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Hosokawa M, Ichihashi Y, Sato Y, Shibata N, Nagasaki K, Ikegawa K, Hasegawa Y, Hamajima T, Nagamatsu F, Suzuki S, Numakura C, Amano N, Sasaki G, Nagahara K, Soneda S, Ariyasu D, Maeda M, Kamasaki H, Aso K, Hasegawa T, Ishii T. Incidence and Risk Factors for Adrenal Crisis in Pediatric-onset Adrenal Insufficiency: A Prospective Study. J Clin Endocrinol Metab 2024; 109:e1602-e1607. [PMID: 38128002 DOI: 10.1210/clinem/dgad753] [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: 08/03/2023] [Revised: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023]
Abstract
CONTEXT Adrenal crisis (AC) is a life-threatening complication that occurs during follow-up of patients with adrenal insufficiency (AI). No prospective study has thoroughly investigated AC in children with primary and secondary AI. OBJECTIVE This work aimed to determine the incidence and risk factors for AC in patients with pediatric-onset AI. METHODS This multicenter, prospective cohort study conducted in Japan enrolled patients diagnosed with AI at age ≤15 years. The incidence of AC was calculated as events per person-year (PY), and risk factors for AC were assessed using Poisson regression multivariable analysis. RESULTS The study population comprised 349 patients (164 male, 185 female) with a total follow-up of 961 PY. The median age at enrollment was 14.3 years (interquartile range [IQR] 8.5-21.2 years), and the median follow-up was 2.8 years (IQR 2.2-3.3 years). Of these patients, 213 (61%) had primary AI and 136 (39%) had secondary AI. Forty-one AC events occurred in 31 patients during the study period. The calculated incidence of AC was 4.27 per 100 PY (95% CI, 3.15-5.75). Poisson regression analysis identified younger age at enrollment (relative risk [RR] 0.93; 95% CI, 0.89-0.97) and increased number of infections (RR 1.17; 95% CI, 1.07-1.27) as significant risk factors. Female sex (RR 0.99; 95% CI, 0.53-1.86), primary AI (RR 0.65; 95% CI, 0.30-1.41), or equivalent dosage of hydrocortisone per square meter of body area (RR 1.02; 95% CI, 0.96-1.08) was not a significant risk factor. CONCLUSION A substantial proportion of patients with pediatric-onset AI experience AC. Younger age and an increased number of infections are independent risk factors for developing AC in these patients.
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Affiliation(s)
- Mayumi Hosokawa
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Keio University School of Medicine, Tokyo 160-8582, Japan
- Department of Pediatrics, Saitama City Hospital, Saitama 336-8522, Japan
| | - Yosuke Ichihashi
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Nao Shibata
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Niigata University Medical and Dental Hospital, Niigata 951-8520, Japan
| | - Keisuke Nagasaki
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Niigata University Medical and Dental Hospital, Niigata 951-8520, Japan
| | - Kento Ikegawa
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Fuchu 183-8561, Japan
| | - Yukihiro Hasegawa
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Fuchu 183-8561, Japan
| | - Takashi Hamajima
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Obu 474-8710, Japan
| | - Fusa Nagamatsu
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Kumamoto University School of Medicine, Kumamoto 860-8556, Japan
| | - Shigeru Suzuki
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Asahikawa Medical University, Asahikawa 078-8510, Japan
| | - Chikahiko Numakura
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Yamagata University Faculty of Medicine, Yamagata 990-9585, Japan
| | - Naoko Amano
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Saitama City Hospital, Saitama 336-8522, Japan
| | - Goro Sasaki
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Tokyo Dental College Ichikawa General Hospital, Ichikawa 272-8513, Japan
| | - Keiko Nagahara
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Shun Soneda
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, St.Marianna University, School of Medicine, Kawasaki 216-8511, Japan
| | - Daisuke Ariyasu
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Kawasaki Municipal Hospital, Kawasaki 210-0013, Japan
| | - Miwako Maeda
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Oita University Faculty of Medicine, Yufu 879-5593, Japan
| | - Hotaka Kamasaki
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Sapporo Medical University, Sapporo 060-8556, Japan
| | - Keiko Aso
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo 143-8541, Japan
| | - Tomonobu Hasegawa
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Tomohiro Ishii
- Japanese Multicenter Study for Adrenal Crisis (JMSAC), Tokyo 160-8582, Japan
- Department of Pediatrics, Keio University School of Medicine, Tokyo 160-8582, Japan
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Øzdemir CM, Nielsen MM, Liimatta J, Voegel CD, Elzenaty RN, Wasehuus VS, Lind-Holst M, Ornstrup MJ, Gram SB, Ousager LB, Flück CE, Gravholt CH. Late diagnosis of partial 3β-hydroxysteroid dehydrogenase type 2 deficiency - characterization of a new genetic variant. Endocrinol Diabetes Metab Case Rep 2024; 2024:23-0090. [PMID: 39089319 DOI: 10.1530/edm-23-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 07/12/2024] [Indexed: 08/03/2024] Open
Abstract
Summary Congenital adrenal hyperplasia (CAH) is one of the most common inherited rare endocrine disorders. This case report presents two female siblings with delayed diagnosis of non-classical CAH 3β-hydroxysteroid dehydrogenase type 2 (3βHSD2D/HSD3B2) despite early hospital admission and apparent CAH manifestations such as infections, hirsutism, menstrual disturbances, and PCOS phenotype. Initially, sister 1 was misdiagnosed with PCOS and then 11-hydroxylase deficiency (CYP11B1), based on ultrasound, biochemical findings, and negative genetic testing for 21-hydroxylase deficiency (CYP21A2). Additional diagnostic workup was performed when sister 2also presented with symptoms of androgen excess. Genetic testing for CAH/steroid disorders finally revealed that both siblings were compound heterozygous for two variants in the HSD3B2 gene: a frameshift variant, c.558dup, p.(Thr187Hisfs*17) and a novel missense variant, c.65T>C, p.(Leu22Ser). A Synacthen test showed an insufficient cortisol increase. In vitro studies of the variants in a cell model revealed loss of function for the p.(Thr187Hisfs*17) and partial activity for p.(Leu22Ser) confirming non-classic CAH. Overlapping symptomatology and lack of specialized knowledge on steroid biosynthesis and associated rarest forms of CAH may explain the delayed diagnosis. However, with newer diagnostic methods comprising a less biased approach, very rare forms of non-classical CAH may no longer be overlooked in the future. Learning points Non-classic 3βHSD2 is likely underdiagnosed. Late diagnosis of mild non-classic 3βHSD2 does occur and one should be aware of this diagnosis. Early diagnosis of NCCAH may prevent many consequences such as severe hirsutism, prolonged menstrual irregularities, infertility, or even adrenal crisis with severe infections. Comprehensive steroid profiling and genetic testing should be used earlier, especially when in doubt about a diagnosis.
