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Prencipe N, Marinelli L, Varaldo E, Cuboni D, Berton AM, Bioletto F, Bona C, Gasco V, Grottoli S. Isolated anterior pituitary dysfunction in adulthood. Front Endocrinol (Lausanne) 2023; 14:1100007. [PMID: 36967769 PMCID: PMC10032221 DOI: 10.3389/fendo.2023.1100007] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/21/2023] [Indexed: 03/29/2023] Open
Abstract
Hypopituitarism is defined as a complete or partial deficiency in one or more pituitary hormones. Anterior hypopituitarism includes secondary adrenal insufficiency, central hypothyroidism, hypogonadotropic hypogonadism, growth hormone deficiency and prolactin deficiency. Patients with hypopituitarism suffer from an increased disability and sick days, resulting in lower health status, higher cost of care and an increased mortality. In particular during adulthood, isolated pituitary deficits are not an uncommon finding; their clinical picture is represented by vague symptoms and unclear signs, which can be difficult to properly diagnose. This often becomes a challenge for the physician. Aim of this narrative review is to analyse, for each anterior pituitary deficit, the main related etiologies, the characteristic signs and symptoms, how to properly diagnose them (suggesting an easy and reproducible step-based approach), and eventually the treatment. In adulthood, the vast majority of isolated pituitary deficits are due to pituitary tumours, head trauma, pituitary surgery and brain radiotherapy. Immune-related dysfunctions represent a growing cause of isolated pituitary deficiencies, above all secondary to use of oncological drugs such as immune checkpoint inhibitors. The diagnosis of isolated pituitary deficiencies should be based on baseline hormonal assessments and/or dynamic tests. Establishing a proper diagnosis can be quite challenging: in fact, even if the diagnostic methods are becoming increasingly refined, a considerable proportion of isolated pituitary deficits still remains without a certain cause. While isolated ACTH and TSH deficiencies always require a prompt replacement treatment, gonadal replacement therapy requires a benefit-risk evaluation based on the presence of comorbidities, age and gender of the patient; finally, the need of growth hormone replacement therapies is still a matter of debate. On the other side, prolactin replacement therapy is still not available. In conclusion, our purpose is to offer a broad evaluation from causes to therapies of isolated anterior pituitary deficits in adulthood. This review will also include the evaluation of uncommon symptoms and main etiologies, the elements of suspicion of a genetic cause and protocols for diagnosis, follow-up and treatment.
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Tanaka S, Yamamoto M, Morita M, Takeno A, Kanazawa I, Yamaguchi T, Yamada S, Inoshita N, Oki Y, Kurosaki M, Sugimoto T. Successful reduction of ACTH secretion in a case of intractable Cushing's disease with pituitary Crooke's cell adenoma by combined modality therapy including temozolomide. Endocr J 2019; 66:701-708. [PMID: 31130573 DOI: 10.1507/endocrj.ej18-0547] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Crooke's cell adenoma (CCA) is an aggressive subtype of corticotroph adenoma; however, CCA is associated with a high incidence of low expression of methyl guanine methyl transferase (MGMT), suggesting that temozolomide (TMZ) treatment might be effective for this tumor type. The case of a 56-year-old woman with Cushing's disease caused by a pituitary CCA is presented. At the age of 38 years, the patient presented to our hospital with polyuria and a visual field defect. MRI and laboratory studies showed a 4.5-cm-diameter pituitary tumor with plasma adrenocorticotropic hormone (ACTH) and serum cortisol levels of more than 500 pg/mL and 40 μg/dL, respectively. At 39 years of age, the patient underwent a craniotomy, and her plasma ACTH and cortisol levels decreased to less than 200 pg/mL and 10 μg/dL, respectively; however, these hormone levels increased gradually to 3,940 pg/mL and 70 μg/dL, respectively, by the time the patient was 56 years old. Histopathological re-examination of the previously resected specimen showed that the pituitary tumor was MGMT-negative CCA. TMZ treatment after the second operation decreased the plasma ACTH levels from 600-800 pg/mL to 70-300 pg/mL. No signs of recurrence were observed in the seven years following these treatments with added prophylactic radiation therapy. These clinical findings suggest that TMZ treatment to patients with CCA accompanied with elevated ACTH may be good indication to induce lowering ACTH levels and tumor shrinkage.
