1
|
Asla Q, Sardà H, Lerma E, Hanzu FA, Rodrigo MT, Urgell E, Pérez JI, Webb SM, Aulinas A. 11-Deoxycorticosterone Producing Adrenal Hyperplasia as a Very Unusual Cause of Endocrine Hypertension: Case Report and Systematic Review of the Literature. Front Endocrinol (Lausanne) 2022; 13:846865. [PMID: 35432204 PMCID: PMC9008131 DOI: 10.3389/fendo.2022.846865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/23/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES 11-deoxycorticosterone overproduction due to an adrenal tumor or hyperplasia is a very rare cause of mineralocorticoid-induced hypertension. The objective is to provide the most relevant clinical features that clinicians dealing with patients presenting with the hallmarks of hypertension due to 11-deoxycorticosterone-producing adrenal lesions should be aware of. DESIGN AND METHODS We report the case of a patient with an 11-deoxycorticosterone-producing adrenal lesion and provide a systematic review of all published cases (PubMed, Web of Science and EMBASE) between 1965 and 2021. RESULTS We identified 46 cases (including ours). Most cases (31, 67%) affected women with a mean age of 42.9 ± 15.2 years and presented with high blood pressure and hypokalemia (average of 2.68 ± 0.62 mmol/L). Median (interquartile range) time from onset of first suggestive symptoms to diagnosis was 24 (55) months. Aldosterone levels were low or in the reference range in 98% of the cases when available. 11-deoxycorticosterone levels were a median of 12.5 (18.9) times above the upper limit of the normal reference range reported in each article and overproduction of more than one hormone was seen in 31 (67%). Carcinoma was the most common histological type (21, 45.7%). Median tumor size was 61.5 (60) mm. Malignant lesions were larger, had higher 11-deoxycorticosterone levels and shorter time of evolution at diagnosis compared to benign lesions. CONCLUSIONS 11-deoxycorticosterone-producing adrenal lesions are very rare, affecting mostly middle-aged women with a primary aldosteronism-like clinical presentation and carcinoma is the most frequent histological diagnosis. Measuring 11-deoxycorticosterone levels, when low aldosterone levels or in the lower limit of the reference range are present in hypertensive patients, is advisable. SYSTEMATIC REVIEW REGISTRATION Open Science Framework, 10.17605/OSF.IO/NR7UV.
Collapse
Affiliation(s)
- Queralt Asla
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, University of Vic-Central University of Catalonia, Vic, Spain
| | - Helena Sardà
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Enrique Lerma
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Department of Pathological Anatomy, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Felicia A. Hanzu
- Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - María Teresa Rodrigo
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Department of Pathological Anatomy, Hospital Clínic, Barcelona, Spain
| | - Eulàlia Urgell
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Ignacio Pérez
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of General and Digestive Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Susan M. Webb
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unit 747), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Anna Aulinas
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, University of Vic-Central University of Catalonia, Vic, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unit 747), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- *Correspondence: Anna Aulinas,
| |
Collapse
|
3
|
Marques P, Tufton N, Bhattacharya S, Caulfield M, Akker SA. Hypertension due to a deoxycorticosterone-secreting adrenal tumour diagnosed during pregnancy. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180164. [PMID: 31051469 PMCID: PMC6499913 DOI: 10.1530/edm-18-0164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/11/2019] [Indexed: 11/25/2022] Open
Abstract