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Affiliation(s)
| | - Mette Mølby Nielsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
| | - Jani Liimatta
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern University Hospital, University of Bern, Switzerland
- Department of Biomedical Research, University of Bern, Switzerland
- Kuopio Pediatric Research Unit (KuPRu), University of Eastern Finland, Kuopio, Finland
| | - Clarissa D Voegel
- Department of Biomedical Research, University of Bern, Switzerland
- Department of Nephrology, Bern University Hospital, University of Bern, Switzerland
| | - Rawda Naamneh Elzenaty
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern University Hospital, University of Bern, Switzerland
- Department of Biomedical Research, University of Bern, Switzerland
- Graduate School of Cellular and Biomedical Sciences, University of Bern, Switzerland
| | - Victor S Wasehuus
- Department of Endocrinology, Aarhus University Hospital, Aarhus N, Denmark
| | - Marie Lind-Holst
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Marie Juul Ornstrup
- Department of Endocrinology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Stine Bjørn Gram
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lilian Bomme Ousager
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christa E Flück
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern University Hospital, University of Bern, Switzerland
- Department of Biomedical Research, University of Bern, Switzerland
| | - Claus H Gravholt
- Department of Endocrinology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
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3
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Tseng T, Seagroves A, Tanawattanacharoen VK, Liang MC, Koppin CM, Keenan M, Davidowitz E, Nguyen E, Chand S, Geffner ME, Chang TP, Kim MS. Electrolyte abnormalities and stress dosing predict illness-related hospitalizations among infants and toddlers with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2023; 98:536-542. [PMID: 36593179 PMCID: PMC10006318 DOI: 10.1111/cen.14876] [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: 08/28/2022] [Revised: 12/22/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Infants and toddlers with classical congenital adrenal hyperplasia (CAH) are at high risk for morbidity/mortality arising from life-threatening adrenal crisis. Management of acute illnesses in CAH requires an understanding of factors leading to emergency department (ED) visits and hospitalizations in the first few years of life. We, therefore, examined adrenal crisis at prehospital and ED stages of illness in young children with CAH as they related to medical outcomes. PATIENTS AND DESIGN Retrospective cohort study of 39 children with CAH due to 21-hydroxylase deficiency (0-4 years of age) and 27 age-matched controls. MEASUREMENTS ED visit, acute illness symptoms (fever, vomiting, diarrhoea) and other characteristics (hospitalizations, administration of stress-dose hydrocortisone, electrolyte abnormalities). RESULTS CAH infants and toddlers had significantly higher rates of ED visits (0.50 [0.25-0.88] per person-year) than controls (0 [0-0] per person-year; p < .001). Moreover, CAH children under 6 months old had significantly higher rates of ED visits compared with older ages. Only 50% (51/102) of illness-related ED visits in CAH children were preceded by the administration of either oral (46/51) or intramuscular (11/51) stress dosing by parents. A total of 10.8% of ED visits resulted in hospital admission. Controlling for age and 17-hydroxyprogesterone at diagnosis, electrolyte abnormalities and administration of parenteral hydrocortisone in the ED significantly predicted hospital admission. Receiving a hydrocortisone injection before the ED was a significant predictor of having electrolyte abnormalities. CONCLUSIONS Infants and toddlers with classical CAH are at high risk for acute illness and hospitalizations and often do not receive adequate stress dosing before the ED.
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Affiliation(s)
- Teresa Tseng
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Amy Seagroves
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Veeraya K Tanawattanacharoen
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mark C Liang
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Christina M Koppin
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Madison Keenan
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Elana Davidowitz
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Eugene Nguyen
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Sanjay Chand
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mitchell E Geffner
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Todd P Chang
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mimi S Kim
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
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4
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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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5
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Ali SR, Bryce J, Krone NP, Claahsen-van der Grinten HL, Ahmed SF. Management of Acute Adrenal Insufficiency-Related Adverse Events in Children with Congenital Adrenal Hyperplasia: Results of an International Survey of Specialist Centres. Horm Res Paediatr 2022; 95:363-373. [PMID: 35569445 DOI: 10.1159/000525075] [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: 11/09/2021] [Accepted: 04/20/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION There is wide variation in reported rates of acute adrenal insufficiency (AI)-related adverse events (sick day episodes and adrenal crises) between centres. This study aimed to evaluate the level of consensus on criteria considered essential for defining and managing these events in children with Congenital Adrenal Hyperplasia. METHODS Active users of the International Congenital Adrenal Hyperplasia and International Disorders of Sex Development (I-CAH/I-DSD) Registries (n = 66), non-active users of I-CAH/I-DSD (n = 35), and the EuRRECa e-Reporting Registry (n = 10) were approached to complete an online survey. RESULTS Fifty-six centres from 27 countries responded to the survey; the response rates for the three groups were 42 (65%), 11 (31%), and 3 (30%), respectively. Steroid management plans, one to one patient education, and contact details of health care staff were provided by over 90% of centres in high-income countries. All 56 centres advised glucocorticoid stress dosing in the event of fever. Less common indications for sick day dosing included vaccination and mild afebrile intercurrent illness, recommended by 17 (30%) and 9 (16%) centres, respectively. The most frequently reported stress dosing regimens were tripling the total daily dose of hydrocortisone and administering 3 times daily and doubling or tripling the largest daily hydrocortisone dose depending on the nature of the trigger and administering 3 times daily, recommended by 24 (43%) and 21 (38%) centres, respectively. Vomiting was the most common indication for intramuscular hydrocortisone injection, reported by 34 (61%) centres. Over 50% of respondents indicated that essential clinical criteria for adrenal crisis should include fatigue and nausea or vomiting and over 60% indicated that hypotension, hyponatraemia, hyperkalaemia, and clinical improvement following parenteral glucocorticoids were essential criteria. In the event of an adrenal crisis, 47 (84%) reported that the majority of patients were admitted to hospital. For the management of an adrenal crisis, a bolus parenteral injection of hydrocortisone was the most frequently administered medication, reported by 50 (89%) centres. CONCLUSION Although there is variation in the definition and management of AI-related adverse events in children amongst centres, there is also a good level of consensus on specific aspects that can lead to greater benchmarking of care.
