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Tsukamoto‐Kawashima S, Ikeda K, Sone M, Ogura M, Okamura E, Kondo A, Ueba Y, Inagaki N. An exploratory study of factors in disordered eating behavior in diabetes self-management in Japan. J Diabetes Investig 2024; 15:874-881. [PMID: 38426367 PMCID: PMC11215692 DOI: 10.1111/jdi.14176] [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: 11/16/2023] [Revised: 02/05/2024] [Accepted: 02/17/2024] [Indexed: 03/02/2024] Open
Abstract
AIMS/INTRODUCTION Diet directly affects glucose metabolism, and eating behavior is influenced by various daily life stressors. This study was conducted to investigate the relationship between common psychosomatic stressors on endocrine hormones and eating behavior in patients with type 2 diabetes. MATERIALS AND METHODS This cross-sectional study was performed in 40 patients with type 2 diabetes. Resting hormone blood sampling and four self-reported questionnaires were employed. RESULTS Patients who scored higher on the 'anger/hostility' (AH) subcategory of the profile of mood state (POMS) questionnaire had significantly higher serum cortisol (β = 0.40, P = 0.01 by least squares adjusted for age and sex). In the eating behavior questionnaire, the subcategories of 'feeling of hunger/satiation' (β = 0.49, P < 0.01) and 'eating as diversion' (β = 0.39, P = 0.03) were associated with higher serum cortisol. Resting morning cortisol levels were higher in participants who rated high on the POMS-AH and in those who reported 'irritated when hungry' and 'tend to eat when irritated or anxious'. Sleep quality showed no association with eating behavior. CONCLUSIONS Mood state is associated with eating behavior. Anger increases cortisol levels and may lead to compulsive eating. Various forms of hostility are important factors in appetite control and increased cortisol secretion, and can be an impediment to successful dietary self-management in patients with type 2 diabetes. Thus, assessment of mood state and control of negative mood are important therapeutic targets in diabetes management.
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Affiliation(s)
- Sachiko Tsukamoto‐Kawashima
- Preemptive Medicine and Lifestyle Related Disease Research CenterKyoto University HospitalKyotoJapan
- Department of Diabetes, Endocrinology and NutritionKyoto University Graduate School of MedicineKyotoJapan
| | - Kaori Ikeda
- Department of Diabetes, Endocrinology and NutritionKyoto University Graduate School of MedicineKyotoJapan
- Department of Clinical Research Facilitation, Institute for Advancement of Clinical and Translational ScienceKyoto University HospitalKyotoJapan
| | - Masakatsu Sone
- Department of Metabolism and EndocrinologySt. Marianna University School of MedicineKawasakiKanagawaJapan
| | - Masahito Ogura
- Department of Diabetes, Endocrinology and NutritionKyoto University Graduate School of MedicineKyotoJapan
- Department of DiabetesNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Emi Okamura
- Department of Diabetes, Endocrinology and NutritionKyoto University Graduate School of MedicineKyotoJapan
| | - Aki Kondo
- Department of Diabetes, Endocrinology and NutritionKyoto University Graduate School of MedicineKyotoJapan
| | - Yoko Ueba
- Department of Diabetes, Endocrinology and NutritionKyoto University Graduate School of MedicineKyotoJapan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and NutritionKyoto University Graduate School of MedicineKyotoJapan
- Medical Research Institute KITANO HOSPITAL, PIIF Tazuke‐kofukaiOsakaJapan
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Unger N, Theodoropoulou M, Schilbach K. [Clinically active pituitary tumors]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:672-680. [PMID: 38869654 DOI: 10.1007/s00108-024-01729-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/14/2024]
Abstract
The widespread use of diagnostic imaging has led to an increase in the incidence of pituitary tumors. The majority of incidentalomas are hormone-inactive (HI) pituitary microadenomas. The most common clinically relevant pituitary adenomas are prolactin-secreting, followed by HI, and far less common are growth hormone (GH)-, adrenocorticotropic hormone (ACTH)- and thyroid-stimulating hormone (TSH)-secreting adenomas. Pituitary adenomas are usually benign, although aggressive growth and invasion occurs in individual cases. Very rarely, they give rise to metastases and are then termed pituitary carcinomas. All pituitary tumors require endocrine testing for pituitary hormone excess. In addition to the medical history and clinical examination, laboratory diagnostics are very important. Symptoms such as irregular menstruation, loss of libido or galactorrhea often lead to the timely diagnosis of prolactinomas, and hyperprolactinemia can easily confirm the diagnosis (considering the differential diagnoses). Diagnosis is more difficult for all other hormone-secreting pituitary adenomas (acromegaly, Cushing's disease, TSHoma), as the symptoms are often non-specific (i.e., headaches, weight gain, fatigue, joint pain). Furthermore, comorbidities such as hypertension, diabetes, and depression are such widespread diseases that pituitary adenomas are rarely considered as the underlying cause. Timely diagnosis and appropriate treatment have a significant impact on morbidity, mortality, and quality of life. Therefore, the role of primary care physicians is very important for achieving an early diagnosis. In addition, patients with pituitary adenomas should always be referred to endocrinologists to ensure optimal diagnosis as well as treatment.
