approximately 10 percent of our patients with the final diagnosis of primary adrenal insufficiency would clearly have been missed for they presented with normal cortisol concentrations. Here, we present five such cases to support the view that normal to high basal concentrations of cortisol in the presence of clearly elevated corticotropin are indicative of primary adrenal insufficiency when the case history is suggestive of Addison's disease. In all cases, treatment with hydrocortisone had been started, after which the symptoms improved. Moreover, autoantibodies to the adrenal cortex had been present and all patients underwent a structured national education program to ensure that self-monitored dose adjustments could be made as needed.
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Affiliation(s)
- Hanna Wäscher
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Andreas Knauerhase
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
| | - Bettina Klar
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
| | - Till Postrach
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Holger Sven Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany
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15
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Duan Y, Zheng W, Xia Y, Zhang H, Liang L, Wang R, Yang Y, Zhang K, Lu D, Sun Y, Han L, Yu Y, Gu X, Sun Y, Xiao B, Qiu W. Genetic and phenotypic spectrum of non-21-hydroxylase-deficiency primary adrenal insufficiency in childhood: data from 111 Chinese patients. J Med Genet 2023; 61:27-35. [PMID: 37586839 DOI: 10.1136/jmg-2022-108952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 07/04/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Primary adrenal insufficiency (PAI) is a rare but life-threatening condition. Differential diagnosis of numerous causes of PAI requires a thorough understanding of the condition. METHODS To describe the genetic composition and presentations of PAI. The following data were collected retrospectively from 111 patients with non-21OHD with defined genetic diagnoses: demographic information, onset age, clinical manifestations, laboratory findings and genetic results. Patients were divided into four groups based on the underlying pathogenesis: (1) impaired steroidogenesis, (2) adrenal hypoplasia, (3) resistance to adrenocorticotropic hormone (ACTH) and (4) adrenal destruction. The age of onset was compared within the groups. RESULTS Mutations in the following genes were identified: NR0B1 (n=39), STAR (n=33), CYP11B1 (n=12), ABCD1 (n=8), CYP17A1 (n=5), HSD3B2 (n=4), POR (n=4), MRAP (n=2), MC2R (n=1), CYP11A1 (n=1), LIPA (n=1) and SAMD9 (n=1). Frequent clinical manifestations included hyperpigmentation (73.0%), dehydration (49.5%), vomiting (37.8%) and abnormal external genitalia (23.4%). Patients with adrenal hypoplasia typically presented manifestations earlier than those with adrenal destruction but later than those with impaired steroidogenesis (both p<0.01). The elevated ACTH (92.6%) and decreased cortisol (73.5%) were the most common laboratory findings. We generated a differential diagnosis flowchart for PAI using the following clinical features: 17-hydroxyprogesterone, very-long-chain fatty acid, external genitalia, hypertension and skeletal malformation. This flowchart identified 84.8% of patients with PAI before next-generation DNA sequencing. CONCLUSIONS STAR and NR0B1 were the most frequently mutated genes in patients with non-21OHD PAI. Age of onset and clinical characteristics were dependent on aetiology. Combining clinical features and molecular tests facilitates accurate diagnosis.
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Affiliation(s)
- Ying Duan
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Wanqi Zheng
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yu Xia
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Huiwen Zhang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Lili Liang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Ruifang Wang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yi Yang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Kaichuang Zhang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Deyun Lu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yuning Sun
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Lianshu Han
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yongguo Yu
- Department of Pediatric Endocrinology and Genetic Metabolism, Clinical Genetics Center, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Xuefan Gu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yu Sun
- Department of Pediatric Endocrinology and Genetic Metabolism, Clinical Genetics Center, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Bing Xiao
- Department of Pediatric Endocrinology and Genetic Metabolism, Clinical Genetics Center, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Wenjuan Qiu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
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16
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Welch MR. Management of Complications in Neuro-oncology Patients. Continuum (Minneap Minn) 2023; 29:1844-1871. [PMID: 38085901 DOI: 10.1212/con.0000000000001359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE The purpose of this article is to familiarize the reader with the spectrum of neurologic and medical complications relevant to the care of patients with neurologic cancer while highlighting best practices to prevent morbidity and mortality. Topics include tumor-related epilepsy, vasogenic edema, complications of corticosteroid use, disruption of the hypothalamic-pituitary axis, venous thromboembolism, and opportunistic infection. LATEST DEVELOPMENTS In 2021, a joint guideline from the Society for Neuro-Oncology and the European Association of Neuro-Oncology reaffirmed recommendations first established in 2000 that patients with newly diagnosed brain tumors should not be prescribed an antiseizure medication prophylactically. For those with tumor-related epilepsy, monotherapy with a non-enzyme-inducing anticonvulsant is the preferred initial treatment, and levetiracetam remains the preferred first choice. Surveys of physician practice continue to demonstrate excessive use of glucocorticoids in the management of patients with both primary and metastatic central nervous system malignancy. This is particularly concerning among patients who require checkpoint inhibitors as the efficacy of these agents is blunted by concomitant glucocorticoid use, resulting in a reduction in overall survival. Finally, direct oral anticoagulants have been shown to be safe in patients with brain tumors and are now favored as first-line treatment among those who require treatment for venous thromboembolism. ESSENTIAL POINTS Medical care for patients impacted by primary and secondary central nervous system malignancy is complex and requires a committed team-based approach that routinely calls upon the expertise of physicians across multiple fields. Neurologists have an important role to play and should be familiar with the spectrum of complications impacting these patients as well as the latest recommendations for management.
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17
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Martella S, Lucas M, Porcu M, Perra L, Denaro N, Pretta A, Deias G, Willard-Gallo K, Parra HS, Saba L, Scartozzi M, Wekking D, Kok M, Aiello MM, Solinas C. Primary adrenal insufficiency induced by immune checkpoint inhibitors: biological, clinical, and radiological aspects. Semin Oncol 2023; 50:144-148. [PMID: 38151399 DOI: 10.1053/j.seminoncol.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023]
Abstract
Immune checkpoint inhibitors (ICI) have become a cornerstone in medical oncology, with evolving therapeutic strategies and applications. These monoclonal antibodies, designed to enhance immune responses, have revealed a spectrum of immune-related adverse events (irAEs). While many irAEs exhibit favorable responses to corticosteroid or immunosuppressive therapy, most ICI-related endocrinopathies necessitate lifelong replacement therapy and pose significant clinical challenges. Adrenal insufficiency (AI), a noteworthy endocrine irAE, can manifest as primary AI (PAI) or secondary AI (SAI), resulting from adrenal or pituitary gland dysfunction, respectively. ICI-induced AI, albeit relatively infrequent, occurs in 1-2% of patients receiving single-agent anti-Programmed Death-1/Programmed Death-Ligand 1 (PD-1/PD-L1) or Cytotoxic T-Lymphocyte Antigen 4 (CTLA-4) therapies and in a higher range of 4-9% when ICIs are used in combinations. Recognizing and addressing ICI-induced PAI is crucial, as it often presents with acute and potentially life-threatening symptoms, especially considering the expanding use of ICI therapy. This review provides an updated overview of ICI-induced PAI, exploring its clinical, diagnostic, and radiological aspects.