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Affiliation(s)
- Sayuri Tanaka
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Masahiro Yamamoto
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Miwa Morita
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Ayumu Takeno
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Ippei Kanazawa
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Toru Yamaguchi
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
| | - Shozo Yamada
- Endocrine Center, Division of Hypothalamic & Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Naoko Inoshita
- Department of Pathology, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Yutaka Oki
- Second Division Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Masamichi Kurosaki
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine Tottori University, Yonago 683-8504, Japan
| | - Toshitsugu Sugimoto
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
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Onori P, Franchitto A, Mancinelli R, Carpino G, Alvaro D, Francis H, Alpini G, Gaudio E. Polycystic liver diseases. Dig Liver Dis 2010; 42:261-71. [PMID: 20138815 PMCID: PMC2894157 DOI: 10.1016/j.dld.2010.01.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 01/07/2010] [Accepted: 01/07/2010] [Indexed: 12/11/2022]
Abstract
Polycystic liver diseases (PCLDs) are genetic disorders with heterogeneous etiologies and a range of phenotypic presentations. PCLD exhibits both autosomal or recessive dominant pattern of inheritance and is characterized by the progressive development of multiple cysts, isolated or associated with polycystic kidney disease, that appear more extensive in women. Cholangiocytes have primary cilia, functionally important organelles (act as mechanosensors) that are involved in both normal developmental and pathological processes. The absence of polycystin-1, 2, and fibrocystin/polyductin, normally localized to primary cilia, represent a potential mechanism leading to cyst formation, associated with increased cell proliferation and apoptosis, enhanced fluid secretion, abnormal cell-matrix interactions, and alterations in cell polarity. Proliferative and secretive activities of cystic epithelium can be regulated by estrogens either directly or by synergizing growth factors including nerve growth factor, IGF1, FSH and VEGF. The abnormalities of primary cilia and the sensitivity to proliferative effects of estrogens and different growth factors in PCLD cystic epithelium provide the morpho-functional basis for future treatment targets, based on the possible modulation of the formation and progression of hepatic cysts.
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Affiliation(s)
- P. Onori
- Experimental Medicine, University of L'Aquila, L'Aquila, Italy
| | - A. Franchitto
- Dept Human Anatomy, University of Rome “La Sapienza”, Rome, Italy
| | - R. Mancinelli
- Dept Human Anatomy, University of Rome “La Sapienza”, Rome, Italy
| | - G. Carpino
- Dept Health Science, University of Rome “Foro Italico”, Italy
| | - D. Alvaro
- Gastroenterology, Polo Pontino, University of Rome “La Sapienza”, Rome, Italy
| | - H. Francis
- Research, Central Texas Veterans Health Care System, USA
| | - G. Alpini
- Research, Central Texas Veterans Health Care System, USA, Scott & White Digestive Disease Research Center, Texas A&M Health Science Center, College of Medicine, USA
| | - E. Gaudio
- Dept Human Anatomy, University of Rome “La Sapienza”, Rome, Italy, Corresponding author. Tel.: +39 0649918060; fax: +39 0649918062. (E. Gaudio)
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Bremer AA, Ranadive S, Conrad SC, Vallette-Kasic S, Rosenthal SM. Isolated adrenocorticotropic hormone deficiency presenting as an acute neurologic emergency in a peripubertal girl. J Pediatr Endocrinol Metab 2008; 21:799-803. [PMID: 18825881 DOI: 10.1515/jpem.2008.21.8.799] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Isolated adrenocorticotropic hormone (ACTH) deficiency (IAD) is extraordinarily rare, and the clinical manifestations of its accompanying adrenal insufficiency are diverse. Early-onset forms of IAD have been linked to mutations in the Tpit transcription factor gene TPIT; however, the genetic basis of juvenile- or late-onset IAD is unknown. Herein, we describe a case of a peripubertal girl with IAD and a normal TPIT gene who presented with an acute neurologic emergency, demonstrating both the variable clinical presentation of IAD and the need for continued investigation into the molecular mechanisms underlying juvenile- and late-onset IAD.