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Affiliation(s)
- Salma Rashid Ali
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, UK,
- Office for Rare Conditions, University of Glasgow, Glasgow, UK,
| | - Jillian Bryce
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Hedi L Claahsen-van der Grinten
- Department of Paediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
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6
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 172] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - 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
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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7
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Weber J, Tanawattanacharoen VK, Seagroves A, Liang MC, Koppin CM, Ross HM, Bachega TASS, Geffner ME, Serrano-Gonzalez M, Bhullar G, Kim MS. Low Adrenomedullary Function Predicts Acute Illness in Infants With Classical Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2022; 107:e264-e271. [PMID: 34397083 PMCID: PMC8826013 DOI: 10.1210/clinem/dgab600] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Indexed: 01/28/2023]
Abstract
CONTEXT Youth with classical congenital adrenal hyperplasia (CAH) exhibit abnormal adrenomedullary function with decreased epinephrine levels noted in newborns and young infants. Little is known about how this relates to morbidity during the first year of life. OBJECTIVE This work aimed to study plasma epinephrine levels in infants with classical CAH and examine the clinical significance of epinephrine deficiency in the first year of life. METHODS This prospective cohort study comprised participants recruited from a pediatric tertiary care center: 36 infants with classical CAH due to 21-hydroxylase deficiency and 27 age-matched unaffected controls with congenital hypothyroidism. Main outcome measures included plasma epinephrine levels (N = 27), CYP21A2 genotype (N = 15), and incidence of acute illnesses from birth to age 1 year (N = 28). RESULTS Epinephrine levels in CAH infants independently predicted illness incidence in the first year of life (β = -0.018, R = -0.45, P = .02) and were negatively correlated with 17-hydroxyprogesterone at diagnosis (R = -0.51, P = .007). Infants with salt-wasting CAH exhibited lower epinephrine levels as newborns than simple-virilizing infants (P = .02). CAH patients had lower epinephrine as newborns than did controls (P = .007) and showed decreases in epinephrine from birth to age 1 year (P = .04). Null genotype was associated with lower newborn epinephrine and more illness in the first year of life, compared to less severe mutation categories. CONCLUSION Lower epinephrine levels are associated with increased risk of illness among CAH infants. While not currently part of clinical standard of care, measuring epinephrine levels and assessing genotype may help predict acute illness in the first year of life.
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Affiliation(s)
- Jonathan Weber
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Veeraya K Tanawattanacharoen
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Amy Seagroves
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Mark C Liang
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Christina M Koppin
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Heather M Ross
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Tania A S S Bachega
- Laboratory of Hormones and Molecular Genetics-LIM 42, Division of Endocrinology, Clinics Hospital, School of Medicine, São Paulo University, São Paulo 05508-220, Brazil
| | - Mitchell E Geffner
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
- Keck School of Medicine of University of Southern California, Los Angeles, California 90033, USA
- The Saban Research Institute at Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Monica Serrano-Gonzalez
- Keck School of Medicine of University of Southern California, Los Angeles, California 90033, USA
- Division of Pediatric Endocrinology, Hasbro Children’s Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA
| | - Gagandeep Bhullar
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Mimi S Kim
- Correspondence: Mimi S. Kim, MD, Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 61, Los Angeles, CA 90027, USA.
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8
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Rushworth RL, Gouvoussis N, Goubar T, Maguire A, Munns CF, Neville KA, Torpy DJ. Acute illness in children with secondary adrenal insufficiency. Clin Endocrinol (Oxf) 2021; 94:913-919. [PMID: 33544418 DOI: 10.1111/cen.14427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/22/2020] [Accepted: 01/14/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE AND BACKGROUND Secondary adrenal insufficiency (SAI) is a rare condition in childhood which can be associated with high levels of morbidity in some patients. The causes of increased levels of illness are not well defined and warrant further investigation. METHODS A retrospective cohort of patients with SAI was constructed by examining records of all attendances for acute illness by SAI patients at the emergency department of the two specialist paediatric hospitals in Sydney, Australia between 2004 and 2016. Demographic, clinical, and physiological characteristics together with pre-hospital illness management strategies were assessed. RESULTS There were 168 presentations for an acute illness by 47 children with SAI. Comorbid diabetes insipidus (DI) was present in 46.8% (n = 22), 77.3% (n = 17) of whom were male (P < .05). Patients with comorbid DI were more likely to be admitted (86.7%, n = 65 vs 60.2%, n = 56 for non-DI, P < .01); had a longer hospital stay (6.5 (8.7) vs 2.5 (2.6) days, P < .001); and higher rates of IV HC administration (56.0%, n = 42 vs 35.5%, n = 33), P < .01). The medically-diagnosed adrenal crisis (AC) rate was 3.68 ACs/100PY. Stress dose use was reported by fewer DI patients (58.7%, n = 44) than non-DI patients (78.5%, n = 73, P < .01). Previous attendance at hospital was positively associated with stress dose use (OR = 1.08, 95% CI 1.00, 1.16). CONCLUSION Secondary adrenal insufficiency can cause significant morbidity in children. Comorbid DI is associated with higher levels of hospitalisation, longer hospital stays and lower levels of pre-emergent stress dose use. Educational interventions in this subgroup of SAI patients may reduce the burden of morbidity.
