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Takebayashi K, Ujiie A, Kubo M, Furukawa S, Yamauchi M, Shinozaki H, Suzuki T, Naruse R, Hara K, Tsuchiya T, Inukai T. Isolated Adrenocorticotropic Hormone Deficiency and Severe Hypercalcemia After Destructive Thyroiditis in a Patient on Nivolumab Therapy With a Malignant Melanoma. J Clin Med Res 2018; 10:358-362. [PMID: 29511426 PMCID: PMC5827922 DOI: 10.14740/jocmr3257w] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/20/2017] [Indexed: 11/25/2022] Open
Abstract
We describe a 58-year-old man with a malignant melanoma metastasis to the liver. After initiation of nivolumab therapy, he developed destructive thyroiditis and subsequently simultaneous isolated adrenocorticotropic hormone (ACTH) deficiency and severe hypercalcemia. Although isolated ACTH deficiency and hypercalcemia due to nivolumab therapy are both rare occurrences, these conditions can often cause a severe clinical course accompanied by a disturbance of consciousness. Therefore, clinicians should pay attention to these possible side effects of nivolumab if the patients have clinical symptoms, such as fatigue and a disturbance of consciousness.
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Affiliation(s)
- Kohzo Takebayashi
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Atsushi Ujiie
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Mio Kubo
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Sho Furukawa
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Mototaka Yamauchi
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Hiroyuki Shinozaki
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Tatsuhiko Suzuki
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Rika Naruse
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Kenji Hara
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Takafumi Tsuchiya
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Toshihiko Inukai
- Department of Internal Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
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Abstract
Our objective was to study the endocrinologic manifestations of the antiphospholipid syndrome (APS). We reviewed the medical literature from 1968 until 2005 using MEDLINE and the key words: APS, anticardiolipin antibodies, lupus anticoagulant, antiphospholipid antibodies, adrenal, thyroid, parathyroid, pituitary, diabetes, ovaries and testes. Adrenal insufficiency is the most common endocrinologic manifestation and can be the presenting symptom of APS. In patients with autoimmune thyroid disease circulating aPL have been detected. However, no clinical manifestations of APS have been described. A few cases of hypopituitarism have been reported, including a case of Sheehan’s syndrome. aPL has been detected in the sera of diabetic patients, probably associated with some macroangiopathic complications. Finally only very few cases of ovarian and testicular involvement have been reported. The adrenals are the most commonly involved glands in the APS. Clinicians should keep a high index of suspicion for adrenal insufficiency in patients with APS.
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Affiliation(s)
- I Uthman
- Division of Rheumatology, Faculty of Medicine, American University of Beirut, Lebanon.
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Shahin AA, El Desouky SM, Awadallah MY, Megahed DE. Adrenal gland abnormalities detected by magnetic resonance imaging in patients with antiphospholipid syndrome. Z Rheumatol 2016; 76:170-175. [PMID: 27307185 DOI: 10.1007/s00393-016-0107-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adrenal infarction is a rare complication of antiphospholipid syndrome (APS). OBJECTIVES The purpose of the current study is to detect and study the magnetic resonance imaging (MRI) findings of adrenal glands in APS patients. MATERIALS AND METHODS In a cross-sectional study, the data of 20 patients with primary or secondary APS were compared to 20 SLE patients without antiphospholipid antibody (aPL) syndrome (controls). MRI of the abdomen showing the adrenal glands was performed. RESULTS Of the patients, 80% were females with a mean age 32.45 ± 9.93 years, and mean disease duration of 46.65 ± 58.71 months. Adrenal gland abnormalities in the MRI study were detected in 35 % of APS patients vs. no abnormalities detected in the SLE controls. Adrenal gland enlargement was found in all patients (35 %). Capsular enhancement (infarction or hemorrhagic infarction) was found in 5 patients, increased stranding of the surrounding fat planes (inflammatory process) in 4 patients and increased signal on T1WI and T2WI (hemorrhage) in 3 patients. In patients with adrenal gland involvement, 71.4 % had triple aPL positivity compared to 23.1 % in patients with normal adrenal findings (p = 0.04). CONCLUSIONS Adrenal gland abnormalities on MRI were detected in 35 % of the APS patients (whether primary or secondary); thus, increased focus on management is needed. This percentage is not small and needs to be focused on in terms of management.
