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Zhu C, Cai S, Zhong X, Huang L. Pregnancies complicated with functioning adrenal adenomas causing severe obstetric outcomes: a 20-year experience at a tertiary center. BMC Endocr Disord 2024; 24:122. [PMID: 39044264 PMCID: PMC11267956 DOI: 10.1186/s12902-024-01655-9] [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: 08/03/2023] [Accepted: 07/15/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Functioning adrenal adenoma during pregnancy is rare, and the diagnosis is challenging owing to unspecific symptoms and restricted investigations. The obstetric outcomes of patients who undergo surgery during pregnancy or who receive only medical treatment are poorly described. OBJECTIVE The aim was to investigate the associations between functioning adrenal adenomas and obstetric outcomes. METHODS A retrospective study was performed in a tertiary center over 20 years. The clinical characteristics, management and obstetric outcomes of the diagnosed pregnant women were reviewed. RESULTS A total of 12 women were diagnosed with functioning adrenal adenomas during pregnancy from January 2002 to September 2022. Eight women had cortisol-secreting adrenal adenomas, two had excessive catecholamine secretion, and two had primary aldosteronism. The initial symptoms of adrenal adenoma during pregnancy included hypertension or preeclampsia, gestational diabetes mellitus or prepregnancy diabetes mellitus, hypokalemia and ecchymosis. Four women underwent adrenalectomy during pregnancy, while 8 women received only medical therapy. Preterm birth occurred in all patients who received medicine, whereas 1 patient who underwent surgery experienced preterm birth. Among the 8 women in the medical treatment group, 3 had neonates who died. CONCLUSIONS Once hypertension, hyperglycemia and hypokalemia occur during the 1st or 2nd trimester, pregnant women with adrenal adenomas should be evaluated via laboratory and imaging examinations. The maternal and fetal outcomes were unpredictable owing to the severity of adrenal adenoma, particularly in patients who received only medical treatment. Adrenalectomy should be recommended during pregnancy.
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Affiliation(s)
- Caixia Zhu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan er Road, No.58, Guangzhou, 510080, China
| | - Shiqin Cai
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan er Road, No.58, Guangzhou, 510080, China
| | - Xue Zhong
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan er Road, No.58, Guangzhou, 510080, China
| | - Linhuan Huang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan er Road, No.58, Guangzhou, 510080, China.
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2
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Cholekho S, Liu Y, Tan H. Cushing's syndrome during pregnancy - two case reports. Front Endocrinol (Lausanne) 2024; 15:1326496. [PMID: 38532898 PMCID: PMC10963388 DOI: 10.3389/fendo.2024.1326496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/28/2024] [Indexed: 03/28/2024] Open
Abstract
Background Cushing's syndrome (CS) during pregnancy is a rare endocrine disorder characterized by hypercortisolism, which is significantly associated with maternal-fetal complications. Despite its rarity, CS during pregnancy may be related to a high risk of complications for both the mother and fetus.The aim of the present case study is to update the diagnostic approach to CS during pregnancy and the therapeutic strategies for this medical condition to minimize maternal-fetal complications. Methods Here, we present two cases of CS in pregnant women, one of whom had twins. Typical clinical symptoms and signs of hypercortisolism developed at the beginning of pregnancy. The plasma cortisol diurnal rhythm of the pregnant patient was absent. CS was confirmed by cortisol and adrenocorticotropic hormone (ACTH) assessment, as well as imaging examination. We investigated the changes in the hypothalamic-pituitary-adrenal axis during normal pregnancy and the etiology, diagnosis and treatment of CS during pregnancy. Conclusion Due to the associated risks of laparoscopic adrenalectomy,it is uncertain whether this treatment significantly decreases overall maternal mortality. Additional observational research and validation through randomized controlled trials (RCTs) are required. We advise that CS in pregnant women be diagnosed and treated by experienced teams in relevant departments and medical centers.
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Affiliation(s)
| | | | - Huiwen Tan
- Division of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
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3
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Zhekov Z, Radeva SY, Yankov YG. Cushing's Syndrome and a Dead Fetus in Pregnancy: A Clinical Case and Behavior Report. Cureus 2024; 16:e56769. [PMID: 38650766 PMCID: PMC11033964 DOI: 10.7759/cureus.56769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024] Open
Abstract
Cushing's syndrome is a rare disease that has a different primary etiology, most often due to chronic hypercortisolism. In addition to the defined causes, in contrast to the general population, the observed etiology in pregnant women is a benign adrenocortical adenoma, less often bilateral hyperplasia of the adrenal glands of hypothalamic-pituitary origin or Cushing's disease, and malignant adrenal root adenoma. In this study, we present the case of a 41-year-old pregnant woman experiencing her first pregnancy. Her general diseases from anamnesis were chronic obstructive pyelonephritis, acute rhythm disturbance, somnolence, pituitary adenoidectomy, and adrenalectomy of both adrenal glands. The patient was obese, with a BMI of 31.25 kg/m2. She sought medical help due to fatigue, anuria, vomiting, a fever of up to 38.9°C, and hypertension. In the 18th gestational week, fetal death was diagnosed. The fever persisted for several days, and the patient had a malaise and became intoxicated with evidence of sepsis. She was hospitalized at two medical facilities for clarification. In the Department of Gynecology at the Specialized Hospital for Obstetrics and Gynecology in Varna, Bulgaria, a cesarean section was performed. The patient's condition remained stable after surgery. She was referred to a central intensive care unit for follow-up.