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Affiliation(s)
- Serafina Martella
- Medical Oncology, University Hospital Policlinico G.Rodolico-San Marco, 95123, Catania, Italy
| | - Minke Lucas
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Michele Porcu
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Laura Perra
- Azienda Tutela Salute Sardegna, via Enrico Costa n. 57, Sassari, Italy
| | - Nerina Denaro
- Oncology Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Andrea Pretta
- Medical Oncology Unit, University Hospital and University of Cagliari, Italy
| | - Giulia Deias
- Medical Oncology Unit, University Hospital and University of Cagliari, Italy
| | - Karen Willard-Gallo
- Molecular Immunology Unit, Institut Jules Bordet, Boulevard de Waterloo, 121, Brussels, Belgium
| | - Hector Soto Parra
- Medical Oncology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-S. Marco", 95123, Catania, Italy
| | - Luca Saba
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Mario Scartozzi
- Medical Oncology Unit, University Hospital and University of Cagliari, Italy
| | - Demi Wekking
- Location Academic Medical Centre, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Marleen Kok
- Department of Medical Oncology, The Netherlands Cancer Institute, 1066 CX, Amsterdam, North Holland, the Netherlands.; Division of Tumor Biology & Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marco Maria Aiello
- Azienda Ospedaliero Universitaria Policlinico San Marco, Via Santa Sofia, 78, Catania, Italy
| | - Cinzia Solinas
- Medical Oncology AOU Cagliari Policlinico Duilio Casula, Monserrato, Cagliari, Italy
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18
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Ruiz-Babot G, Eceiza A, Abollo-Jiménez F, Malyukov M, Carlone DL, Borges K, Da Costa AR, Qarin S, Matsumoto T, Morizane R, Skarnes WC, Ludwig B, Chapple PJ, Guasti L, Storr HL, Bornstein SR, Breault DT. Generation of glucocorticoid-producing cells derived from human pluripotent stem cells. CELL REPORTS METHODS 2023; 3:100627. [PMID: 37924815 PMCID: PMC10694497 DOI: 10.1016/j.crmeth.2023.100627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/07/2023] [Accepted: 10/12/2023] [Indexed: 11/06/2023]
Abstract
Adrenal insufficiency is a life-threatening condition resulting from the inability to produce adrenal hormones in a dose- and time-dependent manner. Establishing a cell-based therapy would provide a physiologically responsive approach for the treatment of this condition. We report the generation of large numbers of human-induced steroidogenic cells (hiSCs) from human pluripotent stem cells (hPSCs). Directed differentiation of hPSCs into hiSCs recapitulates the initial stages of human adrenal development. Following expression of steroidogenic factor 1, activation of protein kinase A signaling drives a steroidogenic gene expression profile most comparable to human fetal adrenal cells, and leads to dynamic secretion of steroid hormones, in vitro. Moreover, expression of the adrenocorticotrophic hormone (ACTH) receptor/co-receptor (MC2R/MRAP) results in dose-dependent ACTH responsiveness. This protocol recapitulates adrenal insufficiency resulting from loss-of-function mutations in AAAS, which cause the enigmatic triple A syndrome. Our differentiation protocol generates sufficient numbers of hiSCs for cell-based therapy and offers a platform to study disorders causing adrenal insufficiency.
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Affiliation(s)
- Gerard Ruiz-Babot
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Harvard Stem Cell Institute, Cambridge, MA, USA; Department of Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - Ariane Eceiza
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Harvard Stem Cell Institute, Cambridge, MA, USA
| | | | - Maria Malyukov
- Department of Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Diana L Carlone
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Harvard Stem Cell Institute, Cambridge, MA, USA
| | - Kleiton Borges
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Harvard Stem Cell Institute, Cambridge, MA, USA
| | - Alexandra Rodrigues Da Costa
- Centre for Endocrinology, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Shamma Qarin
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge Biomedical Campus, University of Cambridge, Puddicombe Way, Cambridge, UK
| | - Takuya Matsumoto
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA; Nephrology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Ryuji Morizane
- Harvard Stem Cell Institute, Cambridge, MA, USA; Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA; Nephrology Division, Massachusetts General Hospital, Boston, MA, USA
| | - William C Skarnes
- Cellular Engineering, The Jackson Laboratory for Genomic Medicine, Farmington, CT 06032, USA
| | - Barbara Ludwig
- Department of Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Paul J Chapple
- Centre for Endocrinology, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Stefan R Bornstein
- Department of Medicine, University Hospital Carl Gustav Carus, Dresden, Germany; Division of Endocrinology, Diabetes and Nutritional Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David T Breault
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Harvard Stem Cell Institute, Cambridge, MA, USA.
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19
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Bao R, Chen B, Pan J, Wang A, Yu H, Chen Q, Zhang Y, Wang T. Pseudohypoadrenalism, a subclinical cortisol metabolism disorder in hyperuricemia. Front Endocrinol (Lausanne) 2023; 14:1279205. [PMID: 38034015 PMCID: PMC10687422 DOI: 10.3389/fendo.2023.1279205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Background Hyperuricemia is a known risk factor of lipid metabolism disorder. However, the mechanisms have not been fully understood. Methods The serum samples from hyperuricemia subjects were used to analyze the correlation between serum uric acid and clinical characteristics. Hyperuricemia mice induced by potassium oxonate (PO) and adenine were used to explore glucocorticoid metabolism. Results In hyperuricemia patients, the levels of serum uric acid were positively correlated with the levels of γ-glutamyltransferase, associated with a cortisol metabolism disorder. In hyperuricemia state, the adrenal glands failed to respond to adrenocorticotropic hormone properly, leading to low cortisol, but not corticosterone production, and decreased mRNA levels of aldosterone synthase, 11β-hydroxylase, and 3β-hydroxysteroid dehydrogenase 1, three key enzymes for cortisol synthesis. The expression of both hepatic 5α-reductase and renal 11β-hydroxysteroid dehydrogenase 2 was significantly reduced, which led to low cortisol clearance. We denominated this cortisol metabolism disorder in hyperuricemia as pseudohypoadrenalism (PHAL). Conclusion PHAL increased exposure to the bioavailable cortisol in the liver, leading to local amplification of the biological action of corticosteroids. Unregulated biosynthesis pathway of bile acid expanded bile acid pool, and further aggravated cholestatic liver injury.
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Affiliation(s)
- Ruixia Bao
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Jinghai District, Tianjin, China
| | - Beibei Chen
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Jinghai District, Tianjin, China
| | - Jujie Pan
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Jinghai District, Tianjin, China
| | - Alexander Wang
- College of Education, University of Texas at Austin, Austin, TX, United States
| | - Haiyang Yu
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Jinghai District, Tianjin, China
| | - Qian Chen
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Jinghai District, Tianjin, China
| | - Yi Zhang
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Jinghai District, Tianjin, China
| | - Tao Wang
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Jinghai District, Tianjin, China
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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20
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Wolff ASB, Kucuka I, Oftedal BE. Autoimmune primary adrenal insufficiency -current diagnostic approaches and future perspectives. Front Endocrinol (Lausanne) 2023; 14:1285901. [PMID: 38027140 PMCID: PMC10667925 DOI: 10.3389/fendo.2023.1285901] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
The adrenal glands are small endocrine glands located on top of each kidney, producing hormones regulating important functions in our body like metabolism and stress. There are several underlying causes for adrenal insufficiency, where an autoimmune attack by the immune system is the most common cause. A number of genes are known to confer early onset adrenal disease in monogenic inheritance patterns, usually genetic encoding enzymes of adrenal steroidogenesis. Autoimmune primary adrenal insufficiency is usually a polygenic disease where our information recently has increased due to genome association studies. In this review, we go through the physiology of the adrenals before explaining the different reasons for adrenal insufficiency with a particular focus on autoimmune primary adrenal insufficiency. We will give a clinical overview including diagnosis and current treatment, before giving an overview of the genetic causes including monogenetic reasons for adrenal insufficiency and the polygenic background and inheritance pattern in autoimmune adrenal insufficiency. We will then look at the autoimmune mechanisms underlying autoimmune adrenal insufficiency and how autoantibodies are important for diagnosis. We end with a discussion on how to move the field forward emphasizing on the clinical workup, early identification, and potential targeted treatment of autoimmune PAI.