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Affiliation(s)
- A A Shahin
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, 453 alharam st., Giza, Egypt.
| | - S M El Desouky
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, 453 alharam st., Giza, Egypt
| | - M Y Awadallah
- Radiology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - D E Megahed
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, 453 alharam st., Giza, Egypt
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Barrou Z, Verny C, Cohen-Bittan J, Verny M. RESPONSE LETTER TO DR. ROSENBERGER AND COLLEAGUES. J Am Geriatr Soc 2011. [DOI: 10.1111/j.1532-5415.2011.03426.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Addison’s disease secondary to connective tissue diseases: a report of six cases. Rheumatol Int 2008; 29:647-50. [DOI: 10.1007/s00296-008-0749-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2008] [Accepted: 10/05/2008] [Indexed: 10/21/2022]
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Naka N, Takenaka S, Nanno K, Moriguchi Y, Chun BM, Sonoda S, Hashimoto N, Tsukamoto Y, Araki N. Acute adrenal crisis after orthopedic surgery for pathologic fracture. World J Surg Oncol 2007; 5:27. [PMID: 17338824 PMCID: PMC1821329 DOI: 10.1186/1477-7819-5-27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Accepted: 03/06/2007] [Indexed: 05/14/2023] Open
Abstract
Background Adrenal crisis after surgical procedure is a rare but potentially catastrophic life-threatening event. Its manifestations, such as hypotension, tachycardia, hypoxia, and fever mimic the other more common postoperative complications. Clinical outcome is dependent upon early recognition of the condition and proper management with exogenous steroid administration. Case presentation We report a 75-year-old man who presented with shock immediately after surgery for a femoral fracture from lung cancer metastasis. Anemia and severe hyponatremia were detected. Despite adequate fluid resuscitation, nonspecific symptoms including hypotension, tachycardia, hypoxia, fever and confusion occurred. Emergent CT revealed enlarged bilateral adrenal glands. Under the diagnosis of adrenal crisis due to metastatic infiltration of adrenal glands, the patient was treated with appropriate steroid replacement resulting in rapid improvement and recovery. Conclusion We describe a case of adrenal crisis caused by the lack of adrenal reserve based on metastatic involvement and surgical stress, the first published case of adrenal crisis after surgery for a pathologic fracture from lung cancer metastasis. Surgeons treating pathologic fractures should be aware of this complication and familiar with its appropriate therapy because of increasing opportunity to care patients with metastatic bone tumors due to recent advances in cancer treatment.
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Affiliation(s)
- Norifumi Naka
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Satoshi Takenaka
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Katsuhiko Nanno
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Yu Moriguchi
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Bang-mi Chun
- Department of Anesthesiology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Shunji Sonoda
- Department of Anesthesiology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Nobuyuki Hashimoto
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Yoshitane Tsukamoto
- Department of Pathology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Nobuhito Araki
- Department of Orthopedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
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Fujishima N, Komatsuda A, Ohyagi H, Fujishima M, Tada M, Ohtani H, Wakui H, Hirokawa M, Sawada KI. Adrenal insufficiency complicated with antiphospholipid syndrome (APS). Intern Med 2006; 45:963-6. [PMID: 16974059 DOI: 10.2169/internalmedicine.45.1603] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a 69-year-old woman with bilateral adrenal hemorrhage complicated with antiphospholipid syndrome (APS). She was hospitalized with nausea and vomiting in September 2003. Laboratory data demonstrated hyponatremia, hypoglycemia and prolongation of activated partial thromboplastin time (aPTT). Abdominal computed tomography showed bilateral adrenal enlargement. In October 2003, she demonstrated altered mental status with progressive hyponatremia, a high level of ACTH, and a low level of serum cortisol. She also showed thrombocytopenia, anti-cardiolipin IgG antibody, anti-beta2GPI antibody, and lupus anticoagulants. After four months, anti-cardiolipin IgG antibody was still positive. Based on these findings, she was diagnosed as having APS complicated with adrenal insufficiency due to hemorrhagic infarction. After treatment with corticosteroid, a low dose of aspirin and normal saline infusion, her condition quickly improved. Platelet counts and aPTT were also normalized. To our knowledge, this is the second Japanese case of APS complicated with bilateral adrenal hemorrhage. APS should be considered an important underlying cause of adrenal insufficiency.