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Affiliation(s)
- Zhivko Zhekov
- Department of Gynecology, Specialized Hospital of Obstetrics and Gynecology for Active Treatment, Varna, BGR
- Department of Obstetrics and Gynecology, Medical University "Prof. Dr. Paraskev Stoyanov", Varna, BGR
| | - Svetlana Y Radeva
- Department of Gynecology, Specialized Hospital of Obstetrics and Gynecology for Active Treatment, Varna, BGR
- Faculty of Public Health, Medical University "Prof. Dr. Paraskev Stoyanov", Varna, BGR
| | - Yanko G Yankov
- Clinic of Maxillofacial Surgery, University Hospital "St. Marina", Varna, BGR
- Department of General and Operative Surgery, Medical University "Prof. Dr. Paraskev Stoyanov", Varna, BGR
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4
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Li Y, Lin J, Fu S, Li L, Huang Z, Yang H, Liang X, Qin Y, Zhou J, Liu D, Luo Z. The mystery of transient pregnancy-induced cushing's syndrome: a case report and literature review highlighting GNAS somatic mutations and LHCGR overexpression. Endocrine 2024; 83:473-482. [PMID: 37828397 DOI: 10.1007/s12020-023-03549-7] [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: 07/10/2023] [Accepted: 09/23/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE Transient pregnancy-induced Cushing's syndrome is a rare condition characterized by the manifestation of symptoms solely during pregnancy, which typically resolve spontaneously following delivery or miscarriage. While it has been established that GNAS is associated with adrenal tumors, its specific role in the pathogenesis of pregnancy-induced Cushing's syndrome remains uncertain.This work aims to examine the association between GNAS mutation and pregnancy-induced Cushing's syndrome. METHODS DNA was extracted from patients' peripheral blood and tumor tissues for whole-exome sequencing (WES) and Sanger sequencing. We used AlphaFold to predict the protein structure of wild-type and mutant GNAS and to make functional predictions, and immunohistochemistry was used to detect disease-associated protein expression. A review and summary of reported cases of transient pregnancy-induced Cushing's syndrome induced by pregnancy was conducted. RESULTS Using WES, we identified a somatic mutation in GNAS (NM_000516, c.C601T, p.R201C) that was predicted to have a deleterious effect using computational methods, such as AlphaFold. Human chorionic gonadotropin (hCG) stimulation tests had weakly positive results, and immunohistochemical staining of adrenal adenoma tissue also revealed positivity for luteinizing hormone/chorionic gonadotropin receptor (LHCGR) and cytochrome P450 family 11 subfamily B member 1 (CYP11B1). We reviewed 15 published cases of transient Cushing's syndrome induced by pregnancy. Among these cases, immunohistochemical staining of the adrenal gland showed positive LHCGR expression in 3 case reports, similar to our findings. CONCLUSION Transient pregnancy-induced Cushing's syndrome may be associated with somatic GNAS mutations and altered adrenal pathology due to abnormal activation of LHCGR.
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Affiliation(s)
- Yufei Li
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Jianfan Lin
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Shien Fu
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Li Li
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Zhenxing Huang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Haiyan Yang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Xinghuan Liang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Yingfen Qin
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Jia Zhou
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Deyun Liu
- Department of Urology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China
| | - Zuojie Luo
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, P. R. China.