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Affiliation(s)
- Nicole Unger
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsklinikum Essen, Essen, Deutschland
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 5, 80336, München, Deutschland
| | - Katharina Schilbach
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 5, 80336, München, Deutschland.
- Technische Hochschule Deggendorf, Deggendorf, Deutschland.
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Motomura Y, Urai S, Bando H, Yamamoto M, Suzuki M, Yamamoto N, Iguchi G, Ogawa W, Fukuoka H. Diagnostic dilemma in Cushing's syndrome: discrepancy between patient-reported and physician-assessed manifestations. Endocrine 2024:10.1007/s12020-024-03935-9. [PMID: 39037671 DOI: 10.1007/s12020-024-03935-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/14/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE Early diagnosis and immediate treatment of Cushing's syndrome (CS) are critical for a better prognosis but remain a challenge. However, few comprehensive reports have focused on this issue or investigated whether patient-reported manifestations are consistent with physician-assessed symptoms of CS. This study aimed to clarify the differences in patient-reported and physician-assessed manifestations of signs and symptoms of CS that prevent early diagnosis. METHODS This single-center retrospective study included 52 patients with CS (16 with Cushing's disease and 36 with adrenal CS). Upon clinical diagnosis, medical records were used to independently review the patient-reported and physician-assessed manifestations of typical (such as purple striae and proximal myopathy) and nonspecific features (such as hirsutism and hypertension). The correlations and differences between the patient-reported and physician-assessed manifestations were then analyzed. RESULTS We observed a positive correlation between the total number of manifestations of nonspecific features reported by patients and those assessed by physicians, but not for typical features. Moreover, manifestations reported by the patients were less frequent than those assessed by physicians for typical features, leading to discrepancies between the two groups. In contrast, there were no differences in most nonspecific features between the patient-reported and physician-assessed manifestations. Notably, the concordance between patient-reported and physician-assessed manifestations of typical features was not associated with urinary free cortisol levels. CONCLUSION Regardless of disease severity, patients often do not complain of the typical features of CS that are crucial for formulating a diagnosis.
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Affiliation(s)
- Yuma Motomura
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Shin Urai
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Hyogo, 650-0017, Japan
| | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Masaki Suzuki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Naoki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
- Medical Center for Student Health, Kobe University, Kobe, Hyogo, 657-8501, Japan
- Department of Biosignal Pathophysiology, Kobe University Graduate School of Medicine, Kobe, Hyogo, 657-8501, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Hyogo, 650-0017, Japan.
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Paes T, Feelders RA, Hofland LJ. Epigenetic Mechanisms Modulated by Glucocorticoids With a Focus on Cushing Syndrome. J Clin Endocrinol Metab 2024; 109:e1424-e1433. [PMID: 38517306 PMCID: PMC11099489 DOI: 10.1210/clinem/dgae151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 02/08/2024] [Accepted: 03/07/2024] [Indexed: 03/23/2024]
Abstract
In Cushing syndrome (CS), prolonged exposure to high cortisol levels results in a wide range of devastating effects causing multisystem morbidity. Despite the efficacy of treatment leading to disease remission and clinical improvement, hypercortisolism-induced complications may persist. Since glucocorticoids use the epigenetic machinery as a mechanism of action to modulate gene expression, the persistence of some comorbidities may be mediated by hypercortisolism-induced long-lasting epigenetic changes. Additionally, glucocorticoids influence microRNA expression, which is an important epigenetic regulator as it modulates gene expression without changing the DNA sequence. Evidence suggests that chronically elevated glucocorticoid levels may induce aberrant microRNA expression which may impact several cellular processes resulting in cardiometabolic disorders. The present article reviews the evidence on epigenetic changes induced by (long-term) glucocorticoid exposure. Key aspects of some glucocorticoid-target genes and their implications in the context of CS are described. Lastly, the effects of epigenetic drugs influencing glucocorticoid effects are discussed for their ability to be potentially used as adjunctive therapy in CS.