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Affiliation(s)
- Anette S. B. Wolff
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Isil Kucuka
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Bergithe E. Oftedal
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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21
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Majumder M, Datta AK, Chakraborty U. Primary Adrenal Insufficiency and Hyperpigmentation. Am J Med 2023; 136:1076-1077. [PMID: 37572742 DOI: 10.1016/j.amjmed.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/18/2023] [Accepted: 07/25/2023] [Indexed: 08/14/2023]
Affiliation(s)
- Manidipa Majumder
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Amlan Kusum Datta
- Bangur institute of Neurosciences, IPGMER SSKM Hospital, Kolkata, India.
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22
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Mirfarsi S, Seleem D, Sathananthan A. A Patient with Addison Disease (Primary Adrenal Insufficiency) Presenting for Surgical Extraction of Third Molars. Dent Clin North Am 2023; 67:585-588. [PMID: 37714600 DOI: 10.1016/j.cden.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
The local prevalence of primary adrenal insufficiency (PAI) depends on various factors such as genetics, environment, and timely disease diagnosis. PAI is uncommon, and the prevalence is reported to be 2 per 10,000 population. PAI is commonly caused by an autoimmune process that destroys the adrenal gland, resulting in the loss of glucocorticoid and mineralocorticoid secretion from the adrenal cortex. The lack of cortisol results in impaired glucose/fat/protein metabolism, hypotension, increased adrenocorticotropic hormone secretion, impaired fluid excretion, and hyperpigmentation. PAI has a female predominance and is commonly seen in ages 20 to 50 years but can occur at any age.
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Affiliation(s)
- Sahar Mirfarsi
- Western University of Health Sciences, College of Dental Medicine, 309 East Second Street, Pomona, CA 91766-1854, USA.
| | - Dalia Seleem
- Western University of Health Sciences, College of Dental Medicine, 309 East Second Street, Pomona, CA 91766-1854, USA
| | - Airani Sathananthan
- Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Department of Internal Medicine, 309 East Second Street, Pomona, CA 91766-1854, USA
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23
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Bouki K, Venetsanaki V, Chrysoulaki M, Pateromichelaki A, Betsi G, Daraki V, Sbyrakis N, Spanakis K, Bertsias G, Sidiropoulos PI, Xekouki P. Primary adrenal insufficiency due to bilateral adrenal hemorrhage-adrenal infarction in a patient with systemic lupus erythematosus and antiphospholipid syndrome: case presentation and review of the literature. Hormones (Athens) 2023; 22:521-531. [PMID: 37436639 PMCID: PMC10449959 DOI: 10.1007/s42000-023-00463-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/22/2023] [Indexed: 07/13/2023]
Abstract
Primary adrenal insufficiency (PAI) is a rare disease which represents the end stage of a destructive process involving the adrenal cortex. Occasionally it may be caused by bilateral adrenal hemorrhagic infarction in patients with antiphospholipid syndrome (APS). We herein report the challenging case of a 30-year-old female patient with systemic lupus erythematosus (SLE) and secondary APS who was admitted to the emergency department (ED) due to fever, lethargy, and syncopal episodes. Hyponatremia, hyperkalemia, hyperpigmentation, shock, altered mental status, and clinical response to glucocorticoid administration were features highly suggestive of an acute adrenal crisis. The patient's clinical status required admission to the intensive care unit (ICU), where steroid replacement, anticoagulation, and supportive therapy were provided, with a good outcome. Imaging demonstrated bilateral adrenal enlargement attributed to recent adrenal hemorrhage. This case highlights the fact that bilateral adrenal vein thrombosis and subsequent hemorrhage can be part of the thromboembolic complications seen in both primary and secondary APS and which, if misdiagnosed, may lead to a life-threatening adrenal crisis. High clinical suspicion is required for its prompt diagnosis and management. A literature search of past clinical cases with adrenal insufficiency (AI) in the setting of APS and SLE was conducted using major electronic databases. Our aim was to retrieve information about the pathophysiology, diagnosis, and management of similar conditions.
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Affiliation(s)
- K Bouki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - V Venetsanaki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - M Chrysoulaki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - A Pateromichelaki
- Rheumatology and Clinical Immunology, University General Hospital of Heraklion, Crete, Greece
| | - G Betsi
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - V Daraki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - N Sbyrakis
- Emergency Department, University General Hospital of Heraklion, Crete, Greece
| | - K Spanakis
- Interventional Radiology Unit, Department of Medical Imaging, University General Hospital of Heraklion, Crete, Greece
| | - G Bertsias
- Rheumatology and Clinical Immunology, University General Hospital of Heraklion, Crete, Greece
| | - P I Sidiropoulos
- Rheumatology and Clinical Immunology, University General Hospital of Heraklion, Crete, Greece
| | - Paraskevi Xekouki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece.
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24
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Zhao KM, Hu JS, Zhu SM, Wen TT, Fang XM. Persistent postoperative hypotension caused by subclinical empty sella syndrome after a simple surgery: A case report. World J Clin Cases 2023; 11:5817-5822. [PMID: 37727724 PMCID: PMC10506010 DOI: 10.12998/wjcc.v11.i24.5817] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Empty sella is an anatomical and radiological finding of the herniation of the subarachnoid space into the pituitary fossa leading to a flattened pituitary gland. Patients with empty sella may present with various symptoms, including headache due to intracranial hypertension and endocrine symptoms related to the specific pituitary hormones affected. Here, we report a female patient who developed persistent postoperative hypotension caused by subclinical empty sella syndrome after a simple surgery. CASE SUMMARY A 47-year-old woman underwent vocal cord polypectomy under general anesthesia with endotracheal intubation. She denied any medical history, and her vital signs were normal before the surgery. Anesthesia and surgery were uneventful. However, she developed dizziness, headache and persistent hypotension in the ward. Thus, intravenous dopamine was started to maintain normal blood pressure, which improved her symptoms. However, she remained dependent on dopamine for over 24 h without any obvious anesthesia- and surgery-related complications. An endocrine etiology was then suspected, and further examination showed a high prolactin level, a low normal adrenocorticotropic hormone level and a low cortisol level. Magnetic resonance imaging of the brain revealed an empty sella. Therefore, she was diagnosed with empty sella syndrome and secondary adrenal insufficiency. Her symptoms disappeared one week later after daily glucocorticoid supplement. CONCLUSION Endocrine etiologies such as pituitary and adrenal-related dysfunction should be considered in patients showing persistent postoperative hypotension when anesthesia- and surgery-related factors are excluded.
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Affiliation(s)
- Kang-Mei Zhao
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Jia-Sheng Hu
- Department of Anesthesiology, Sanmen People’s Hospital, Sanmen 317100, Zhejiang Province, China
| | - Sheng-Mei Zhu
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Ting-Ting Wen
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Xiang-Ming Fang
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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25
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Bahsoun A, Fakih Y, Zareef R, Bitar F, Arabi M. Corticosteroids in COVID-19: pros and cons. Front Med (Lausanne) 2023; 10:1202504. [PMID: 37644981 PMCID: PMC10461317 DOI: 10.3389/fmed.2023.1202504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023] Open
Abstract
The wide and rapid spread of the COVID-19 pandemic has placed an unanticipated burden on the global healthcare sector. This necessitated a swift response from the international community to reach a solution. Efforts were made in parallel to develop preventative and therapeutic modalities. Since then, drug repurposing has blossomed as a potentially rapid resolution and has included various agents with anti-viral and anti-inflammatory properties. Corticosteroids, being potent anti-inflammatory agents, have been placed under extensive investigation. Various trials have recorded the beneficial outcome of corticosteroids in decreasing the mortality and morbidity of COVID-19. With the high pace of escalating events, the quality and study design of clinical trials are varied. Therefore, this study aims to explore the role of corticosteroids in COVID-19 disease. It inspects the molecular, pharmacologic, and clinical proof behind this theory.