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5
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Xu S, Liu M, Xu J, Che B, Zhang W, Li W, Huang T, Yu Y, Zha C, Peng Z, Huang K, Tang K. Pregnancy complicated with adrenal adenoma causing ACTH-independent Cushing's syndrome, accompanied by obstetric antiphospholipid syndrome and severe pre-eclampsia: case report and literature review. Front Endocrinol (Lausanne) 2023; 14:1147316. [PMID: 37274343 PMCID: PMC10235702 DOI: 10.3389/fendo.2023.1147316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
This case report shares the management experience of a patient with pregnancy combined with adrenal adenoma causing ACTH-independent Cushing's syndrome (CS), accompanied by obstetric antiphospholipid syndrome (OAPS) and severe pre-eclampsia. The case was a 26-year-old that presented with typical clinical symptoms and signs of CS. The patient had a history of 4 spontaneous abortions in the last 4 years. The 24-hour urinary free cortisol was significantly increased, an abnormal cortisol circadian rhythm was demonstrated by a high late-night salivary cortisol, blood ACTH was suppressed (< 1ng/dL), anticardiolipin antibody was positive, and imaging examination showed an adrenal tumor. The patient underwent laparoscopic adrenal tumor resection under general anesthesia at 23 weeks of gestation. The tumor was pathologically confirmed to be an adrenocortical adenoma. The patient underwent a cesarean section at 39 weeks of gestation to give birth to a healthy baby girl with an Apgar score of 10. Pregnancy complicated by CS is clinically rare, easily masked by normal physiological changes of pregnancy, and is difficult to diagnose. The determination of 24-hour urinary free cortisol, the circadian rhythm of serum cortisol, ultrasound, and MRI can be helpful in the diagnosis of CS during pregnancy. Surgery is the first choice for the treatment of CS during pregnancy. As a subtype of antiphospholipid syndrome, patients with OAPS are prone to thrombotic events and recurrent miscarriages if not treated accordingly. To our knowledge no cases of CS with OAPS and severe pre-eclampsia have been reported. We summarize the experience of the treatment of this patient and review the literature to improve clinicians' awareness of this disease.
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Affiliation(s)
- Shenghan Xu
- Department of Urology and Andrology, the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Miao Liu
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Jiamu Xu
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Bangwei Che
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Wenjun Zhang
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Wei Li
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Tao Huang
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Ying Yu
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Cheng Zha
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Zheng Peng
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Kunyuan Huang
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
| | - Kaifa Tang
- Department of Urology and Andrology, the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
- The Clinical Medical College of Guizhou Medical University, Guiyang, China
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6
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Younes N, St-Jean M, Bourdeau I, Lacroix A. Endogenous Cushing's syndrome during pregnancy. Rev Endocr Metab Disord 2023; 24:23-38. [PMID: 35670990 DOI: 10.1007/s11154-022-09731-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2022] [Indexed: 02/01/2023]
Abstract
Endogenous Cushing's syndrome (CS) is rare during pregnancy, probably because hypercortisolism induces anovulation and infertility. To date, slightly above 200 cases have been reported in the literature. The most frequent etiology of CS diagnosed during gestation is from primary adrenal causes, namely adrenal adenomas and an entity called pregnancy-induced CS. The latter can be secondary to the aberrant adrenal expression of luteinizing hormone/human chorionic gonadotropin receptor (LHCGR) in the adrenal lesions. Diagnosis of CS during pregnancy is extremely challenging, as a consequence of the physiologic hypercortisolism normally present during pregnancy. Assessment of excess cortisol production tests should be interpreted cautiously using adapted upper limits of normal criteria for pregnant patients and a high index of suspicion is required for diagnosis. Imaging is also limited due to high risk of radiation exposure with computed tomography and teratogenicity with contrast agents. The optimal treatment strategy is surgical resection of adrenal adenoma or pituitary adenoma, ideally before 24 weeks of gestation to reduce the risk of maternal and fetal complications. In mild cases, surgery can be postponed until after delivery and treatment should focus on controlling metabolic complications of hypercortisolism, such as hypertension and dysglycemia. Maternal and fetal outcomes of excess cortisol exposure, except fetal loss, are not readily improved by successful treatment of hypercortisolism.
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Affiliation(s)
- Nada Younes
- Division of Endocrinology, Department of Medicine Research Center, Centre hospitalier de l'Université de Montréal (CHUM), CHUM 900 Saint-Denis Street, H2X 0A9, Montréal, Québec, Canada
| | - Matthieu St-Jean
- Division of Endocrinology, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine Research Center, Centre hospitalier de l'Université de Montréal (CHUM), CHUM 900 Saint-Denis Street, H2X 0A9, Montréal, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine Research Center, Centre hospitalier de l'Université de Montréal (CHUM), CHUM 900 Saint-Denis Street, H2X 0A9, Montréal, Québec, Canada.