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Affiliation(s)
- Ticiana Paes
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston 02115, MA, USA
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Leo J Hofland
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
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5
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Moctezuma S, Perez JL, Baraban E, Caturegli P, Morris-Wiseman L, Salvatori R. Cushing Syndrome Due to a Corticotropin-Releasing Hormone- and Adrenocorticotropic Hormone-Secreting Silent Pheochromocytoma. AACE Clin Case Rep 2024; 10:84-88. [PMID: 38799040 PMCID: PMC11127585 DOI: 10.1016/j.aace.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 05/29/2024] Open
Abstract
Background/Objective Ectopic cosecretion of corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) in silent (ie, non-catecholamine-secreting) pheochromocytoma is a rare cause of Cushing syndrome. Case Report A 57-year-old woman rapidly developed hypercortisolism, clinically manifesting as fatigue, muscle weakness, weight gain, and worsening hypertension and biochemically characterized by hypokalemia and marked increases in the serum cortisol and plasma ACTH levels. This acute presentation suggested a diagnosis of ectopic ACTH syndrome (EAS). Imaging studies revealed a right adrenal mass that enhanced after administration of the radioisotope gallium-68-DOTATATE. Plasma metanephrines were normal in 2 separate measurements. The possibility of a silent pheochromocytoma was considered. After controlling her hypercortisolism with metyrapone and surgical preparation with alpha blockade, the patient underwent elective right adrenalectomy. Pathology revealed a pheochromocytoma that stained focally for ACTH and CRH. Postoperatively, the cortisol levels normalized, the hypothalamic-pituitary-adrenal axis was not suppressed, and clinical symptoms from hypercortisolism abated. Discussion Patients who exhibit a rapid progression of ACTH-dependent hypercortisolism should be screened for EAS. The use of functional imaging radioisotopes (eg, gallium DOTA-peptides) improves the detection of ACTH-secreting tumors. Preoperative treatment with steroidogenesis inhibitors helps control clinical and metabolic derangements associated with severe hypercortisolemia, whereas alpha blockade prevents the onset of an adrenergic crisis. Conclusion We present a rare case of EAS due to a silent pheochromocytoma that cosecreted ACTH and CRH. Pheochromocytoma should be considered in patients with EAS who have an adrenal mass even in the absence of excessive catecholamine secretion.
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Affiliation(s)
- Sananda Moctezuma
- Division of Endocrinology, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jonathan L. Perez
- Department of Pathology, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ezra Baraban
- Department of Pathology, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Patrizio Caturegli
- Department of Pathology, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lilah Morris-Wiseman
- Department of Surgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Roberto Salvatori
- Division of Endocrinology, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Sawamura T, Kometani M, Karashima S, Yoneda T. Violaceous abdominal striae noted on physical examination: a clue to the diagnosis of Cushing's syndrome. BMJ Case Rep 2024; 17:e259687. [PMID: 38458764 PMCID: PMC10928762 DOI: 10.1136/bcr-2024-259687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024] Open
Affiliation(s)
- Toshitaka Sawamura
- Internal Medicine, Asanogawa General Hospital, Kanazawa, Ishikawa, Japan
- Department of Endocrinology and Metabolism, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Mitsuhiro Kometani
- Department of Endocrinology and Metabolism, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shigehiro Karashima
- Department of Endocrinology and Metabolism, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Takashi Yoneda
- Department of Endocrinology and Metabolism, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
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7
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Mirzaian M, van Zundert SKM, Schilleman WF, Mohseni M, Kuckuck S, van Rossum EFC, van Schaik RHN, van den Berg SAA. Determination of cortisone and cortisol in human scalp hair using an improved LC-MS/MS-based method. Clin Chem Lab Med 2024; 62:118-127. [PMID: 37485925 DOI: 10.1515/cclm-2023-0341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/13/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVES Human scalp hair is an easily available but complex matrix for determination of cortisone and cortisol, and has been shown to reflect long-term glucocorticoid exposure. Hair glucocorticoid analysis has been used to detect hypo- and hypercortisolism. In this study, we describe the development and validation of a LC-MS/MS method for quantification of cortisone and cortisol in human scalp hair, and provide a novel approach for analysis and interpretation of the results. METHODS Improved sample preparation using pulverization and solid phase extraction allowed for low sample volumes (10 mg). Baseline chromatographic separation without matrix interference was achieved by reversed phase chromatography and MRM measurement in negative ion mode. Run-to-run time was 8 min. Mixed model analyses were performed to create individual patterns of cortisone and cortisol concentrations. RESULTS Matrix matched calibration curves showed excellent linearity up to 100 pg (analyte)/mg (hair) for both cortisone and cortisol (R2>0.995). LLOQ was 1.5 and 1.0 pg/mg for cortisone and cortisol, respectively. Matrix effect was negligible for hair color (recoveries 95-105 %). Cortisone and cortisol concentrations decreased from proximal to distal hair segments, following a predictable, but subject-specific pattern, with less individual variation for cortisone than for cortisol. CONCLUSIONS This improved LC-MS/MS method is able to accurately quantify cortisone and cortisol in human hair with minimum matrix interference. This new way of data analysis and interpretation including individual patterns of cortisone and cortisol will be of help with detection of pathological concentrations in both the high - and the low ranges of glucocorticoids.