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Affiliation(s)
| | - Nikki Gouvoussis
- School of Medicine, Sydney, The University of Notre Dame, Sydney, Australia
| | - Thomas Goubar
- School of Medicine, Sydney, The University of Notre Dame, Sydney, Australia
| | - Ann Maguire
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, Australia
- Faculty of Medicine and Health, Children's Hospital Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Craig F Munns
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, Australia
- Faculty of Medicine and Health, Children's Hospital Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Kristen A Neville
- Department of Endocrinology, Sydney Children's Hospital, Randwick, NSW, Australia
- School of Women and Children's Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, SA, Australia
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9
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Chrisp GL, Quartararo M, Torpy DJ, Falhammar H, Rushworth RL. Use of medical identification jewellery in children and young adults with adrenal insufficiency in Australia. Endocrine 2021; 72:539-545. [PMID: 33704679 DOI: 10.1007/s12020-020-02595-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 12/15/2020] [Indexed: 10/21/2022]
Abstract
PURPOSE Patients with adrenal insufficiency (AI) are at risk of life-threatening illness. Medical jewellery is recommended for emergencies, but its uptake is unknown. This study assessed the use of medical jewellery among Australian AI patients aged 25 years and under. METHODS Data on the age, sex, region, and diagnosis of subscribers to the largest medical jewellery provider in Australia were analysed. Subscription rates were calculated using 2017 Australian population data. RESULTS There were 666 patients aged 25 years and under in the database but only 358 (53.8%) had an active (up to date) subscription, corresponding to a subscription rate of 43.67/million or approximately 14.6% of the estimated patient population. The majority (n = 238, 66.5%) had primary AI; followed by secondary AI (n = 82, 22.9%); and the remaining patients (n = 38, 10.6%) could not be classified. Congenital adrenal hyperplasia (CAH) was the most frequent diagnosis (n = 153, 42.7%), corresponding to a subscription rate of 18.67/ million or 28.9% of the estimated number of patients with CAH. The mean age of subscribers was 15.9 (SD = 5.8) years. Only 18 (5%) patients were aged under 5 years. More females (n = 199, 55.9%) than males were active subscribers and subscription rates differed significantly by geographic area. Inactive (lapsed) subscriptions increased with age and were highest in the 20-25 year age group. CONCLUSION Subscription rates were lower than recommended; increased with age; and were more common in females. Older age was associated with higher levels of lapsed subscriptions. Factors leading to low use and discontinuation in young adults should be addressed.
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Affiliation(s)
- Georgina L Chrisp
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.
| | - Maria Quartararo
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- The University of Adelaide, Adelaide, SA, 5000, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
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10
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Hahner S, Ross RJ, Arlt W, Bancos I, Burger-Stritt S, Torpy DJ, Husebye ES, Quinkler M. Adrenal insufficiency. Nat Rev Dis Primers 2021; 7:19. [PMID: 33707469 DOI: 10.1038/s41572-021-00252-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/25/2022]
Abstract
Adrenal insufficiency (AI) is a condition characterized by an absolute or relative deficiency of adrenal cortisol production. Primary AI (PAI) is rare and is caused by direct adrenal failure. Secondary AI (SAI) is more frequent and is caused by diseases affecting the pituitary, whereas in tertiary AI (TAI), the hypothalamus is affected. The most prevalent form is TAI owing to exogenous glucocorticoid use. Symptoms of AI are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors and aldosterone (especially in PAI). Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones and stimulation tests. The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs. This Primer provides insights into the epidemiology, mechanisms and management of AI during pregnancy as well as challenges of long-term management. In addition, the importance of identifying life-threatening adrenal emergencies (acute AI and adrenal crisis) is highlighted and strategies for prevention, which include patient education, glucocorticoid emergency cards and injection kits, are described.
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Affiliation(s)
- Stefanie Hahner
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Richard J Ross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Wiebke Arlt
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephanie Burger-Stritt
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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11
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Ali SR, Bryce J, Haghpanahan H, Lewsey JD, Tan LE, Atapattu N, Birkebaek NH, Blankenstein O, Neumann U, Balsamo A, Ortolano R, Bonfig W, Claahsen-van der Grinten HL, Cools M, Costa EC, Darendeliler F, Poyrazoglu S, Elsedfy H, Finken MJJ, Fluck CE, Gevers E, Korbonits M, Guaragna-Filho G, Guran T, Guven A, Hannema SE, Higham C, Hughes IA, Tadokoro-Cuccaro R, Thankamony A, Iotova V, Krone NP, Krone R, Lichiardopol C, Luczay A, Mendonca BB, Bachega TASS, Miranda MC, Milenkovic T, Mohnike K, Nordenstrom A, Einaudi S, van der Kamp H, Vieites A, de Vries L, Ross RJM, Ahmed SF. Real-World Estimates of Adrenal Insufficiency-Related Adverse Events in Children With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:e192-e203. [PMID: 32995889 PMCID: PMC7990061 DOI: 10.1210/clinem/dgaa694] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/24/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although congenital adrenal hyperplasia (CAH) is known to be associated with adrenal crises (AC), its association with patient- or clinician-reported sick day episodes (SDE) is less clear. METHODS Data on children with classic 21-hydroxylase deficiency CAH from 34 centers in 18 countries, of which 7 were Low or Middle Income Countries (LMIC) and 11 were High Income (HIC), were collected from the International CAH Registry and analyzed to examine the clinical factors associated with SDE and AC. RESULTS A total of 518 children-with a median of 11 children (range 1, 53) per center-had 5388 visits evaluated over a total of 2300 patient-years. The median number of AC and SDE per patient-year per center was 0 (0, 3) and 0.4 (0.0, 13.3), respectively. Of the 1544 SDE, an AC was reported in 62 (4%), with no fatalities. Infectious illness was the most frequent precipitating event, reported in 1105 (72%) and 29 (47%) of SDE and AC, respectively. On comparing cases from LMIC and HIC, the median SDE per patient-year was 0.75 (0, 13.3) vs 0.11 (0, 12.0) (P < 0.001), respectively, and the median AC per patient-year was 0 (0, 2.2) vs 0 (0, 3.0) (P = 0.43), respectively. CONCLUSIONS The real-world data that are collected within the I-CAH Registry show wide variability in the reported occurrence of adrenal insufficiency-related adverse events. As these data become increasingly used as a clinical benchmark in CAH care, there is a need for further research to improve and standardize the definition of SDE.