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Affiliation(s)
- Aymen Bahsoun
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yeva Fakih
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana Zareef
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
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26
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Falhammar H. Specialty grand challenge in adrenal endocrinology. Front Endocrinol (Lausanne) 2023; 14:1237733. [PMID: 37484952 PMCID: PMC10358978 DOI: 10.3389/fendo.2023.1237733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/26/2023] [Indexed: 07/25/2023] Open
Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
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27
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Chang CWJ, Provencio JJ, Pascual J, Heavner MS, Olson D, Livesay SL, Kaplan LJ. State-of-the-Art Evaluation of Acute Adult Disorders of Consciousness for the General Intensivist. Crit Care Med 2023; 51:948-963. [PMID: 37070819 DOI: 10.1097/ccm.0000000000005893] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVES To provide a concise review of knowledge and practice pertaining to the diagnosis and initial management of unanticipated adult patient disorders of consciousness (DoC) by the general intensivist. DATA SOURCES Detailed search strategy using PubMed and OVID Medline for English language articles describing adult patient acute DoC diagnostic evaluation and initial management strategies including indications for transfer. STUDY SELECTION Descriptive and interventional studies that address acute adult DoC, their evaluation and initial management, indications for transfer, as well as outcome prognostication. DATA EXTRACTION Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for adult critical care practice. DATA SYNTHESIS Acute adult DoC may be categorized by etiology including structural, functional, infectious, inflammatory, and pharmacologic, the understanding of which drives diagnostic investigation, monitoring, acute therapy, and subsequent specialist care decisions including team-based local care as well as intra- and inter-facility transfer. CONCLUSIONS Acute adult DoC may be initially comprehensively addressed by the general intensivist using an etiology-driven and team-based approach. Certain clinical conditions, procedural expertise needs, or resource limitations inform transfer decision-making within a complex care facility or to one with greater complexity. Emerging collaborative science helps improve our current knowledge of acute DoC to better align therapies with underpinning etiologies.
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Affiliation(s)
| | | | - Jose Pascual
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mojdeh S Heavner
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - DaiWai Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern, Dallas, TX
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Abstract
PURPOSE OF REVIEW Adrenal insufficiency (AI) is the clinical manifestation of deficient production of glucocorticoids with occasionally deficiency also in mineralocorticoids and adrenal androgens and constitutes a fatal disorder if left untreated. The aim of this review is to summarize the new trends in diagnostic methods used for determining the presence of AI. RECENT FINDINGS Novel aetiologies of AI have emerged; severe acute respiratory syndrome coronavirus 2 infection was linked to increased frequency of primary AI (PAI). A new class of drugs, the immune checkpoint inhibitors (ICIs) widely used for the treatment of several malignancies, has been implicated mostly with secondary AI, but also with PAI. Salivary cortisol is considered a noninvasive and patient-friendly tool and has shown promising results in diagnosing AI, although the normal cut-off values remain an issue of debate depending on the technique used. Liquid chromatography-mass spectrometry (LC-MS/MS) is the most reliable technique although not widely available. SUMMARY Our research has shown that little progress has been made regarding our knowledge on AI. Coronavirus disease 2019 and ICIs use constitute new evidence on the pathogenesis of AI. The short synacthen test (SST) remains the 'gold-standard' method for confirmation of AI diagnosis, although salivary cortisol is a promising tool.
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Affiliation(s)
- Vasiliki Siampanopoulou
- Endocrinology Unit, First Department of Internal Medicine, Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens
| | - Elisavet Tasouli
- First Department of Internal Medicine, Thriasio General Hospital of Elefsina, Elefsina, Greece
| | - Anna Angelousi
- Endocrinology Unit, First Department of Internal Medicine, Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens
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29
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Shaikh S, Nagendra L, Shaikh S, Pappachan JM. Adrenal Failure: An Evidence-Based Diagnostic Approach. Diagnostics (Basel) 2023; 13:diagnostics13101812. [PMID: 37238296 DOI: 10.3390/diagnostics13101812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/14/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023] Open
Abstract
The diagnosis of adrenal insufficiency (AI) requires a high index of suspicion, detailed clinical assessment including detailed drug history, and appropriate laboratory evaluation. The clinical characteristics of adrenal insufficiency vary according to the cause, and the presentation may be myriad, e.g. insidious onset to a catastrophic adrenal crisis presenting with circulatory shock and coma. Secondary adrenal insufficiency (SAI) often presents with only glucocorticoid deficiency because aldosterone production, which is controlled by the renin angiotensin system, is usually intact, and rarely presents with an adrenal crisis. Measurements of the basal serum cortisol at 8 am (<140 nmol/L or 5 mcg/dL) coupled with adrenocorticotrophin (ACTH) remain the initial tests of choice. The cosyntropin stimulation (short synacthen) test is used for the confirmation of the diagnosis. Newer highly specific cortisol assays have reduced the cut-off points for cortisol in the diagnosis of AI. The salivary cortisol test is increasingly being used in conditions associated with abnormal cortisol binding globulin (CBG) levels such as pregnancy. Children and infants require lower doses of cosyntropin for testing. 21-hydoxylase antibodies are routinely evaluated to rule out autoimmunity, the absence of which would require secondary causes of adrenal insufficiency to be ruled out. Testing the hypothalamic-pituitary-adrenal (HPA) axis, imaging, and ruling out systemic causes are necessary for the diagnosis of AI. Cancer treatment with immune checkpoint inhibitors (ICI) is an emerging cause of both primary AI and SAI and requires close follow up. Several antibodies are being implicated, but more clarity is required. We update the diagnostic evaluation of AI in this evidence-based review.
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Affiliation(s)
- Salomi Shaikh
- KGN Diabetes and Endocrine Centre, Mumbai 400001, India
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College, JSS Academy of Higher Education and Research Center, Mysore 570015, India
| | - Shehla Shaikh
- Department of Endocrinology, Saifee Hospital, Mumbai 400004, India
| | - Joseph M Pappachan
- Department of Endocrinology & Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, UK
- Faculty of Science, Manchester Metropolitan University, Manchester M15 6BH, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK
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30
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Uslar T, Olmos R, Martínez-Aguayo A, Baudrand R. Clinical Update on Congenital Adrenal Hyperplasia: Recommendations from a Multidisciplinary Adrenal Program. J Clin Med 2023; 12:jcm12093128. [PMID: 37176569 PMCID: PMC10179176 DOI: 10.3390/jcm12093128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a common genetic disorder in endocrinology, especially its milder clinical presentation, often caused by a partial or total deficiency of the 21-hydroxylase enzyme located in the adrenal cortex. CAH is characterized by the overproduction of androgen, along with variable degrees of cortisol and aldosterone deficiency. The age at diagnosis can provide some information about underlying mutations, with those diagnosed at birth/early infancy more likely to have severe enzymatic defects, which may include adrenal insufficiency, sexual development disorders, short stature in adulthood, hirsutism, and a higher risk for metabolic syndrome and infertility. Non-classic CAH, a milder form of CAH, is usually manifested later in life and is a common differential diagnosis of Polycystic Ovary Syndrome and should be actively evaluated during initial studies of clinical or biochemical hyperandrogenism. The main goals of CAH treatment are hormone supplementation for severe cases, controlling adrenal androgen overproduction to minimize long-term side effects, managing fertility and genetic counseling, and optimizing patients' quality of life.