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7
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Olinger K, Maheshwari E, Shenoy-Bhangle AS, Adejolu M, McGettigan M, Mathew H, Lee KS, Nicola R. Mimics of cancer in pregnancy. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 48:1752-1773. [PMID: 36577923 DOI: 10.1007/s00261-022-03783-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/30/2022]
Abstract
Pregnancy is a remarkable time of pronounced growth and development of the fetus. Benign pathologies outside of the uterus, including those containing hormonally responsive tissue which undergo physiologic changes and other incidentally identified lesions, may mimic malignancy on clinical evaluation and imaging. A detailed history and physical exam, ultrasound and non-contrast magnetic resonance imaging features and comparison with prior imaging if available may help to narrow the list of potential differential diagnoses. Follow-up imaging in the postpartum period is often vital to confirm benignity and, in some cases, sampling to confirm the diagnosis is necessary. This review will cover the clinical, pathological and multimodality imaging features of numerous potential mimickers of cancer in the setting of pregnancy organized by organ systems. The goal is to better equip abdominal radiologists to accurately identify benign disease and help guide further imaging or follow-up recommendations to avoid unnecessarily aggressive intervention and improve patient care.
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Affiliation(s)
- Kristen Olinger
- Division of Abdominal Radiology, Department of Radiology, University of North Carolina at Chapel Hill, 2021 Old Clinic Building, Chapel Hill, NC, 27599, USA.
| | - Ekta Maheshwari
- Division of Abdominal Imaging, Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, 15143, USA
| | - Anuradha S Shenoy-Bhangle
- Division of Abdominal Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, 02214, USA
| | - Margaret Adejolu
- Department of Radiology, The Royal Marsden Hospital, London, England, UK
| | | | | | - Karen S Lee
- Division of Abdominal Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Refky Nicola
- Division of Abdominal Imaging, Department of Radiology, SUNY Upstate Medical University, Syracuse, NY, 13210, USA
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8
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Bertherat J, Bourdeau I, Bouys L, Chasseloup F, Kamenicky P, Lacroix A. Clinical, pathophysiologic, genetic and therapeutic progress in Primary Bilateral Macronodular Adrenal Hyperplasia. Endocr Rev 2022:6957368. [PMID: 36548967 DOI: 10.1210/endrev/bnac034] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/07/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) usually present bilateral benign adrenocortical macronodules at imaging and variable levels of cortisol excess. PBMAH is a rare cause of primary overt Cushing's syndrome, but may represent up to one third of bilateral adrenal incidentalomas with evidence of cortisol excess. The increased steroidogenesis in PBMAH is often regulated by various G-protein coupled receptors aberrantly expressed in PBMAH tissues; some receptor ligands are ectopically produced in PBMAH tissues creating aberrant autocrine/paracrine regulation of steroidogenesis. The bilateral nature of PBMAH and familial aggregation, led to the identification of germline heterozygous inactivating mutations of the ARMC5 gene, in 20-25% of the apparent sporadic cases and more frequently in familial cases; ARMC5 mutations/pathogenic variants can be associated with meningiomas. More recently, combined germline mutations/pathogenic variants and somatic events inactivating the KDM1A gene were specifically identified in patients affected by GIP-dependent PBMAH. Functional studies demonstrated that inactivation of KDM1A leads to GIP-receptor (GIPR) overexpression and over or down-regulation of other GPCRs. Genetic analysis is now available for early detection of family members of index cases with PBMAH carrying identified germline pathogenic variants. Detailed biochemical, imaging, and co-morbidities assessment of the nature and severity of PBMAH is essential for its management. Treatment is reserved for patients with overt or mild cortisol/aldosterone or other steroid excesses taking in account co-morbidities. It previously relied on bilateral adrenalectomy; however recent studies tend to favor unilateral adrenalectomy, or less frequently, medical treatment with cortisol synthesis inhibitors or specific blockers of aberrant GPCR.
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Affiliation(s)
- Jerôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Lucas Bouys
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Fanny Chasseloup
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - Peter Kamenicky
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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Monoamine Neurotransmitters Control Basic Emotions and Affect Major Depressive Disorders. Pharmaceuticals (Basel) 2022; 15:ph15101203. [PMID: 36297314 PMCID: PMC9611768 DOI: 10.3390/ph15101203] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Major depressive disorder (MDD) is a common and complex mental disorder, that adversely impacts an individual’s quality of life, but its diagnosis and treatment are not accurately executed and a symptom-based approach is utilized in most cases, due to the lack of precise knowledge regarding the pathophysiology. So far, the first-line treatments are still based on monoamine neurotransmitters. Even though there is a lot of progress in this field, the mechanisms seem to get more and more confusing, and the treatment is also getting more and more controversial. In this study, we try to review the broad advances of monoamine neurotransmitters in the field of MDD, and update its effects in many advanced neuroscience studies. We still propose the monoamine hypothesis but paid special attention to their effects on the new pathways for MDD, such as inflammation, oxidative stress, neurotrophins, and neurogenesis, especially in the glial cells, which have recently been found to play an important role in many neurodegenerative disorders, including MDD. In addition, we will extend the monoamine hypothesis to basic emotions; as suggested in our previous reports, the three monoamine neurotransmitters play different roles in emotions: dopamine—joy, norepinephrine—fear (anger), serotonins—disgust (sadness). Above all, this paper tries to give a full picture of the relationship between the MDD and the monoamine neurotransmitters such as DA, NE, and 5-HT, as well as their contributions to the Three Primary Color Model of Basic Emotions (joy, fear, and disgust). This is done by explaining the contribution of the monoamine from many sides for MDD, such the digestive tract, astrocytes, microglial, and others, and very briefly addressing the potential of monoamine neurotransmitters as a therapeutic approach for MDD patients and also the reasons for its limited clinical efficacy, side effects, and delayed onset of action. We hope this review might offer new pharmacological management of MDD.