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Affiliation(s)
- Salma R Ali
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - Jillian Bryce
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - Houra Haghpanahan
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - James D Lewsey
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Li En Tan
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | | | - Niels H Birkebaek
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Oliver Blankenstein
- Centre for Chronic Sick Children, Institute for Experimental Paediatric Endocrinology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Uta Neumann
- Centre for Chronic Sick Children, Institute for Experimental Paediatric Endocrinology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Pediatric Unit, Center for Rare Endocrine Conditions (Endo-ERN), S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Rita Ortolano
- Department of Medical and Surgical Sciences, Pediatric Unit, Center for Rare Endocrine Conditions (Endo-ERN), S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Walter Bonfig
- Department of Paediatrics, Technical University München, Munich, Germany
- Department of Paediatrics, Klinikum Wels-Grieskirchen, Wels, Austria
| | | | - Martine Cools
- University Hospital Ghent, Ghent University, Ghent, Belgium
| | - Eduardo Correa Costa
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
| | - Feyza Darendeliler
- Istanbul Faculty of Medicine, Department of Paediatrics, Paediatric Endocrinology Unit, Istanbul University, Istanbul, Turkey
| | - Sukran Poyrazoglu
- Istanbul Faculty of Medicine, Department of Paediatrics, Paediatric Endocrinology Unit, Istanbul University, Istanbul, Turkey
| | - Heba Elsedfy
- Department of Pediatrics, Ain Shams University, Cairo, Egypt
| | - Martijn J J Finken
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Endocrinology, Amsterdam, The Netherlands
| | - Christa E Fluck
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics and Department of BioMedical Research, Bern University Hospital Inselspital, University of Bern, Bern, Switzerland
| | - Evelien Gevers
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Márta Korbonits
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Guilherme Guaragna-Filho
- Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Tulay Guran
- Marmara University, Department of Pediatric Endocrinology and Diabetes, Pendik, Istanbul, Turkey
| | - Ayla Guven
- Health Science University, Medical Faculty, Zeynep Kamil Women and Children Hospital, Pediatric Endocrinology Clinic, Istanbul, Turkey
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, University Of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | - Ajay Thankamony
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Violeta Iotova
- Department of Paediatrics, Medical University-Varna, UMHAT “Sv. Marina,” Varna, Bulgaria
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Ruth Krone
- Birmingham Women’s & Children’s Hospital, Department for Endocrinology & Diabetes, Birmingham, UK
| | - Corina Lichiardopol
- Department of Endocrinology, University of Medicine and Pharmacy Craiova, University Emergency Hospital, Craiova, Romania
| | - Andrea Luczay
- Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Tania A S S Bachega
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Mirela C Miranda
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Tatjana Milenkovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia “Dr Vukan Čupić,” Belgrade, Serbia
| | | | | | - Silvia Einaudi
- Pediatric Endocrinology Regina Margherita Children’s Hospital, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Hetty van der Kamp
- Wilhelmina Kinderziekenhuis, Division of Pediatric Endocrinology, Utrecht, Netherlands
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas, División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Liat de Vries
- The Jesse and Sara Lea Shafer Institute of Endocrinology and Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikvah, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Richard J M Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
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12
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Affiliation(s)
- R Louise Rushworth
- From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) - all in Australia; and the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (H.F.)
| | - David J Torpy
- From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) - all in Australia; and the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (H.F.)
| | - Henrik Falhammar
- From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) - all in Australia; and the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (H.F.)
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13
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Eyal O, Levin Y, Oren A, Zung A, Rachmiel M, Landau Z, Schachter-Davidov A, Segev-Becker A, Weintrob N. Adrenal crises in children with adrenal insufficiency: epidemiology and risk factors. Eur J Pediatr 2019; 178:731-738. [PMID: 30806790 DOI: 10.1007/s00431-019-03348-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/10/2019] [Accepted: 02/12/2019] [Indexed: 02/21/2023]
Abstract
The aim of the study was to assess the epidemiology and risk factors of adrenal crises (AC) in children with adrenal insufficiency (AI). Children diagnosed with AI between 1990 and 2017 at four Israeli pediatric endocrinology units were studied. Demographic and clinical data were retrieved retrospectively from their files. The study population consisted of 120 children (73 boys, 47 girls) and comprised 904 patient years. Median age at diagnosis was 0.3 years (0-17.5). Thirty-one AC events in 26 children occurred during the study period, accounting for a frequency of 3.4 crises/100 patient years. Fifty-two percent of AC events occurred at presentation. The significant risk factors for developing AC were the following: younger age at diagnosis (P = 0.003), primary AI vs. secondary AI (P = 0.016), specific diagnosis of autoimmune AI, adrenal hypoplasia congenita and salt wasting congenital adrenal hyperplasia (P < 0.001), mineralocorticoid treatment (P < 0.001), and recurrent hospital admissions (P > 0.001). After applying a stepwise logistic regression model, only the group of diagnoses, including salt wasting CAH, AHC, and Addison's disease, remained significant predictor of AC (OR 17.5, 95% CI 4.7-64.9, P < 0.001). There was no AC-associated mortality during the study period.Conclusions: Since significant percent of AC events occurred at presentation, measures to increase the awareness to signs and symptoms of AI among primary care physicians should be taken. Efforts to prevent AC should be focused on younger patients, especially those with primary AI. What Is Known: • Diagnosis and long-term management of pediatric patients with adrenal insufficiency (AI) remain a challenge. • Adrenal crises (AC) pose life-threatening emergencies in affected youngsters. Studies on the rate and risk factors of AC in children with AI are scarce, and they were done mainly on children with congenital adrenal hyperplasia (CAH). What Is New: • The rate of AC was relatively low and there was no AC-associated mortality during the study period. • Children with primary AI were at higher risk for AC than children with secondary AI. Specifically, children with salt wasting CAH, adrenal hypoplasia congenita, and Addison's disease at the highest risk.