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Affiliation(s)
- Andrew A Bremer
- Department of Pediatrics, Division of Endocrinology, University of California Davis Medical Center, Sacramento, CA 95817-2208, USA.
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Kim I, Fu Y, Hui K, Moeckel G, Mai W, Li C, Liang D, Zhao P, Ma J, Chen XZ, George AL, Coffey RJ, Feng ZP, Wu G. Fibrocystin/polyductin modulates renal tubular formation by regulating polycystin-2 expression and function. J Am Soc Nephrol 2008; 19:455-68. [PMID: 18235088 DOI: 10.1681/asn.2007070770] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Autosomal recessive polycystic kidney disease is caused by mutations in PKHD1, which encodes the membrane-associated receptor-like protein fibrocystin/polyductin (FPC). FPC associates with the primary cilia of epithelial cells and co-localizes with the Pkd2 gene product polycystin-2 (PC2), suggesting that these two proteins may function in a common molecular pathway. For investigation of this, a mouse model with a gene-targeted mutation in Pkhd1 that recapitulates phenotypic characteristics of human autosomal recessive polycystic kidney disease was produced. The absence of FPC is associated with aberrant ciliogenesis in the kidneys of Pkhd1-deficient mice. It was found that the COOH-terminus of FPC and the NH2-terminus of PC2 interact and that lack of FPC reduced PC2 expression but not vice versa, suggesting that PC2 may function immediately downstream of FPC in vivo. PC2-channel activities were dysregulated in cultured renal epithelial cells derived from Pkhd1 mutant mice, further supporting that both cystoproteins function in a common pathway. In addition, mice with mutations in both Pkhd1 and Pkd2 had a more severe renal cystic phenotype than mice with single mutations, suggesting that FPC acts as a genetic modifier for disease severity in autosomal dominant polycystic kidney disease that results from Pkd2 mutations. It is concluded that a functional and molecular interaction exists between FPC and PC2 in vivo.
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Affiliation(s)
- Ingyu Kim
- Division of Genetic Medicine, Department of Medicine and Cell and Developmental Biology, Vanderbilt University, 539 LH, 2215 Garland Avenue, Nashville, TN 37232, USA
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Abstract
Isolated ACTH deficiency (IAD) is a rare disorder, characterized by secondary adrenal insufficiency (AI) with low or absent cortisol production, normal secretion of pituitary hormones other than ACTH and the absence of structural pituitary defects. In adults, IAD may appear after a traumatic injury or a lymphocytic hypophysitis, the latter possibly due to autoimmune etiology. Conversely, a genetic origin may come into play in neonatal or childhood IAD. Patients with IAD usually fare relatively well during unstressed periods until intervening events spark off an acute adrenal crisis presenting with non specific symptoms, such as asthenia, anorexia, unintentional weight loss and tendency towards hypoglycemia. Blood chemistry may reveal mild hypoglycemia, hyponatremia and normal-high potassium levels, mild anemia, lymphocytosis and eosinophilia. Morning serum cortisol below 3 microg/dl are virtually diagnostic for adrenal insufficiency. whereas cortisol values comprised between 5-18 microg/dl require additional investigations: insulin tolerance test (ITT) is considered the gold standard but-when contraindicated-high or low dose-ACTH stimulation test with serum cortisol determination provides a viable alternative. Plasma ACTH concentration and prolonged ACTH infusion test are useful in differential diagnosis between primary and secondary adrenal insufficiency. For some patients with mild, near-to-asymptomatic disease, glucocorticoid replacement therapy may not be required except during stressful events; for symptomatic patients, replacement doses i.e., mean daily dose 20 mg (0.30 mg/kg) hydrocortisone or 25 mg (0.35 mg/kg) cortisone acetate, are usually sufficient. Administration of mineralocorticoids is generally not necessary as their production is maintained.
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