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Affiliation(s)
- Naohito Fujishima
- Third Department of Internal Medicine, Akita University School of Medicine
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Abstract
Although clinical conditions associated with dysfunction of the ad-renal gland are often subtle, even insidious, in their presentation,and diagnosis and treatment usually are confined to outpatient clinics and offices, there are several situations that warrant the attention of emergency physicians. Recognition of the spectrum of presentations of pheochromocytoma, adrenal insufficiency, and pituitary apoplexy, and the sequelae of corticosteroid therapy and withdrawal, are critically important areas to emergency medicine. Prompt diagnosis with appropriate treatment and referral will reduce morbidity and mortality in many patients each year. A related topic pertinent to emergency physicians is the management of incidental adrenal masses that are discovered on abdominal radio-logic imaging.
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Affiliation(s)
- Susan P Torrey
- Tufts University School of Medicine, 136 Harrison Avenue Boston, MA 02111, USA.
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Riddell AM, Khalili K. Sequential Adrenal Infarction Without MRI-Detectable Hemorrhage in Primary Antiphospholipid-Antibody Syndrome. AJR Am J Roentgenol 2004; 183:220-2. [PMID: 15208142 DOI: 10.2214/ajr.183.1.1830220] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- A M Riddell
- Department of Medical Imaging, Toronto General Hospital, University Health Network, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
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Berneis K, Buitrago-Téllez C, Müller B, Keller U, Tsakiris DA. Antiphospholipid syndrome and endocrine damage: why bilateral adrenal thrombosis? Eur J Haematol 2003; 71:299-302. [PMID: 12950241 DOI: 10.1034/j.1600-0609.2003.00145.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We describe a rare case of bilateral hemorrhagic infarction of the adrenal glands diagnosed in the context of positive antiphospholipid antibodies (aPL). The patient presented atypical clinical symptoms of adrenal insufficiency. Laboratory investigation showed complete adrenal failure and increased aPL, both manifestations persisted 1 yr after the initial event. MR imaging at baseline was compatible with bilateral hemorrhagic infarction and showed almost complete loss of viable adrenal tissue 1 yr later. Although no direct causal effect can be proved, the sequence of events and the exclusion of other common causes of bilateral adrenal hemorrhage (e.g. tuberculosis, severe coagulation disorder) support an association between aPL and adrenal hemorrhagic infarction. A unique link between particular anatomical characteristics of the adrenal fascicular zone and a novel, previously described, explanation model of aPL-thrombosis is hypothesized. It is based on the properties of late endosomes, which are important organelles participating in cholesterol trafficking and protein sorting within cells and express epitopes recognized by aPL. It would be interesting to investigate adrenal tissue for presence of late endosomes and their aPL relevant epitopes for proof of this tempting hypothesis. Focal accumulation of aPL and isolated, simultaneous, bilateral adrenal infarctions could thus be explained.
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Affiliation(s)
- Kaspar Berneis
- Department of Medicine, University Hospital Bruderholz, Basel, Switzerland
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