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Affiliation(s)
- Ori Eyal
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel. .,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Yair Levin
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Asaf Oren
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Amnon Zung
- Pediatric Endocrinology Unit, Kaplan Medical Center, Rehovot, Israel.,The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marianna Rachmiel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Endocrinology Unit, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Zohar Landau
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Endocrinology Unit, Wolfson Medical Center, Holon, Israel
| | - Anita Schachter-Davidov
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Anat Segev-Becker
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Naomi Weintrob
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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14
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Chrisp GL, Maguire AM, Quartararo M, Falhammar H, King BR, Munns CF, Torpy DJ, Hameed S, Rushworth RL. Variations in the management of acute illness in children with congenital adrenal hyperplasia: An audit of three paediatric hospitals. Clin Endocrinol (Oxf) 2018; 89:577-585. [PMID: 30086199 DOI: 10.1111/cen.13826] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Episodes of acute adrenal insufficiency (AI)/adrenal crises (AC) are a serious consequence of congenital adrenal hyperplasia (CAH). This study aimed to assess morbidity from acute illness in CAH and identify factors associated with use of IV hydrocortisone, admission and diagnosis of an AC. METHOD An audit of acute illness presentations among children with CAH to paediatric hospitals in New South Wales, Australia, between 2000 and 2015. RESULTS There were 321 acute presentations among 75 children with CAH. Two-thirds (66.7%, n = 214) of these resulted in admission and 49.2% (n = 158) of the patients received intravenous (IV) hydrocortisone. An AC was diagnosed in (9.0%). Prior to presentation, 64.2% (n = 206) had used oral stress dosing and 22.1% (n = 71) had been given intramuscular (IM) hydrocortisone. Vomiting was recorded in 61.1% (n = 196), 32.7% (n = 64) of whom had used IM hydrocortisone. Admission, AC diagnosis and use of stress dosing varied significantly between hospitals. IM use varied from 7.0% in one metropolitan hospital to 45.8% in the regional hospital. Children aged up to 12 months had the lowest levels of stress dosing and IV hydrocortisone administration. Higher numbers of prior hospital attendances for acute illness were associated with increased use of IM hydrocortisone. CONCLUSION Prehospital and in-hospital management of children with CAH can vary between health services. Children under 12 months have lower levels of stress dosing prior to hospital than other age groups. Experience with acute episodes improves self-management of CAH in the context of acute illness in educated patient populations.
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Affiliation(s)
- Georgina L Chrisp
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Ann M Maguire
- The Children's Hospital, Westmead, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Maria Quartararo
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Bruce R King
- John Hunter Children's Hospital, Newcastle, New South Wales, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Craig F Munns
- The Children's Hospital, Westmead, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Shihab Hameed
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Children's Hospital, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Kensington, New South Wales, Australia
| | - R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
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15
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Rushworth RL, Torpy DJ, Stratakis CA, Falhammar H. Adrenal Crises in Children: Perspectives and Research Directions. Horm Res Paediatr 2018; 89:341-351. [PMID: 29874655 DOI: 10.1159/000481660] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/20/2017] [Indexed: 11/19/2022] Open
Abstract
Adrenal crises (AC) are life-threatening physiological disturbances that occur at a rate of 5-10/100 patient years in patients with adrenal insufficiency (AI). Despite their seriousness, there is a paucity of information on the epidemiology of AC events in the paediatric population specifically, as most investigations have focused on AI and ACs in adults. Improved surveillance of AC-related morbidity and mortality should improve the delineation of AC risk overall and among different subgroups of paediatric patients with AI. Valid incidence measures are essential for this purpose and also for the evaluation of interventions aimed at reducing adverse health outcomes from ACs. However, the absence of an agreed AC definition limits the potential benefit of research and surveillance in this area. While approaches to the treatment and prevention of ACs have much in common across the lifespan, there are important differences between children and adults with regards to the physiological, psychological, and social milieu in which these events occur. Education is considered to be an essential element of AC prevention but studies have shown that ACs occur even among well-educated patients, suggesting that new strategies may be needed. In this review, we examine the current knowledge regarding AC events in children with AI; assess the existing definitions of an AC and offer a new definition for use in research and the clinic; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in the paediatric age group.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northwest Territories, Australia
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16
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Rushworth RL, Chrisp GL, Dean B, Falhammar H, Torpy DJ. Hospitalisation in Children with Adrenal Insufficiency and Hypopituitarism: Is There a Differential Burden between Boys and Girls and between Age Groups? Horm Res Paediatr 2018; 88:339-346. [PMID: 28898882 DOI: 10.1159/000479370] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/07/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND/AIMS To determine the burden of hospitalisation in children with adrenal insufficiency (AI)/hypopituitarism in Australia. METHODS A retrospective study of Australian hospitalisation data. All admissions between 2001 and 2014 for patients aged 0-19 years with a principal diagnosis of AI/hypopituitarism were included. Denominator populations were extracted from national statistics datasets. RESULTS There were 3,779 admissions for treatment of AI/hypopituitarism in patients aged 0-19 years, corresponding to an average admission rate of 48.7 admissions/million/year. There were 470 (12.4%) admissions for an adrenal crisis (AC). Overall, admission for AI/hypopituitarism was comparable between the sexes. Admission rates for all AI, hypopituitarism, congenital adrenal hyperplasia (CAH), and "other and unspecified causes" of AI were highest among infants and decreased with age. Admissions for primary AI increased with age in both sexes. Males had significantly higher rates of admission for hypopituitarism. AC rates differed by both sex and age group. CONCLUSION This nationwide study of the epidemiology of hospital admissions for a principal diagnosis of AI/hypopituitarism shows that admissions generally decreased with age; males had higher rates of admission for hypopituitarism; females had higher rates of admission for CAH and "other and unspecified causes" of AI; and AC incidence varied by age and sex. Increased awareness of AI and AC prevention strategies may reduce some of these admissions.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - Georgina L Chrisp
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - Benjamin Dean