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Affiliation(s)
- Mina Mirzaian
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sofie K M van Zundert
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Wim F Schilleman
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mostafa Mohseni
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Obesity Center CGG, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Susanne Kuckuck
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Obesity Center CGG, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Elisabeth F C van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Obesity Center CGG, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sjoerd A A van den Berg
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Gadelha M, Gatto F, Wildemberg LE, Fleseriu M. Cushing's syndrome. Lancet 2023; 402:2237-2252. [PMID: 37984386 DOI: 10.1016/s0140-6736(23)01961-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/04/2023] [Accepted: 09/13/2023] [Indexed: 11/22/2023]
Abstract
Endogenous Cushing's syndrome results from excess glucocorticoid secretion, which leads to a myriad of clinical manifestations, comorbidities, and increased mortality despite treatment. Molecular mechanisms and genetic alterations associated with different causes of Cushing's syndrome have been described in the last decade. Imaging modalities and biochemical testing have evolved; however, both the diagnosis and management of Cushing's syndrome remain challenging. Surgery is the preferred treatment for all causes, but medical therapy has markedly advanced, with new drug options becoming available. Nevertheless, several comorbidities remain even after patient remission, which can affect quality of life. Accurate and timely diagnosis and treatment are essential for mitigating chronic complications of excess glucocorticoids and improving patient quality of life. In this Seminar, we aim to update several important aspects of diagnosis, complications, and treatment of endogenous Cushing's syndrome of all causes.
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Affiliation(s)
- Mônica Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Molecular Genetics Laboratory, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
| | - Federico Gatto
- Endocrinology Unit, Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Maria Fleseriu
- Pituitary Center, Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
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9
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Mohammedi K, Bertherat J, Raverot G, Drui D, Reznik Y, Castinetti F, Chanson P, Fafin M, Brossaud J, Tabarin A. Evidence of Persistent Mild Hypercortisolism in Patients Medically Treated for Cushing Disease: the Haircush Study. J Clin Endocrinol Metab 2023; 108:e963-e970. [PMID: 37144820 DOI: 10.1210/clinem/dgad251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/06/2023]
Abstract
CONTEXT Cortisol-lowering drugs may not restore a normal cortisol secretion in Cushing disease (CD). OBJECTIVE This work aimed to assess the long-term cortisol exposure in medically treated CD patients using hair-cortisol (HF) and hair-cortisone (HE) measurement. METHODS This multicenter prospective study included 3 groups of female patients: CushMed = 16 treated with a stable cortisol-lowering drug dosage and normal urinary free cortisol (UFC); CushSurg = 13 cured by pituitary surgery; CushBla = 15 receiving stable recommended doses of hydrocortisone following bilateral adrenalectomy. Patients were evaluated for 3 months with their usual treatments. Two late-night saliva and 24-hour urine samples were collected monthly in CushMed, and at study end in CushSurg and CushBla patients. A 3-cm hair sample was collected at study end from all patients. Main outcome measures included clinical score and centralized measurement of UFC, late-night salivary cortisol (LNSF), late-night salivary cortisone (LNSE), HE, HF. RESULTS Despite having almost all UFCs normalized, CushMed patients exhibited increased HE as compared to CushSurg controls (P = .003). CushMed patients also had increased clinical score (P = .001), UFC (P = .03), LNSF, LNSE (P = .0001), and variability in the latter parameters (P = .004). CushBla patients had increased HF and HE, contrasting with LNSEs similar to CushSurg patients. Six of 15 CushMed patients exhibited increased HE concentrations and had increased antihypertensive drug dosage compared to CushMed patients with normal HE (P = .05). CONCLUSION Despite normalized UFCs, a subset of medically treated CD patients displays an altered circadian rhythm of serum cortisol. A single HE measurement identifies chronic mild persistent hypercortisolism and could replace multiple saliva analyzes to monitor medical treatments in CD patients once UFC is normalized.