Mineralocorticoid hypertension is most often caused by autonomous overproduction of aldosterone, but excess of other mineralocorticoid precursors can lead to a similar presentation. 11-Deoxycorticosterone (DOC) excess, which can occur in 11-β hydroxylase or 17-α hydroxylase deficiencies, in DOC-producing adrenocortical tumours or in patients taking 11-β hydroxylase inhibitors, may cause mineralocorticoid hypertension. We report a 35-year-old woman who in the third trimester of pregnancy was found to have a large adrenal mass on routine obstetric ultrasound. On referral to our unit, persistent hypertension and long-standing hypokalaemia was noted, despite good compliance with multiple antihypertensives. Ten years earlier, she had hypertension noted in pregnancy which had persisted after delivery. A MRI scan confirmed the presence of a 12 cm adrenal mass and biochemistry revealed high levels of DOC and low/normal renin, aldosterone and dehydroepiandrosterone, with normal catecholamine levels. The patient was treated with antihypertensives until obstetric delivery, following which she underwent an adrenalectomy. Histology confirmed a large adrenal cortical neoplasm of uncertain malignant potential. Postoperatively, blood pressure and serum potassium normalised, and the antihypertensive medication was stopped. Over 10 years of follow-up, she remains asymptomatic with normal DOC measurements. This case should alert clinicians to the possibility of a diagnosis of a DOC-producing adrenal tumours in patients with adrenal nodules and apparent mineralocorticoid hypertension in the presence of low or normal levels of aldosterone. The associated diagnostic and management challenges are discussed. Learning points: Hypermineralocorticoidism is characterised by hypertension, volume expansion and hypokalaemic alkalosis and is most commonly due to overproduction of aldosterone. However, excess of other mineralocorticoid products, such as DOC, lead to the same syndrome but with normal or low aldosterone levels. The differential diagnosis of resistant hypertension with low renin and low/normal aldosterone includes congenital adrenal hyperplasia, syndrome of apparent mineralocorticoid excess, Cushing's syndrome, Liddle's syndrome and 11-deoxycorticosterone-producing tumours. DOC is one intermediate product in the mineralocorticoid synthesis with weaker activity than aldosterone. However, marked DOC excess seen in 11-β hydroxylase or 17-α hydroxylase deficiencies in DOC-producing adrenocortical tumours or in patients taking 11-β hydroxylase inhibitors, may cause mineralocorticoid hypertension. Excessive production of DOC in adrenocortical tumours has been attributed to reduced activity of the enzymes 11-β hydroxylase and 17-α hydroxylase and increased activity of 21-α hydroxylase. The diagnosis of DOC-producing adrenal tumours is challenging because of its rarity and poor availability of DOC laboratory assays.
Collapse
Affiliation(s)
- Pedro Marques
- Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London, UK
| | - Nicola Tufton
- Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London, UK
| | - Satya Bhattacharya
- Hepatobiliary and Pancreatic Surgery Unit, The Royal London Hospital, London, UK
| | - Mark Caulfield
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Scott A Akker
- Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London, UK
| |
Collapse
|
4
|
Salter SJ, Cook P, Davies JH, Armston AE. Analysis of 17 α-hydroxyprogesterone in bloodspots by liquid chromatography tandem mass spectrometry. Ann Clin Biochem 2014; 52:126-34. [DOI: 10.1177/0004563214530676] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Monitoring of treatment for patients diagnosed with congenital adrenal hyperplasia (CAH) can be performed by measuring the concentration of 17α-hydroxyprogesterone (17OHP) in bloodspots collected on filter papers. A method is described here for measuring 17OHP by liquid chromatography tandem mass spectrometry (LCMSMS). Methods 17OHP was extracted by liquid–liquid extraction and analysed by LCMSMS. The method was validated for sensitivity, specificity, linearity, recovery, ion suppression, precision and bias. Results The standard curve was linear from 0 to 400 nmol/L. Intra-assay %CVs were <10 and inter-assay %CVs were <15 over the range 10–200 nmol/L. Limit of quantitation was 6 nmol/L. No ion suppression was detected. The only interfering compound detected was deoxycorticosterone, an intermediate steroid with the same molecular weight as 17α-hydroxyprogesterone. The method was more accurate and precise than an existing radioimmunoassay. There was poor correlation between the two assays. Conclusions We have developed a sensitive and specific assay suitable for quantitation of 17OHP in bloodspots. This method performs better than radioimmunoassay and allows smaller samples to be used.
Collapse
Affiliation(s)
| | - Paul Cook
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Justin H Davies
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Annie E Armston
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|