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northwest Territories, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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17
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El-Maouche D, Hargreaves CJ, Sinaii N, Mallappa A, Veeraraghavan P, Merke DP. Longitudinal Assessment of Illnesses, Stress Dosing, and Illness Sequelae in Patients With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2018; 103:2336-2345. [PMID: 29584889 PMCID: PMC6276663 DOI: 10.1210/jc.2018-00208] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with congenital adrenal hyperplasia (CAH) are at risk for life-threatening adrenal crises. Management of illness episodes aims to prevent adrenal crises. OBJECTIVE We evaluated rates of illnesses and associated factors in patients with CAH followed prospectively and receiving repeated glucocorticoid stress dosing education. METHODS Longitudinal analysis of 156 patients with CAH followed at the National Institutes of Health Clinical Center over 23 years was performed. The rates of illnesses and stress-dose days, emergency room (ER) visits, hospitalizations, and adrenal crises were analyzed in relation to phenotype, age, sex, treatment, and hormonal evaluations. RESULTS A total of 2298 visits were evaluated. Patients were followed for 9.3 ± 6.0 years. During childhood, there were more illness episodes and stress dosing than adulthood (P < 0.001); however, more ER visits and hospitalizations occurred during adulthood (P ≤ 0.03). The most robust predictors of stress dosing were young age, low hydrocortisone and high fludrocortisone dose during childhood, and female sex during adulthood. Gastrointestinal and upper respiratory tract infections (URIs) were the two most common precipitating events for adrenal crises and hospitalizations across all ages. Adrenal crisis with probable hypoglycemia occurred in 11 pediatric patients (ages 1.1 to 11.3 years). Undetectable epinephrine was associated with ER visits during childhood (P = 0.03) and illness episodes during adulthood (P = 0.03). CONCLUSIONS Repeated stress-related glucocorticoid dosing teaching is essential, but revised age-appropriate guidelines for the management of infectious illnesses are needed for patients with adrenal insufficiency that aim to reduce adrenal crises and prevent hypoglycemia, particularly in children.
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Affiliation(s)
- Diala El-Maouche
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health,
Bethesda, Maryland
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human
Development, National Institutes of Health, Bethesda, Maryland
- Correspondence and Reprint Requests: Deborah P. Merke, MD, National Institutes of Health Clinical Center, 10 Center
Drive, Room 1-2740, Bethesda, Maryland 20892. E-mail:
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18
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MacKay D, Nordenström A, Falhammar H. Bilateral Adrenalectomy in Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2018; 103:1767-1778. [PMID: 29554355 DOI: 10.1210/jc.2018-00217] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/09/2018] [Indexed: 02/04/2023]
Abstract
CONTEXT Management of congenital adrenal hyperplasia (CAH) involves suppression of the hypothalamic-pituitary-adrenal axis using supraphysiological doses of exogenous glucocorticoids. This can pose a challenge, with Cushing syndrome a frequent complication of adequate suppression. Bilateral adrenalectomy, with subsequent replacement of glucocorticoids and mineralocorticoids at physiological doses, has been proposed as an alternative therapeutic strategy. OBJECTIVE To review the outcomes after bilateral adrenalectomy for CAH. DATA SOURCES A systematic search of PubMed/MEDLINE and Web of Science, identifying relevant reports published up to 10 January 2018. STUDY SELECTION Case reports or case series were included if they reported individual patient data from patients with CAH who had undergone bilateral adrenalectomy. DATA EXTRACTION Information regarding the following was extracted: first author, country, sex, age at adrenalectomy, year of adrenalectomy, diagnosis, molecular abnormality, pre- and postoperative biochemistry, pre- and postoperative medications, pre- and postoperative body mass index, indication for adrenalectomy, surgical technique, gross and microscopic adrenal characteristics, follow-up duration, and short- and long-term postoperative outcomes. DATA SYNTHESIS We identified 48 cases of bilateral adrenalectomy for CAH, with patients aged from 4 months to 56 years at surgery. The most common indication for surgery was the inability to control hyperandrogenism/virilization and/or Cushing syndrome (n = 30; 62%). Most patients (n = 34; 71%) reported symptomatic improvement postoperatively, with some cases of short-term (n = 5; 10%) and long-term (n = 13; 27%) adverse outcomes. CONCLUSIONS Bilateral adrenalectomy for CAH appears to be a reasonable therapeutic option for carefully selected patients who have had unsatisfactory outcomes with conventional medical management.
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Affiliation(s)
- Diana MacKay
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, Northern Territory, Australia
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19
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Fleming L, Knafl K, Knafl G, Van Riper M. Parental management of adrenal crisis in children with congenital adrenal hyperplasia. J SPEC PEDIATR NURS 2017; 22:10.1111/jspn.12190. [PMID: 28771930 PMCID: PMC5884098 DOI: 10.1111/jspn.12190] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Congenital adrenal hyperplasia (CAH) requires parents to inject their child with hydrocortisone intramuscularly during times of illness and adrenal crisis. The purpose of this study was to describe circumstances surrounding adrenal crisis events in children with CAH; to explore parents' perceptions of the consequences of having a child with a life-threatening condition; and to examine a relationship between parents' perceived management ability and the impact CAH has on the family. METHODS In Phase 1 of this mixed-methods, cross-sectional study, 77 parents were asked to complete questionnaires comprising measures of family life in the context of childhood illness. Descriptive statistics were computed with four separate analyses using linear mixed models allowing for correlation between responses from parents of the same family and for the variance to be different for fathers and mothers. The following relationships were examined: (1) parental management ability and type of provider instruction on how to manage adrenal crises; (2) parental management ability and child age; (3) the perceived impact of the condition on the family and management ability; and (4) the age of the child and number of adrenal crisis events. In Phase 2, 16 semi-structured interviews were conducted to elicit detailed descriptions of parents' experiences in managing crises. RESULTS There was a significant, positive relationship between detailed provider instruction to parents on adrenal crisis management and perceived management ability (p = .02), additionally the stronger the perceived management ability, the less impact CAH had on the family (p < .001). From birth to age 5, parents reported more frequent crisis events and less perceived ability to manage the condition when compared with parents of older children (p = .009). The threat of an adrenal crisis event is a pervasive concern for parents, especially when they are not being properly prepared by providers. PRACTICE IMPLICATIONS Provider support is needed for these parents throughout childhood, but especially in the first 5 years of life when parents are adjusting to having a child with a life-threatening condition. Identifying gaps in parent education by healthcare providers is necessary to promote positive family outcomes.