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Affiliation(s)
- Thomas Uslar
- Program for Adrenal Disorders CETREN-UC, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago 8330077, Chile
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago 8330077, Chile
| | - Roberto Olmos
- Program for Adrenal Disorders CETREN-UC, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago 8330077, Chile
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago 8330077, Chile
| | - Alejandro Martínez-Aguayo
- Program for Adrenal Disorders CETREN-UC, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago 8330077, Chile
- Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago 8330077, Chile
| | - René Baudrand
- Program for Adrenal Disorders CETREN-UC, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago 8330077, Chile
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago 8330077, Chile
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31
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Lindh JD, Patrova J, Rushworth RL, Mannheimer B, Falhammar H. Tuberculosis of Adrenal Glands-A Population-based Case-control Study. J Endocr Soc 2023; 7:bvad047. [PMID: 37122590 PMCID: PMC10139439 DOI: 10.1210/jendso/bvad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Indexed: 05/02/2023] Open
Abstract
Purpose Adrenal tuberculosis (ATB) can cause primary adrenal insufficiency (PAI) or may be misdiagnosed as nonfunctional adrenal tumors (NFATs) in patients with tuberculosis. Very little is known about its epidemiology in a modern, high-income setting. The aim was to investigate adrenal involvement and associated mortality in patients with tuberculosis. Methods By using national registers, patients with tuberculosis and adrenal lesions were compared with controls without adrenal tumors. To analyze mortality in individuals with ATB or possible adrenal affection (ie, tuberculosis and NFAT), a subgroup of controls with tuberculosis was selected. The study population was included from 2005 to 2019 and followed until death or 2020. In mortality adjustments were made for age and sex. Results Eight patients with ATB, 23 232 patients with NFAT, and 144 124 controls were included. Among those with NFAT, we found 34 with tuberculosis and NFAT. Among controls, 129 individuals diagnosed with tuberculosis were identified. The risk of having an adrenal tumor was increased in tuberculosis (odds ratio, 1.64; 95% CI, 1.12-2.39). Of those with ATB, 7 (88%) had PAI. One patient (3%) with tuberculosis and NFAT and 1 (0.8%) control with tuberculosis had PAI. Compared with controls with tuberculosis, mortality was increased in patients with ATB (hazard ratio, 5.4; 95% CI, 2.2-13.2; adjusted hazard ratio, 6.2; 95% CI, 2.5-15.6), and in patients with tuberculosis and NFAT (1.3; 0.6-2.7; 2.3; 1.1-5.1). PAI was a contributing factor in 4/6 (67%) deaths in patients with ATB. Conclusions Tuberculosis with adrenal lesions was extremely rare. Most patients with ATB had PAI and mortality was increased.
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Affiliation(s)
- Jonatan D Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jekaterina Patrova
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - R Louise Rushworth
- School of Medicine, The University of Notre Dame, Sydney, NSW, Australia
| | - Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Correspondence: Henrik Falhammar, MD, PhD, FRACP, Department of Endocrinology, SE-171 76 Karolinska University Hospital, Stockholm, Sweden.
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32
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Helderman N, Lucas M, Blank C. Autoantibodies involved in primary and secondary adrenal insufficiency following treatment with immune checkpoint inhibitors. IMMUNO-ONCOLOGY TECHNOLOGY 2023; 17:100374. [PMID: 36937704 PMCID: PMC10014276 DOI: 10.1016/j.iotech.2023.100374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Primary and secondary adrenal insufficiency (AI) are commonly known immune-related adverse events following treatment with immune checkpoint inhibitors (ICIs), and are clinically relevant due to their morbidity and potential mortality. For this reason, upfront identification of patients susceptible for ICI-induced AI could be a step in improving patient's safety. Multiple studies have focused on the identification of novel biomarkers for ICI-induced AI, including autoantibodies, which may be involved in ICI-induced AI as a result of the T-cell-mediated activation of autoreactive B cells. This review highlights the currently described autoantibodies that may be involved in either primary [e.g. anti-21-hydroxylase, anti-17α-hydroxylase, anti-P450scc, anti-aromatic L-amino acid decarboxylase (AADC), anti-interferon (IFN)α and anti-IFNΩ] or secondary AI [e.g. anti-guanine nucleotide-binding protein G(olf) subunit alpha (GNAL), anti-integral membrane protein 2B (ITM2B), anti-zinc finger CCHC-type containing 8 (ZCCHC8), anti-pro-opiomelanocortin (POMC), anti-TPIT (corticotroph-specific transcription factor), anti-pituitary-specific transcriptional factor-1 (PIT-1) and others], and discusses the current evidence concerning their role as biomarker for ICI-induced AI. Standardized autoantibody measurements in patients (to be) treated with ICIs would be a clinically accessible and patient-friendly screening method to identify the patients at risk, and could change the management of ICI-induced AI.
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Affiliation(s)
- N.C. Helderman
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - M.W. Lucas
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam
| | - C.U. Blank
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam
- Correspondence to: Prof. Dr Christian U. Blank, Department of Medical Oncology, Netherlands Cancer Institute, Plesmanlaan 121 A, 1066 CX, Amsterdam, The Netherlands. Tel: +31-(0)20-512-9111
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Coluzzi F, LeQuang JAK, Sciacchitano S, Scerpa MS, Rocco M, Pergolizzi J. A Closer Look at Opioid-Induced Adrenal Insufficiency: A Narrative Review. Int J Mol Sci 2023; 24:ijms24054575. [PMID: 36902007 PMCID: PMC10003084 DOI: 10.3390/ijms24054575] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Among several opioid-associated endocrinopathies, opioid-associated adrenal insufficiency (OIAI) is both common and not well understood by most clinicians, particularly those outside of endocrine specialization. OIAI is secondary to long-term opioid use and differs from primary adrenal insufficiency. Beyond chronic opioid use, risk factors for OIAI are not well known. OIAI can be diagnosed by a variety of tests, such as the morning cortisol test, but cutoff values are not well established and it is estimated that only about 10% of patients with OIAI will ever be properly diagnosed. This may be dangerous, as OIAI can lead to a potentially life-threatening adrenal crisis. OIAI can be treated and for patients who must continue opioid therapy, it can be clinically managed. OIAI resolves with opioid cessation. Better guidance for diagnosis and treatment is urgently needed, particularly in light of the fact that 5% of the United States population has a prescription for chronic opioid therapy.
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Affiliation(s)
- Flaminia Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, 04100 Latina, Italy
- Unit of Anaesthesia, Intensive Care, and Pain Medicine, Sant’Andrea University Hospital, 00189 Rome, Italy
- Correspondence:
| | | | - Salvatore Sciacchitano
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00189 Rome, Italy
- Laboratory of Biomedical Research, Niccolò Cusano University Foundation, 00166 Rome, Italy
| | - Maria Sole Scerpa
- Unit of Anaesthesia, Intensive Care, and Pain Medicine, Sant’Andrea University Hospital, 00189 Rome, Italy
| | - Monica Rocco
- Unit of Anaesthesia, Intensive Care, and Pain Medicine, Sant’Andrea University Hospital, 00189 Rome, Italy
- Department of Surgical and Medical Science and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy
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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.
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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.
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Raff H, Zhang CD. A New Approach - Home Waking Salivary Cortisone to Screen for Adrenal Insufficiency. NEJM EVIDENCE 2023; 2:EVIDe2200306. [PMID: 38320042 DOI: 10.1056/evide2200306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Adrenal insufficiency is a common and potentially life-threatening endocrine disorder that can be drug induced or endogenous and of adrenal (primary) or pituitary/hypothalamic (secondary/tertiary) origin.1,2 Of particular concern in drug-induced disease is the patient with glucocorticoid- or opioid-induced adrenal insufficiency. Adrenal insufficiency of any cause is typically diagnosed biochemically with a subnormal morning serum cortisol (the circadian, awakening peak) and serum dehydroepiandrosterone sulfate, followed by or simultaneously with an assessment of the acute (30 and 60 minutes) serum cortisol response to injected synthetic corticotropin (ACTH[1-24]), if clinically indicated.