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Affiliation(s)
- Kamel Mohammedi
- Department of Endocrinology, French Reference Center for Adrenal Cancer, EURACAN European Expert Center on Rare Neuroendocrine Tumors, Hôpital Haut-Lévèque, CHU and University of Bordeaux, F-33604 Pessac, France
| | - Jerome Bertherat
- Department of Endocrinology, French Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Université Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, F-75014, Paris, France
| | - Gerald Raverot
- Department of Endocrinology, French Reference Center for Rare Pituitary Diseases HYPO, Hospices Civils de Lyon and Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Cancer Research Center of Lyon, F-69001, Lyon, France
| | - Delphine Drui
- Department of Endocrinology and Institut du thorax, CHU de Nantes, F-44000 Nantes, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte de Nacre, F-14033 Caen, France
| | - Frederic Castinetti
- Department of Endocrinology, Assistance Publique-Hopitaux de Marseille, French Reference Center for Rare Pituitary Diseases, EURACAN European Expert Center on Rare Pituitary Tumors, La Conception Hospital, Aix Marseille University, F-13385, Marseille, France
| | - Philippe Chanson
- Department of Endocrinology, Reference Center for Rare Pituitary Diseases HYPO, CHU Bicêtre, F-94270 Le Kremlin-Bicêtre, France
| | - Manon Fafin
- Department of Endocrinology, French Reference Center for Adrenal Cancer, EURACAN European Expert Center on Rare Neuroendocrine Tumors, Hôpital Haut-Lévèque, CHU and University of Bordeaux, F-33604 Pessac, France
| | - Julie Brossaud
- Laboratory of Hormonology and Tumor Markers, Nutrition and Integrated Neurobiology Laboratory, UMR 1286, CHU de Bordeaux, F-33300, Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, French Reference Center for Adrenal Cancer, EURACAN European Expert Center on Rare Neuroendocrine Tumors, Hôpital Haut-Lévèque, CHU and University of Bordeaux, F-33604 Pessac, France
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10
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Zeer AMM, Noman M, Zeer ZMM, Attawneh A, Bairmani ZA, Alfroukh KMA, Oweina L. Factitious cushing's syndrome with unusual presentation: a case report and literature review. Ann Med Surg (Lond) 2023; 85:4161-4166. [PMID: 37554867 PMCID: PMC10406003 DOI: 10.1097/ms9.0000000000001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/01/2023] [Indexed: 08/10/2023] Open
Abstract
UNLABELLED Munchausen syndrome is known as a factitious disorder imposed on the self. Factitious Cushing's syndrome (CS) is a very rare form of Munchausen syndrome, presenting with varied clinical and biochemical features, making diagnosis challenging. CASE PRESENTATION A 40-year-old female patient who worked as a registered nurse presented with clinical features of CS but denied any exogenous corticosteroid use. The endocrine workup revealed that the patient had a high 24 h urinary-free cortisol collection before admission. Subsequent evaluations showed low levels of morning cortisol and plasma adrenocorticotropic hormone along with a suppressed overnight low-dose dexamethasone suppression test, leading to an investigation of hypercortisolism. Unexpectedly, subsequent testing showed a normal 24 h urinary-free cortisol level. Additionally, the patient was diagnosed with panhypopituitarism, the radiological investigations showed normal pituitary and adrenal glands. Despite consistently denying the use of corticosteroids, it was finally discovered that the patient had been surreptitiously taking prednisone and receiving multiple dexamethasone injections over the past few months. The patient received treatment through a gradual prednisone tapering regimen, accompanied by comprehensive psychiatric evaluation and management. CONCLUSION This case underscores the exceptional rarity of factitious CS and emphasizes the importance of considering it as a potential differential diagnosis in hypercortisolism cases, particularly when the patient's medical history contradicts investigative findings. Furthermore, it highlights the criticality of adopting a multidisciplinary approach to investigate patients whose clinical presentation aligns with factitious CS.