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10
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Hamblin R, Coulden A, Fountas A, Karavitaki N. The diagnosis and management of Cushing's syndrome in pregnancy. J Neuroendocrinol 2022; 34:e13118. [PMID: 35491087 PMCID: PMC9541401 DOI: 10.1111/jne.13118] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/01/2022] [Accepted: 03/05/2022] [Indexed: 11/28/2022]
Abstract
Endogenous Cushing's syndrome (CS) is rarely encountered during pregnancy. Clinical and biochemical changes in healthy pregnancy overlap with those seen in pregnancy complicated by CS; the diagnosis is therefore challenging and can be delayed. During normal gestation, adrenocorticotrophic hormone, corticotrophin-releasing hormone, cortisol, and urinary free cortisol levels rise. Dexamethasone administration fails to fully suppress cortisol in pregnant women without CS. Localisation may be hindered by non-suppressed adrenocorticotrophic hormone levels in a large proportion of those with adrenal CS; smaller corticotroph adenomas may go undetected as a result of a lack of contrast administration or the presence of pituitary hyperplasia; and inferior petrosal sinus sampling is not recommended given the risk of radiation and thrombosis. Yet, diagnosis is essential; active disease is associated with multiple insults to both maternal and foetal health, and those cured may normalise the risk of maternal-foetal complications. The published literature consists mostly of case reports or small case series affected by publication bias, heterogeneous definitions of maternal or foetal outcomes or lack of detail on severity of hypercortisolism. Consequently, conclusive recommendations, or a standardised management approach for all, cannot be made. Management is highly individualised: the decision for surgery, medical control of hypercortisolism or adoption of a conservative approach is dependent on the timing of diagnosis (respective to stage of gestation), the ability to localise the tumour, severity of CS, pre-existing maternal comorbidity, and, ultimately, patient choice. Close communication is a necessity with the patient placed at the centre of all decisions, with risks, benefits, and uncertainties around any investigation and management carefully discussed. Care should be delivered by an experienced, multidisciplinary team, with the resources and expertise available to manage such a rare and challenging condition during pregnancy.
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Affiliation(s)
- Ross Hamblin
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Amy Coulden
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Athanasios Fountas
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Centre for Endocrinology, Diabetes and MetabolismBirmingham Health PartnersBirminghamUK
- Department of Endocrinology, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
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11
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A Rare Occurrence of Premature Birth and Recurrent Acute Pulmonary Oedema in the Mother due to Cushing's Syndrome: A Case Report. J ASEAN Fed Endocr Soc 2021; 36:200-204. [PMID: 34966205 PMCID: PMC8666499 DOI: 10.15605/jafes.036.02.04] [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: 02/25/2021] [Accepted: 06/18/2021] [Indexed: 11/17/2022] Open
Abstract
Presentation of Cushing's syndrome during pregnancy is extremely rare. We report a 21-year-old female with Cushing's syndrome diagnosed at 23 weeks of gestation and had recurrent acute pulmonary oedema during the antepartum and postpartum period. She delivered prematurely via emergency caesarean section at 28 weeks of gestation. This case highlights the rare occurrence of recurrent acute pulmonary oedema during pregnancy and consequential premature birth in a patient with adrenal Cushing's. She was diagnosed with adrenal Cushing's during the postpartum period based on unsuppressed serum cortisol after overnight and low-dose dexamethasone suppression test with a suppressed ACTH. CT scan of the adrenal glands revealed a right adrenal cortical adenoma. The risk of complications in infants and mothers who suffer from Cushing's syndrome needs to be handled carefully. The diagnosis of Cushing's syndrome in pregnant women often overlaps and is difficult to establish in early pregnancy.