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Affiliation(s)
- Hershel Raff
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Milwaukee
| | - Catherine D Zhang
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee
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Beun JG, Burman P, Kämpe O, Husebye ES, Hahner S, Kristensen J, Noordzij A, Dahlqvist P. Doctors, teach your adrenal insufficiency patients well: provide them with a European Emergency Card! Endocr Connect 2023; 12:e220345. [PMID: 36327148 PMCID: PMC9782421 DOI: 10.1530/ec-22-0345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/03/2022] [Indexed: 11/06/2022]
Abstract
Adrenal insufficiency is a life-threatening condition requiring chronic glucocorticoid replacement therapy, as well as stress adaptation to prevent adrenal crises. To increase patients' self-sustainability, education on how to tackle an adrenal crisis is crucial. All patients should carry the European Emergency Card.
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Affiliation(s)
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, Lund University, Sweden
| | - Olle Kämpe
- Department of Medicine (Solna), Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Stephanie Hahner
- Division of Endocrinology and Diabetes, University Hospital of Wuerzburg, Germany
| | | | | | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Palones E, Curto E, Pelegrí A, Arilla M, Solanes I, Crespo-Lessmann A. Iatrogenic Adrenal Insufficiency Following Post COVID-19 Organizing Pneumonia. Arch Bronconeumol 2023; 59:63-65. [PMID: 35970652 PMCID: PMC9329133 DOI: 10.1016/j.arbres.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Esther Palones
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Institut de Recerca IIB Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Elena Curto
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Institut de Recerca IIB Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Anna Pelegrí
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Institut de Recerca IIB Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Marina Arilla
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Institut de Recerca IIB Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Ingrid Solanes
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Institut de Recerca IIB Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Astrid Crespo-Lessmann
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Institut de Recerca IIB Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain.
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Li D. Quality of Life in Patients with Adrenal Insufficiency. Endocrinol Metab Clin North Am 2022; 51:741-753. [PMID: 36244690 DOI: 10.1016/j.ecl.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with adrenal insufficiency, despite standard glucocorticoid replacement therapy, continue to experience and report impaired self-perceived health status and quality of life. In this review, we will describe quality of life in this patient population, and summarize the determinants of quality of life, based on previous survey-based studies and clinical trials. In addition, some new emerging data during the still ongoing coronavirus disease pandemic are also reviewed in the present article.
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Affiliation(s)
- Dingfeng Li
- Department of Endocrinology, Endocrine and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH 44195, USA.
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Geng D, Wang Y, Zhang X, Zhao C, Fan Y, Liu C, Wei J, Huo B, Zhao Y, Zhang F, Zhang R. Clinical course and management of insidious adrenal crisis manifested initially as hyperpyrexia secondary to pembrolizumab: Case reports and literature review. Front Oncol 2022; 12:981084. [PMID: 36033475 PMCID: PMC9403738 DOI: 10.3389/fonc.2022.981084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are novel drugs with a dramatic survival benefit in patients with advanced malignancies. With the widespread use, several immune-related adverse events (irAEs) have emerged, which may be life-threatening. Herein we report two patients with adrenal crisis who received anti-programmed cell death protein 1 (PD-1) (pembrolizumab) therapy. Several reports of secondary adrenal insufficiency caused by pembrolizumab exist, including during treatment or late onset. Severe adrenal insufficiency according to the Common Terminology Criteria for Adverse Events (CTCAE) has rarely been described in the literature, since it initially manifests as high-grade fever. The two male patients developed adrenal crisis that was first characterized by hyperpyrexia accompanied by abdominal symptoms. These initial manifestations confused the clinicians who misdiagnosed them as infection. Timely identification, hydrocortisone pulse therapy, and fluid resuscitation improved the patients’ condition. Compliance with the standardized treatment approach and course can prevent or relieve the crisis as soon as possible. Assessment of relevant laboratory test results and patient education, including when to use stress-dose hydrocortisone and guidance on route of administration, can reduce the incidence of adrenal crisis. We report these two cases and have evaluated the literature on previously reported cases to improve our understanding of this condition and offer a more scientific approach to diagnosis and treatment options.
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Affiliation(s)
- Dandan Geng
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yingnan Wang
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xin Zhang
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chenguang Zhao
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yao Fan
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chang Liu
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jinmei Wei
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bingjie Huo
- Department of Traditional Chinese Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yang Zhao
- Office of Academic Research, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Fengbin Zhang
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
- *Correspondence: Zhang Fengbin, ; Ruixing Zhang,
| | - Ruixing Zhang
- Department of Gastroenterology and Hepatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
- *Correspondence: Zhang Fengbin, ; Ruixing Zhang,
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Kim JH. Time to Care for Adrenal Insufficiency in Cancer Patients. J Korean Med Sci 2022; 37:e232. [PMID: 35851865 PMCID: PMC9294499 DOI: 10.3346/jkms.2022.37.e232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Li D, Brand S, Hamidi O, Westfall AA, Suresh M, Else T, Vaidya A, Bancos I. Quality of Life and its Determinants in Patients With Adrenal Insufficiency: A Survey Study at 3 Centers in the United States. J Clin Endocrinol Metab 2022; 107:e2851-e2861. [PMID: 35350067 PMCID: PMC9202727 DOI: 10.1210/clinem/dgac175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Current evidence on determinants of quality of life (QoL) in patients with adrenal insufficiency (AI) is limited. OBJECTIVE This work aimed to identify the determinants of QoL in different subtypes of AI. METHODS This multicenter cross-sectional survey study was conducted using a patient-centered questionnaire, the Short Form-36. RESULTS Of 529 participants, 223 (42.2%) had primary AI, 190 (35.9%) had secondary AI, and 116 (21.9%) had glucocorticoid-induced AI. Median age was 58 years (interquartile range: 43-68 years) and 342 (64.8%) were women. In multivariable analyses, patients were more likely to report worse physical scores if they were women (odds ratio [OR]: 3.3; 95% CI, 1.8-6.0), had secondary AI or glucocorticoid-induced AI (OR: 2.5; 95% CI, 1.4-4.3), had shorter duration of AI (OR: 2.0; 95% CI, 1.1-3.6), were treated with more than 25 mg hydrocortisone equivalent daily (OR: 2.3; 95% CI, 1.2-4.6), had more comorbidities related to glucocorticoid excess (OR: 2.3; 95% CI, 1.3-4.0), reported a higher financial burden from AI (OR: 2.1; 95% CI, 1.3-3.6), and reported difficulties with AI management (OR: 2.5; 95% CI, 1.2-5.2). Women (OR: 2.1; 95% CI, 1.08-4.0), shorter duration of AI (OR: 2.4; 95% CI, 1.4-4.3), higher financial burden (OR: 2.3; 95% CI, 1.3-4.0), difficulties with AI management (OR: 2.6; 95% CI, 1.4-4.9), and lack of family support (OR: 9.1; 95% CI, 2.3-33.3) were associated with worse mental component scores. CONCLUSION In patients with AI, QoL could be improved by addressing certain determinants, such as avoiding GC overreplacement, providing in-depth education on self-management, offering more comprehensive insurance coverage, and ensuring better family support.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Sarah Brand
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Ashleigh A Westfall
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Malavika Suresh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts 02115, USA
| | - Irina Bancos
- Correspondence: Irina Bancos, MD, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Rushworth RL, Chrisp GL, Bownes S, Torpy DJ, Falhammar H. Adrenal crises in adolescents and young adults. Endocrine 2022; 77:1-10. [PMID: 35583847 PMCID: PMC9242908 DOI: 10.1007/s12020-022-03070-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/03/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE Review the literature concerning adrenal insufficiency (AI) and adrenal crisis (AC) in adolescents and young adults. METHODS Searches of PubMed identifying relevant reports up to March 2022. RESULTS AI is rare disorder that requires lifelong glucocorticoid replacement therapy and is associated with substantial morbidity and occasional mortality among adolescents and young adults. Aetiologies in this age group are more commonly congenital, with acquired causes, resulting from tumours in the hypothalamic-pituitary area and autoimmune adrenalitis among others, increasing with age. All patients with AI are at risk of AC, which have an estimated incidence of 6 to 8 ACs/100 patient years. Prevention of ACs includes use of educational interventions to achieve competency in dose escalation and parenteral glucocorticoid administration during times of physiological stress, such as an intercurrent infection. While the incidence of AI/AC in young children and adults has been documented, there are few studies focussed on the AC occurrence in adolescents and young adults with AI. This is despite the range of developmental, psychosocial, and structural changes that can interfere with chronic disease management during this important period of growth and development. CONCLUSION In this review, we examine the current state of knowledge of AC epidemiology in emerging adults; examine the causes of ACs in this age group; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in these patients.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - Georgina L Chrisp
- School of Medicine, Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - Suzannah Bownes
- School of Medicine, Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, SE-17176, Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden.