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Affiliation(s)
| | | | | | - Alaa Attawneh
- Endocrinologist at Augusta Victoria Hospital, Jerusalem
| | | | | | - Layth Oweina
- Psychiatry at Bethlehem Psychiatric Hospital, UK
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Wright K, van Rossum EFC, Zan E, Werner N, Harris A, Feelders RA, Agrawal N. Emerging diagnostic methods and imaging modalities in cushing's syndrome. Front Endocrinol (Lausanne) 2023; 14:1230447. [PMID: 37560300 PMCID: PMC10407789 DOI: 10.3389/fendo.2023.1230447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/05/2023] [Indexed: 08/11/2023] Open
Abstract
Endogenous Cushing's syndrome (CS) is a rare disease characterized by prolonged glucocorticoid excess. Timely diagnosis is critical to allow prompt treatment and limit long-term disease morbidity and risk for mortality. Traditional biochemical diagnostic modalities each have limitations and sensitivities and specificities that vary significantly with diagnostic cutoff values. Biochemical evaluation is particularly complex in patients whose hypercortisolemia fluctuates daily, often requiring repetition of tests to confirm or exclude disease, and when delineating CS from physiologic, nonneoplastic states of hypercortisolism. Lastly, traditional pituitary MRI may be negative in up to 60% of patients with adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas (termed "Cushing's disease" [CD]) whereas false positive pituitary MRI findings may exist in patients with ectopic ACTH secretion. Thus, differentiating CD from ectopic ACTH secretion may necessitate dynamic testing or even invasive procedures such as bilateral inferior petrosal sinus sampling. Newer methods may relieve some of the diagnostic uncertainty in CS, providing a more definitive diagnosis prior to subjecting patients to additional imaging or invasive procedures. For example, a novel method of cortisol measurement in patients with CS is scalp hair analysis, a non-invasive method yielding cortisol and cortisone values representing long-term glucocorticoid exposure of the past months. Hair cortisol and cortisone have both shown to differentiate between CS patients and controls with a high sensitivity and specificity. Moreover, advances in imaging techniques may enhance detection of ACTH-secreting pituitary adenomas. While conventional pituitary MRI may fail to identify microadenomas in patients with CD, high-resolution 3T-MRI with 3D-spoiled gradient-echo sequence has thinner sections and superior soft-tissue contrast that can detect adenomas as small as 2 mm. Similarly, functional imaging may improve the identification of ACTH-secreting adenomas noninvasively; Gallium-68-tagged corticotropin-releasing hormone (CRH) combined with PET-CT can be used to detect CRH receptors, which are upregulated on corticotroph adenomas. This technique can delineate functionality of adenomas in patients with CD from patients with ectopic ACTH secretion and false positive pituitary lesions on MRI. Here, we review emerging methods and imaging modalities for the diagnosis of CS, discussing their diagnostic accuracy, strengths and limitations, and applicability to clinical practice.