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12
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Wang C, Sun Y, Yin X, Feng R, Feng R, Xu M, Liang K, Zhao R, Gu G, Jiang X, Su P, Zhang X, Liu J. Alterations of DNA methylation were associated with the rapid growth of cortisol-producing adrenocortical adenoma during pregnancy. Clin Epigenetics 2021; 13:213. [PMID: 34863285 PMCID: PMC8642905 DOI: 10.1186/s13148-021-01205-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/26/2021] [Indexed: 02/04/2023] Open
Abstract
Background Cortisol-producing adrenocortical adenoma (CPA) during pregnancy rarely occurs in clinic. Growing evidence suggests that DNA methylation plays a key role in adrenocortical adenomas. The present study aims to examine the genome-wide DNA methylation profiles and identify the differences in DNA methylation signatures of non-pregnant and pregnant patients with CPA. Results Four pregnant and twelve non-pregnant patients with CPA were enrolled. The pregnant patients with CPA had higher serum cortisol, Estradiol, Progesterone, and human chorionic gonadotropin concentration, while having lower serum FSH (follicle-stimulating hormone) and luteinizing hormone concentrations (P < 0.01). Compared with the non-pregnant patients, the duration is shorter, and the growth rate of the tumor is faster in pregnant patients with CPA (P < 0.05). Morphology and cell proliferation assay showed that the percentage of Ki-67 positive cells in CPA were higher in pregnant group than non-pregnant group (8.0% vs 5.5%, P < 0.05). The DNA methylation analysis showed that Genome-wide DNA methylation signature difference between pregnant and non-pregnant with CPA, that the pregnant group had more hypermethylated DMPs (67.94% vs 22.16%) and less hypomethylated DMPs (32.93% vs 77.84%). The proportion of hypermethylated DMPs was relatively high on chromosomes 1 (9.68% vs 8.67%) and X (4.99% vs 3.35%) but lower on chromosome 2(7.98% vs 12.92%). In pregnant patients with CPA, 576 hypomethylated DMPs and 1109 hypermethylated DMPs were identified in the DNA promoter region. Bioinformatics analysis indicated that the Wnt/β-Catenin pathway, Ras/MAPK Pathway and PI3K-AKT Pathway were associated with the development of CPA during pregnancy. Conclusions Genome-wide DNA methylation profiling of CPA in non-pregnant and pregnant patients was identified in the present study. Alterations of DNA methylation were associated with the pathogenesis and exacerbation of CPA during pregnancy. Supplementary Information The online version contains supplementary material available at 10.1186/s13148-021-01205-3.
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Affiliation(s)
- Chuan Wang
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.,Institute of Endocrine and Metabolic Diseases, Shandong University, Jinan, 250012, Shandong Province, People's Republic of China.,Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, 250012, Shandong Province, People's Republic of China
| | - Yujing Sun
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.,Institute of Endocrine and Metabolic Diseases, Shandong University, Jinan, 250012, Shandong Province, People's Republic of China.,Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, 250012, Shandong Province, People's Republic of China
| | - Xiaofei Yin
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.,Institute of Endocrine and Metabolic Diseases, Shandong University, Jinan, 250012, Shandong Province, People's Republic of China.,Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, 250012, Shandong Province, People's Republic of China
| | - Ruoqi Feng
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.,Institute of Endocrine and Metabolic Diseases, Shandong University, Jinan, 250012, Shandong Province, People's Republic of China.,Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, 250012, Shandong Province, People's Republic of China
| | - Ruiying Feng
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.,Institute of Endocrine and Metabolic Diseases, Shandong University, Jinan, 250012, Shandong Province, People's Republic of China.,Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, 250012, Shandong Province, People's Republic of China
| | - Mingyue Xu
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.,Institute of Endocrine and Metabolic Diseases, Shandong University, Jinan, 250012, Shandong Province, People's Republic of China.,Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, 250012, Shandong Province, People's Republic of China
| | - Kai Liang
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.,Institute of Endocrine and Metabolic Diseases, Shandong University, Jinan, 250012, Shandong Province, People's Republic of China.,Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, 250012, Shandong Province, People's Republic of China
| | - Ruxing Zhao
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.,Institute of Endocrine and Metabolic Diseases, Shandong University, Jinan, 250012, Shandong Province, People's Republic of China.,Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, 250012, Shandong Province, People's Republic of China
| | - Gangli Gu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, 250012, People's Republic of China
| | - Xuewen Jiang
- Department of Urology, Qilu Hospital of Shandong University, Jinan, 250012, People's Republic of China
| | - Peng Su
- Department of Pathology, Qilu Hospital of Shandong University, Jinan, 250012, People's Republic of China
| | - Xiaofang Zhang
- Department of Pathology, Qilu Hospital of Shandong University, Jinan, 250012, People's Republic of China
| | - Jinbo Liu
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China. .,Institute of Endocrine and Metabolic Diseases, Shandong University, Jinan, 250012, Shandong Province, People's Republic of China. .,Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Jinan, 250012, Shandong Province, People's Republic of China.