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Ryan A, Twomey PJ. Thoughts on adrenal insufficiency best practice article. J Clin Pathol 2022; 75:433-434. [PMID: 35715195 DOI: 10.1136/jclinpath-2022-208162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/13/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Aidan Ryan
- National Centre for Inherited Metabolic Disorders Adult Service, The Mater Misericordiae University Hospital, Dublin, Ireland
| | - Patrick J Twomey
- Clinical Chemistry, St Vincent's University Hospital, Dublin, Ireland .,School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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Deprescribing in Palliative Cancer Care. Life (Basel) 2022; 12:life12050613. [PMID: 35629281 PMCID: PMC9147815 DOI: 10.3390/life12050613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/23/2022] Open
Abstract
The aim of palliative care is to maintain as high a quality of life (QoL) as possible despite a life-threatening illness. Thus, the prescribed medications need to be evaluated and the benefit of each treatment must be weighed against potential side effects. Medications that contribute to symptom relief and maintained QoL should be prioritized. However, studies have shown that treatment with preventive drugs that may not benefit the patient in end-of-life is generally deprescribed very late in the disease trajectory of cancer patients. Yet, knowing how and when to deprescribe drugs can be difficult. In addition, some drugs, such as beta-blockers, proton pump inhibitors, anti-depressants and cortisone need to be scaled down slowly to avoid troublesome withdrawal symptoms. In contrast, other medicines, such as statins, antihypertensives and vitamins, can be discontinued directly. The aim of this review is to give some advice according to when and how to deprescribe medications in palliative cancer care according to current evidence and clinical praxis. The review includes antihypertensive drugs, statins, anti-coagulants, aspirin, anti-diabetics, proton pump inhibitors, histamin-2-blockers, bisphosphonates denosumab, urologicals, anti-depressants, cortisone, thyroxin and vitamins.
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Pilz S, Krebs M, Bonfig W, Högler W, Hochgerner A, Vila G, Trummer C, Theiler-Schwetz V, Obermayer-Pietsch B, Wolf P, Scherer T, Kiefer F, Fröhlich-Reiterer E, Gottardi-Butturini E, Kapelari K, Schatzl S, Kaser S, Höfle G, Schiller D, Stepan V, Luger A, Riedl S. Notfallausweis, Notfallmedikation und Informationsmaterial zur Prävention und Therapie der Nebennierenkrise (Addison-Krise): Ein österreichisches Konsensusdokument. JOURNAL FÜR KLINISCHE ENDOKRINOLOGIE UND STOFFWECHSEL 2022; 15:5-27. [PMID: 35251520 PMCID: PMC8889064 DOI: 10.1007/s41969-022-00155-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 12/03/2022]
Abstract
Ein wichtiges Ziel bei der Behandlung der Nebenniereninsuffizienz ist die Prävention der Nebennierenkrise (auch akute Nebenniereninsuffizienz oder Addison-Krise genannt). Um in Österreich eine bessere Implementierung sowie Harmonisierung der Maßnahmen zur Prävention und Therapie der Nebennierenkrise zu erreichen, wurde dieses Konsensusdokument erarbeitet. Folgende Maßnahmen werden grundsätzlich für alle Patient*innen mit Nebenniereninsuffizienz empfohlen und in diesem Manuskript ausführlich erörtert: 1. Versorgung mit einer Notfallkarte („steroid emergency card“) sowie evtl. auch mit einem Armband oder einer Halskette (oder Ähnlichem) mit medizinischem Alarmhinweis „Nebenniereninsuffizienz, benötigt Glukokortikoide“. 2. Versorgung mit einem Hydrocortison-Notfallkit zur Injektion (alternativ auch Suppositorien/Zäpfchen zur Notfallapplikation) sowie ausreichenden oralen Glukokortikoiddosen für Stresssituationen/Erkrankungen. 3. Schulung von Patient*innen und Angehörigen zur Steigerung der Glukokortikoidtherapie in Stresssituationen bzw. bei Erkrankungen („sick day rules“) und zur Selbstinjektion von Hydrocortison. 4. Versorgung mit einer Behandlungsleitlinie (Informationszettel) zur Prävention und Therapie der Nebennierenkrise, welche bei Bedarf auch dem Gesundheitspersonal gezeigt werden soll. 5. Versorgung mit einer Notfall-Telefonnummer des behandelnden endokrinologischen Teams und/oder medizinisch geschulter Betreuungspersonen bzw. Angehöriger. 6. Regelmäßige (vorzugsweise jährliche) Wiederholung der Schulungsmaßnahmen. Dieses Konsensusdokument beinhaltet auch ausführliche Empfehlungen für die perioperative Glukokortikoidtherapie sowie für diverse andere Stresssituationen.
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Affiliation(s)
- Stefan Pilz
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Michael Krebs
- Abteilung für Endokrinologie und Stoffwechsel, Klinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Walter Bonfig
- Abteilung für Kinder- und Jugendheilkunde, Klinikum Wels-Grieskirchen, Wels, Österreich
| | - Wolfgang Högler
- Universitätsklinik für Kinder- und Jugendheilkunde, Johannes Kepler Universität Linz, Linz, Österreich
| | - Anna Hochgerner
- Selbsthilfegruppe Netzwerk AGS-Österreich und Selbsthilfebeauftragte des Ordensklinikum Linz, Linz, Österreich
| | - Greisa Vila
- Abteilung für Endokrinologie und Stoffwechsel, Klinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Christian Trummer
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Verena Theiler-Schwetz
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Barbara Obermayer-Pietsch
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Peter Wolf
- Abteilung für Endokrinologie und Stoffwechsel, Klinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Thomas Scherer
- Abteilung für Endokrinologie und Stoffwechsel, Klinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Florian Kiefer
- Abteilung für Endokrinologie und Stoffwechsel, Klinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Elke Fröhlich-Reiterer
- Klinische Abteilung für allgemeine Pädiatrie, Medizinische Universität Graz, Graz, Österreich
| | - Elena Gottardi-Butturini
- Universitätsklinikum für Kinder- und Jugendheilkunde, Uniklinikum Salzburg, Salzburg, Österreich
| | - Klaus Kapelari
- Abteilung für Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Stefan Schatzl
- Univ. Klinik für Innere Medizin 1 , Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Susanne Kaser
- Univ. Klinik für Innere Medizin 1 , Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Günter Höfle
- Abteilung für Innere Medizin, LKH Hohenems, Hohenems, Österreich
| | - Dietmar Schiller
- 4. Interne Abteilung, Ordensklinikum Barmherzige Schwestern, Linz, Österreich
| | - Vinzenz Stepan
- Abteilung für Innere Medizin, Krankenhaus der Elisabethinen, Graz, Österreich
| | - Anton Luger
- Abteilung für Endokrinologie und Stoffwechsel, Klinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Stefan Riedl
- St. Anna Kinderspital, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Wien, Österreich
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Paul SN, Wingenfeld K, Otte C, Meijer OC. Brain Mineralocorticoid receptor in health and disease: from molecular signaling to cognitive and emotional function. Br J Pharmacol 2022; 179:3205-3219. [PMID: 35297038 PMCID: PMC9323486 DOI: 10.1111/bph.15835] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/22/2022] [Accepted: 03/08/2022] [Indexed: 11/27/2022] Open
Abstract
Brain mineralocorticoid receptors (MR) mediate effects of glucocorticoid hormones in stress adaptation, as well as the effects of aldosterone itself in relation to salt homeostasis. Brain stem MRs respond to aldosterone, whereas forebrain MRs mediate rapid and delayed glucocorticoid effects in conjunction with the glucocorticoid receptor (GR). MR‐mediated effects depend on age, gender, genetic variations, and environmental influences. Disturbed MR activity through chronic stress, certain (endocrine) diseases or during glucocorticoid therapy can cause deleterious effects on affective state, cognitive and behavioural function in susceptible individuals. Considering the important role MR plays in cognition and emotional function in health and disease, MR modulation by pharmacological intervention could relieve stress‐ and endocrine‐related symptoms. Here, we discuss recent pharmacological interventions in the clinic and genetic developments in the molecular underpinnings of MR signalling. Further understanding of MR‐dependent pathways may help to improve psychiatric symptoms in a diversity of settings.