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Affiliation(s)
- Kyla Wright
- New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Elisabeth F. C. van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical College (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Elcin Zan
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Nicole Werner
- New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Alan Harris
- Department of Medicine, Division of Endocrinology, New York University (NYU) Langone Medical Center, New York, NY, United States
| | - Richard A. Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical College (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Nidhi Agrawal
- Department of Medicine, Division of Endocrinology, New York University (NYU) Langone Medical Center, New York, NY, United States
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Dhar A, Banerjee M, Bhattacharjee R, Chowdhury S. Low DHEAS Level: A Surrogate Marker of Adrenal Cushing Syndrome with Grey Zone ACTH Levels. Indian J Endocrinol Metab 2023; 27:365-367. [PMID: 37867991 PMCID: PMC10586549 DOI: 10.4103/ijem.ijem_161_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/03/2023] [Accepted: 06/25/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Abhranil Dhar
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Mainak Banerjee
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Rana Bhattacharjee
- Department of Endocrinology, Medical College and Hospital, Kolkata, West Bengal, India
| | - Subhankar Chowdhury
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
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Flowers KC, Shipman KE. Pitfalls in the Diagnosis and Management of Hypercortisolism (Cushing Syndrome) in Humans; A Review of the Laboratory Medicine Perspective. Diagnostics (Basel) 2023; 13:diagnostics13081415. [PMID: 37189516 DOI: 10.3390/diagnostics13081415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Biochemical confirmation of a diagnosis of hypercortisolism (Cushing syndrome) is vital to direct further investigations, especially given the overlap with non-autonomous conditions, such as pseudo-Cushing, and the morbidity associated with missed diagnoses. A limited narrative review was performed focusing on the laboratory perspective of the pitfalls of making a biochemical diagnosis of hypercortisolism in those presenting with presumed Cushing syndrome. Although analytically less specific, immunoassays remain cheap, quick, and reliable in most situations. Understanding cortisol metabolism can help with patient preparation, specimen selection (e.g., consideration of urine or saliva for those with possible elevations of cortisol binding globulin concentration), and method selection (e.g., mass spectrometry if there is a high risk of abnormal metabolites). Although more specific methods may be less sensitive, this can be managed. The reduction in cost and increasing ease of use makes techniques such as urine steroid profiles and salivary cortisone of interest in future pathway development. In conclusion, the limitations of current assays, particularly if well understood, do not impede diagnosis in most cases. However, in complex or borderline cases, there are other techniques to consider to aid in the confirmation of hypercortisolism.
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Affiliation(s)
- Kade C Flowers
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
| | - Kate E Shipman
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
- Department of Medical Education, Brighton and Sussex Medical School, University of Sussex, Falmer Campus, Brighton BN1 9PX, UK
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14
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Park SS, Kim YH, Kang H, Ahn CH, Byun DJ, Choi MH, Kim JH. Serum and hair steroid profiles in patients with nonfunctioning pituitary adenoma undergoing surgery: A prospective observational study. J Steroid Biochem Mol Biol 2023; 230:106276. [PMID: 36858289 DOI: 10.1016/j.jsbmb.2023.106276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/23/2023] [Accepted: 02/26/2023] [Indexed: 03/02/2023]
Abstract
Patients who undergo transsphenoidal surgery (TSS) experience perioperative hormonal changes, but there are few studies on the perioperative changes of serum and hair steroid profiles. This study investigated the perioperative changes in steroid metabolic signatures in patients with nonfunctioning pituitary adenoma (NFPA) who underwent transsphenoidal surgery (TSS). A total of 55 participants who underwent TSS for NFPA at a single center between July 2017 and October 2018 were enrolled. Fifteen serum steroids and their metabolic ratios were profiled using gas chromatography-mass spectrometry (GC-MS) before and 1 day, 1 week, and 3 months after TSS. Five steroids from hair samples collected 1 day and 3 months after TSS were also quantitatively compared. Serum cortisol and its A-ring reductive metabolites, as well as 6β-hydroxycortisol, increased dramatically 1 day after TSS and then gradually decreased. Seven serum steroids, including adrenal androgens and mineralocorticoids, and hair cortisone levels were significantly lower in patients with preoperative adrenocorticotropic hormone (ACTH) deficiency (N = 7) than in those without ACTH deficiency (N = 48). Serum levels of dehydroepiandrosterone (DHEA) levels 1 week after TSS predicted ACTH deficiency 3 months after TSS, with 100 % sensitivity and 86 % specificity. A significant positive correlation between the preoperative serum and hair DHEA levels (r = 0.356, P = 0.008) was observed. These findings suggest that the levels of DHEA in both the serum and hair could be an early marker of ACTH deficiency after TSS. In addition, hair cortisone may be a useful preoperative indicator of chronic ACTH deficiency.
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Affiliation(s)
- Seung Shin Park
- Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea; Department of Internal Medicine, Seoul National University Hospital, Republic of Korea
| | - Yong Hwy Kim
- Pituitary Center, Seoul National University Hospital, Republic of Korea; Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Ho Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Chang Ho Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea; Department of Internal Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Dong Jun Byun
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Republic of Korea
| | - Man Ho Choi
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Republic of Korea.
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea; Department of Internal Medicine, Seoul National University Hospital, Republic of Korea,; Pituitary Center, Seoul National University Hospital, Republic of Korea.