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13
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Grossman A. Thought for food: a Cushing's syndrome enigma explained. Lancet Diabetes Endocrinol 2021; 9:800-801. [PMID: 34655520 DOI: 10.1016/s2213-8587(21)00237-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Ashley Grossman
- Centre for Endocrinology, Barts and the London School of Medicine, Queen Mary University of London, London EC1M 6BQ, UK; Green Templeton College, University of Oxford, Oxford, UK.
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14
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Serati M, Grassi S, Redaelli M, Pergoli L, Cantone L, La Vecchia A, Barkin JL, Colombo E, Tiso G, Abbiati C, Bollati V, Buoli M. Is There an Association Between Oxytocin Levels in Plasma and Pregnant Women's Mental Health? J Am Psychiatr Nurses Assoc 2021; 27:222-230. [PMID: 31782341 DOI: 10.1177/1078390319890400] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND: Mood and anxiety disorders are prevalent in women during peripartum. AIMS: Purpose of the present article was to study the relationship between oxytocin (OT) plasma levels and affective symptoms in women during the third trimester of pregnancy. METHODS: Thirty-four pregnant women (13 with an affective disorder, 9 with preeclampsia, and 12 controls) were evaluated through the Edinburgh Postnatal Depression Scale (EPDS), the State/Trait Anxiety Inventory Form Y (STAI-Y), and the Prenatal Attachment Inventory (PAI). A blood sample was collected from all participants, and OT plasma levels have been compared between diagnostic groups. The total sample has been divided into two groups, according to OT median plasma levels, and compared using (a) χ2 tests for qualitative variables and (b) a multivariate analysis of covariance for quantitative ones. RESULTS: No statistically significant difference was found among the diagnostic groups in terms of OT plasma levels (F = 0.49, p = .62). Women with lower OT plasma levels, independent from the presence of preeclampsia or an affective disorder, showed worse EPDS and STAI-S total scores than individuals with higher hormone levels (F = 5.93, p = .02 and F = 7.57, p = .01, respectively). CONCLUSIONS: OT may play a role in the etiology of anxious/depressive symptoms during perinatal period independent from a medical or psychiatric diagnosis. This result has a clear effect on the quality of the relationship of patients with mental health professionals, including nurses, and higher levels of this hormone, in the light of its anxiolytic and antidepressive effect, may make easier medical and nursing procedures.
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Affiliation(s)
- Marta Serati
- Marta Serati, MD, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Grassi
- Silvia Grassi, MD, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Redaelli
- Marta Redaelli, PsyD, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Pergoli
- Laura Pergoli, ScD, University of Milan, Milan, Italy
| | - Laura Cantone
- Laura Cantone, ScD, University of Milan, Milan, Italy
| | - Adriano La Vecchia
- Adriano La Vecchia, MD, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jennifer L Barkin
- Jennifer L. Barkin, PhD, Mercer University School of Medicine, Macon, GA, USA
| | - Elisa Colombo
- Elisa Maria Colombo, MD, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Tiso
- Giulia Tiso, MD, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Cristina Abbiati
- Cristina Abbiati, PMHCNS, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Massimiliano Buoli
- Massimiliano Buoli, MD, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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15
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Benothman W, Saad G, Kacem M, Ach K. Three Successful Pregnancies in a Patient with Recurrent Cushing's Disease. Case Rep Endocrinol 2021; 2021:5517303. [PMID: 33628528 PMCID: PMC7899752 DOI: 10.1155/2021/5517303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 11/30/2022] Open
Abstract
The association of pregnancy and Cushing's disease (CD) is rare. A 28-year-old woman was admitted for clinical suspicion of Cushing's syndrome. The investigations confirmed the diagnosis of CD with secondary hypogonadotropic hypogonadism due to an invasive pituitary macroadenoma. The patient underwent transsphenoidal adenomectomy, and histopathology showed an adrenocorticotropic hormone pituitary adenoma. Initial remission of CD ensued, and fertility was restored as the patient had 2 uncomplicated pregnancies. Five years and 10 months after surgery, a third spontaneous pregnancy was confirmed with underlying recurrent CD. Having mild hypercortisolism, CD was managed expectantly. The outcome was a healthy full-term neonate with no maternal complications during pregnancy or labor. Our case highlights the challenge faced by physicians of choosing the optimal approach to active CD in pregnancy. In cases where maternal and fetal complications are mild, conservative approach may be used and specific treatment can be postponed until after delivery.