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Affiliation(s)
- Louise Fleming
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, NC, USA
| | - Kathleen Knafl
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, NC, USA
| | - George Knafl
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, NC, USA
| | - Marcia Van Riper
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, NC, USA
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20
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Schoelwer MJ, Viswanathan V, Wilson A, Nailescu C, Imel EA. Infants With Congenital Adrenal Hyperplasia Are at Risk for Hypercalcemia, Hypercalciuria, and Nephrocalcinosis. J Endocr Soc 2017; 1:1160-1167. [PMID: 29264571 PMCID: PMC5686705 DOI: 10.1210/js.2017-00145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/27/2017] [Indexed: 12/12/2022] Open
Abstract
Context: Hypercalcemia is reported as a rare finding in adrenal insufficiency, but is not well described in congenital adrenal hyperplasia (CAH). Methods: A retrospective chart review was conducted of patients with CAH diagnosed before the age of 2 years who had at least one recorded serum calcium measurement. Data from birth to 6 years of age were reviewed. Results: Of the 40 patients who met inclusion criteria, 33 (82.5%) had at least one elevated calcium concentration and 21 (53%) had two or more elevated calcium concentrations. Of the 126 elevated serum calcium concentrations, the median was 10.9 mg/dL (range, 10.6 to 14.2 mg/dL). Median age at the last elevated calcium measurement was 5 months (range, 0.3 to 46 months). Serum calcium concentration was inversely related to age (r = −0.124; P = 0.004). Overall, calcium level positively correlated with 17-hydroxyprogesterone (17OHP) concentration (r = 0.170; P = 0.003), and this remained significant after adjusting for age (P < 0.05). However, patients had hypercalcemia with both high and low 17OHP concentrations. Serum calcium concentration also was positively related to glucocorticoid (r = 0.196; P = 0.012) and fludrocortisone (r = 0.229; P = 0.003) doses, and remained significant after age adjustment. Only seven patients were evaluated for hypercalciuria. Of these, six had at least one period of documented hypercalciuria. Three patients had nephrocalcinosis on renal ultrasound. Conclusion: Children with CAH are at risk for developing hypercalcemia, hypercalciuria, and nephrocalcinosis. Further studies are needed to determine the broader prevalence and the etiology of hypercalcemia in CAH.
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Affiliation(s)
- Melissa J Schoelwer
- Department of Pediatrics, Division of Endocrinology, Riley Hospital for Children, Indianapolis, Indiana 46202
| | - Vidhya Viswanathan
- Department of Pediatrics, Division of Endocrinology, Advocate Children's Hospital, Oak Lawn, Illinois 60453
| | - Amy Wilson
- Department of Pediatrics, Division of Nephrology, Riley Hospital for Children, Indianapolis, Indiana 46202
| | - Corina Nailescu
- Department of Pediatrics, Division of Nephrology, Riley Hospital for Children, Indianapolis, Indiana 46202
| | - Erik A Imel
- Department of Pediatrics, Division of Endocrinology, Riley Hospital for Children, Indianapolis, Indiana 46202.,Department of Medicine, Division of Endocrinology, Indiana University School of Medicine, Indianapolis, Indiana 46202
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21
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Rushworth RL, Torpy DJ, Falhammar H. Adrenal crises: perspectives and research directions. Endocrine 2017; 55:336-345. [PMID: 27995500 DOI: 10.1007/s12020-016-1204-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/08/2016] [Indexed: 01/25/2023]
Abstract
Adrenal crises are life-threatening complications of adrenal insufficiency. These events have an estimated incidence of between 5 and 10 adrenal crises/100 patient years and are responsible for some of the increased morbidity and excess mortality experienced by patients with adrenal insufficiency. Treatment involves urgent administration of IV/IM hydrocortisone and IV fluids. Patient education regarding preventive measures, such as increasing the dose of replacement therapy ("stress dosing") when sick, using parenteral hydrocortisone as necessary and accessing medical assistance promptly, is still considered the best approach to averting the onset of an adrenal crisis at times of physiological stress, most commonly an infection. However, recent evidence has demonstrated that patient education does not prevent many adrenal crisis events and the reasons for this are not fully understood. Furthermore, there is no widely accepted definition of an adrenal crisis. Without a validated adrenal crisis definition it is difficult to interpret variations in the incidence of adrenal crises and determine the effectiveness of preventive measures. This article aims to review the clinical aspects of adrenal crisis events, to explore the epidemiology, and to offer a definition of an adrenal crisis and to offer a perspective on future directions for research into adrenal crisis prevention.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Sydney, NSW, Australia.
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research and Royal Darwin Hospital, Darwin, NT, Australia
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22
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Bulsari K, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Endocrine 2017; 55:19-36. [PMID: 27928728 DOI: 10.1007/s12020-016-1189-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency is a rare autosomal recessive genetic disorder. It is caused by reduced or absent activity of 11β-hydroxylase (CYP11B1) enzyme and the resultant defects in adrenal steroidogenesis. The most common clinical features of 11 beta-hydroxylase deficiency are ambiguous genitalia, accelerated skeletal maturation and resultant short stature, peripheral precocious puberty and hyporeninemic hypokalemic hypertension. The biochemical diagnosis is based on raised serum 11-deoxycortisol and 11-deoxycorticosterone levels together with increased adrenal androgens. More than 100 mutations in CYP11B1 gene have been reported to date. The level of in-vivo activity of CYP11B1 relates to the degree of severity of 11 beta-hydroxylase deficiency. Clinical management of 11 beta-hydroxylase deficiency can pose a challenge to maintain adequate glucocorticoid dosing to suppress adrenal androgen excess while avoiding glucocorticoid-induced side effects. The long-term outcomes of clinical and surgical management are not well studied. This review article aims to collate the current available data about 11 beta-hydroxylase deficiency and its management.
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Affiliation(s)
- Krupali Bulsari
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia.
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
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