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Affiliation(s)
- Susana N Paul
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands.,Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Wingenfeld
- Klinik für Psychiatrie und Psychotherapie, Charité Universitätsmedizin Campus Benjamin Franklin, Berlin, Germany
| | - Christian Otte
- Klinik für Psychiatrie und Psychotherapie, Charité Universitätsmedizin Campus Benjamin Franklin, Berlin, Germany.,NeuroCure Cluster of Excellence, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Onno C Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands.,Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Quinkler M, Kienitz T. The ISAQ Score Does Not Predict Adrenal Crisis in Patients with Primary Adrenal Insufficiency. Exp Clin Endocrinol Diabetes 2022; 130:554-560. [PMID: 35240692 DOI: 10.1055/a-1734-2466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to investigate the ability of the immune system assessment questionnaire (ISAQ) to predict adrenal crisis (AC) and infectious events in patients with primary adrenal insufficiency (PAI). DESIGN This was a prospective single-centre study over three years. METHODS Patients answered the ISAQ at baseline and were seen every 4-6 months in the endocrine outpatient clinic. At each visit previous infectious periods which required an increase in daily glucocorticoid dosage and AC were reported and documented. Seventy-five patients with PAI (53 women; 43 patients with autoimmune PAI, 20 patients with salt-wasting congenital adrenal hyperplasia and 12 patients who underwent bilateral adrenalectomy) were analysed. Due to the COVID-19 pandemic and consecutive lockdown measures, the data were analysed separately for March 2018 to March 2020 (period 1), and March 2020 to March 2021 (period 2). RESULTS During period 1 the ISAQ score significantly correlated with the number of reported infectious events (r=0.351; p<0.01), but not during period 2 (r=0.059, p=0.613), in which the number of infectious events per patient-year significantly decreased (1.1±0.1 vs 0.4±0.1; p<0.001). The frequency of AC decreased from 8.8 to 2.4 per 100 patient-years between the two study periods. The ISAQ score was not different between patients with or without AC. CONCLUSIONS The ISAQ score does not identify patients prone to ACs. The COVID-19 pandemic and consecutive lockdown measures significantly diminished the frequency of infectious events and ACs.
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Affiliation(s)
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
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Reeves PT, Packett AC, Burklow CS, Echelmeyer S, Larson NS. Development and assessment of a low-health-literacy, pictographic adrenal insufficiency action plan. J Pediatr Endocrinol Metab 2022; 35:205-215. [PMID: 34592068 DOI: 10.1515/jpem-2021-0541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Adrenal insufficiency (AI) is an overall rare disorder characterized by the chronic need for pharmacotherapy to prevent threat to life. The Pediatric Endocrine Society has recommended the use of clinical action tools to improve patient education and help guide acute management of AI. We aimed to develop and assess an easy-to-use, patient-friendly, evidence-based, personalized pictogram-based adrenal insufficiency action plan (AIAP) to aid in the management of AI in children. METHODS Patients/caregivers (P/Cs) responded to surveys which measured the concepts of transparency, translucency, and recall in order to assess the pictograms. Readability was assessed using six formulas to generate a composite readability score. Quality was graded by P/Cs using the Consumer Information Rating Form (CIRF) (>80% rating considered acceptable). Understandability and actionability was assessed by medical librarians using the Patient Education Materials Assessment Tool-Printable (PEMAT-P) (>80% rating was acceptable). Suitability was evaluated by clinicians using the Suitability Assessment of Materials (SAM) instrument (>70% rating considered superior). RESULTS All pictograms met criteria for inclusion in the AIAP. Composite readability score=5.4 was consistent with a fifth-grade level. P/Cs (n=120) judged the AIAP to be of high quality with CIRF rating=85.2%. Three medical librarians rated the AIAP to have 100% understandability and 100% actionability. Thirty-three clinicians completing the SAM generated a suitability rating of 90.0%. CONCLUSIONS The AIAP visually highlights individualized care plan components to facilitate optimized preventative and acute AI care. Further investigation will determine if AIAP improves clinical outcomes for patients with AI.
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Affiliation(s)
- Patrick T Reeves
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ashley C Packett
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Carolyn Sullivan Burklow
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sofia Echelmeyer
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Noelle S Larson
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Abstract
Addison's disease typically results from the autoimmune destruction of the adrenal cortex and requires lifelong replacement with glucocorticoids and mineralocorticoids. Main symptoms are non-specific and, therefore, often overlooked or misleading. Patients are frequently not diagnosed until experiencing a life-threatening adrenal crisis. This article highlights the essential clinical characteristics, diagnostic aspects and principles of management of adrenal insufficiency.
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50
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Endocrine Toxicities of Antineoplastic Therapy: The Adrenal Topic. Cancers (Basel) 2022; 14:cancers14030593. [PMID: 35158860 PMCID: PMC8833706 DOI: 10.3390/cancers14030593] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/06/2022] [Accepted: 01/14/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Primary adrenal insufficiency (PAI) induced by anticancer drugs is a rare occurrence. However, with the expanding use of immune checkpoint inhibitors (ICIs), an increasing number of patients affected by ICI-induced PAI are expected. As a result, oncologists should be aware of the risk of PAI in patients on ICIs (and other anticancer agents) and the related clinical presentations to diagnose this condition early, provide the appropriate treatment, and timely involve endocrinologists in the management of those patients. In parallel, patients on these medications, together with their caregivers and relatives, should receive detailed information about PAI risk and be trained to act appropriately at the onset of alarm symptoms. Large collaborative trials are needed to develop appropriate tests to assess the personal risk of drug induced PAI better and improve its early diagnosis in cancer patients and patients affected by other forms of PAI. Abstract Immune checkpoint inhibitors (ICIs) have improved survival in patients affected by several solid tumours at the cost of new autoimmune adverse events. Endocrine toxicity is frequently reported in patients treated with these agents, mainly as thyroid dysfunction and hypophysitis. Primary adrenal insufficiency is reported in 1–2% of patients receiving a single ICI, but its rate is approximately 5% in patients treated with a combination of two ICIs. The clinical presentation of adrenal insufficiency may be insidious due to symptoms that are not specific. The same symptoms in cancer patients are frequently multifactorial, rendering the early diagnosis of adrenal insufficiency challenging in this group of patients. As adrenal insufficiency can be fatal if not rapidly diagnosed and treated, oncologists should be aware of its clinical presentations to timely involve endocrinologists to offer patients the appropriate management. In parallel, it is essential to educate patients, their caregivers, and relatives, providing them with detailed information about the risk of adrenal insufficiency and how to manage alarming symptoms at their onset. Finally, large collaborative trials are needed to develop appropriate tests to assess better the personal risk of drug-induced adrenal insufficiency and its early diagnosis and treatment, not only in cancer patients.
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