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Choy KW, Liwayan R, Wijeratne N. Screening for Cushing's syndrome: The 'CS-Screening' Shiny app. Ann Clin Biochem 2023; 60:217-218. [PMID: 36592057 DOI: 10.1177/00045632221148961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Kay Weng Choy
- Department of Pathology, 3234Northern Health, Epping, VIC, Australia
| | - Rachelle Liwayan
- Department of Pathology, 3234Northern Health, Epping, VIC, Australia
| | - Nilika Wijeratne
- 60099Dorevitch Pathology, Heidelberg, VIC, Australia.,Department of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
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Ceccato F, Barbot M, Mondin A, Boscaro M, Fleseriu M, Scaroni C. Dynamic testing for differential diagnosis of ACTH-dependent Cushing Syndrome: a systematic review and meta-analysis. J Clin Endocrinol Metab 2022; 108:e178-e188. [PMID: 36453141 DOI: 10.1210/clinem/dgac686] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Diagnostic accuracy of testing currently used for the differential diagnosis of Cushing's disease (CD) vs ectopic -ACTH secretion (EAS) is difficult to interpret. The present study aimed to identify and evaluate the diagnostic accuracy of corticotropin-releasing hormone (CRH) test, desmopressin test, and high-dose dexamethasone suppression test (HDDST) when used to establish a CD or EAS diagnosis. DESIGN This study is a systematic review of the literature and meta-analysis. METHODS MEDLINE, OVID, and Web of Science databases were searched for articles published between the years 1990-2021. Articles included described at least one test(s) (CRH, desmopressin, or HDDST) and the diagnostic reference standard(s) (histopathology, petrosal sinus sampling, surgical remission, imaging, and long-term follow-up) used to establish a CD or EAS diagnosis. RESULTS Sixty-two studies were included: 43 reported the use of HDDST, 32 CRH test, and 21 desmopressin test. CRH test was found to have the highest sensitivity in detecting CD (ACTH 86.9%, 95% confidence interval [CI] 82.1-90.6, cortisol 86.2%, 95%CI 78.3-91.5) and the highest specificity in detecting EAS (ACTH 93.9%, 95%CI 87-98.3, cortisol 89.4%, 95%CI 82.8-93.7). This resulted in a high diagnostic odds ratio (58, 95%CI 43.25-77.47), large area under the curve, and a receiver-operating characteristic (ROC) of 0.934. The diagnostic accuracy of HDDST and desmopressin test(s) was lower than that of the CRH test. CONCLUSION The meta-analysis indicates that a patient with a positive ACTH response after a CRH test is highly likely to have CD. Further studies analysing role of dynamic testing in addition to imaging are needed.
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Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Alessandro Mondin
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Maria Fleseriu
- Oregon Health & Science University, Pituitary Center, Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition and Department of Neurological Surgery, Portland, USA
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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Lam-Chung CE, Cuevas-Ramos D. The promising role of risk scoring system for Cushing syndrome: Time to reconsider current screening recommendations. Front Endocrinol (Lausanne) 2022; 13:1075785. [PMID: 36482998 PMCID: PMC9725023 DOI: 10.3389/fendo.2022.1075785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/01/2022] [Indexed: 11/24/2022] Open
Abstract
Despite the current screening approach for Cushing syndrome (CS), delayed diagnosis is common due to broad spectrum of presentation, poor discriminant symptoms featured in diabetes and obesity, and low clinical index of suspicion. Even if initial tests are recommended to screen CS, divergent results are not infrequent. As global prevalence of type 2 diabetes and obesity increases, CS may not be frequent enough to back routine screening to avoid false-positive results. This represents a greater challenge in countries with limited health resources. The development of indexes incorporates clinical features and biochemical data that are largely used to provide a tool to predict the presence of disease. In clinical endocrinology, indexes have been used in Graves' ophthalmology, hirsutism, and hypothyroidism. The use of clinical risk scoring system may assist clinicians in discriminating CS in the context of at-risk populations and, thus, may provide a potential intervention to decrease time to diagnosis. Development and validation of clinical model to estimate pre-test probability of CS in different geographic source population may help to establish regional prediction model for CS. Here, we review on the latest progress in clinical risk scoring system for CS and attempt to raise awareness for the use, validation, and/or development of clinical risk scores in CS.
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Affiliation(s)
- CE. Lam-Chung
- Department of Endocrinology and Metabolism, Complejo Hospitalario Dr. Manuel Amador Guerrero, Colón, Panama
| | - D. Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- *Correspondence: D. Cuevas-Ramos,
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