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Affiliation(s)
- W. Benothman
- Endocrinology Unit, Department of Endocrinology, Farhat Hached University Hospital, Avenue Ibn El Jazzar, Sousse 4000, Tunisia
| | - G. Saad
- Endocrinology Unit, Department of Endocrinology, Farhat Hached University Hospital, Avenue Ibn El Jazzar, Sousse 4000, Tunisia
| | - M. Kacem
- Endocrinology Unit, Department of Endocrinology, Farhat Hached University Hospital, Avenue Ibn El Jazzar, Sousse 4000, Tunisia
| | - K. Ach
- Endocrinology Unit, Department of Endocrinology, Farhat Hached University Hospital, Avenue Ibn El Jazzar, Sousse 4000, Tunisia
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16
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Azzola A, Eastabrook G, Matsui D, Berberich A, Tirona RG, Gray D, Gallego P, Van Uum S. Adrenal Cushing Syndrome Diagnosed During Pregnancy: Successful Medical Management With Metyrapone. J Endocr Soc 2020; 5:bvaa167. [PMID: 33305159 PMCID: PMC7712789 DOI: 10.1210/jendso/bvaa167] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Indexed: 11/19/2022] Open
Abstract
Adrenal Cushing syndrome during pregnancy is rare, and there is limited information on the effect and safety of metyrapone treatment both for mother and fetus. We present a 24-year-old woman diagnosed with adrenal Cushing syndrome at the end of the second trimester. We elected treatment with metyrapone titrated to 250 mg 3 times daily, resulting in good clinical response and maternal serum and saliva cortisol levels in the upper half of the normal pregnancy range. A healthy male infant was born at 35 weeks’ gestation, with no clinical signs of adrenal insufficiency, this despite a low cortisol of 5 nmol/L on the first day of life. We measured metyrapone in maternal and umbilical cord blood samples, demonstrating fetal venous metyrapone levels similar to maternal venous concentration, and a fetal arterial cord concentration at about 60% of the fetal venous cord concentration. This case demonstrates that salivary cortisol levels may be used to monitor the effect of metyrapone on adrenal Cushing syndrome during pregnancy. We show, for the first time in humans, that metyrapone does cross the placenta and may suppress fetal cortisol production without necessarily causing clinical signs of adrenal insufficiency.
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Affiliation(s)
- Alescia Azzola
- Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Genevieve Eastabrook
- Obstetrics and Gynaecology, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Doreen Matsui
- Paediatrics, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Amanda Berberich
- Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Rommel G Tirona
- Physiology and Pharmacology, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Daryl Gray
- Surgery, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Patricia Gallego
- Paediatrics, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Stan Van Uum
- Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
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17
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Estrogen receptor α plays an important role in Cushing’s syndrome during pregnancy. Med Hypotheses 2020; 143:109817. [DOI: 10.1016/j.mehy.2020.109817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/22/2020] [Accepted: 05/05/2020] [Indexed: 11/18/2022]
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18
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Kersten M, Hancke K, Janni W, Kraft K. Pregnancy induced Cushing's syndrome and primary aldosteronism: a case report. BMC Pregnancy Childbirth 2020; 20:421. [PMID: 32711486 PMCID: PMC7382848 DOI: 10.1186/s12884-020-03117-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background First manifestation of Cushing’s syndrome during pregnancy is rare. The diagnosis of both Cushing’s and primary aldosteronism within a pregnancy has not been previously documented. Diagnosis is especially challenging due to the normal physiological changes that occur during pregnancy. Consequently, many tests that are normally used for diagnosis are not reliable. Tumor based etiologies can be surgically removed. Etiologies that are not tumor based are challenging to treat during pregnancy. Case presentation A 25 year old G1P0 was admitted in the 22 5/7 week of pregnancy with elevated blood pressure (200/100 mm Hg), acne, moon facies, abdominal striae and hirsutism. With five antihypertensive medications her blood pressure remained 190/100 mm Hg. The patient was admitted to the ICU for intravenous medications and monitoring. She was diagnosed with Cushing’s syndrome and primary aldosteronism. In spite of therapy with spironolactone and metyrapone she developed preeclampsia and was delivered in the 26 0/7 week of pregnancy. At her follow up visit eight weeks postpartum she had blood pressure within normal limits, no clinical signs or symptoms, and all medications had been discontinued. Conclusions Early diagnosis of pregnancy induced Cushing’s syndrome and primary aldosteronism requires an interdisciplinary approach. Late detection has been associated with increased perinatal morbidity and mortality including but not limited to placental abruption and intrauterine demise. Collaboration is essential in the optimization of maternal and fetal outcomes.
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Affiliation(s)
- Maria Kersten
- Department of Obstetrics and Gynecology, University of Ulm (Universitätsklinikum Ulm), Ulm, Germany
| | - Katharina Hancke
- Department of Obstetrics and Gynecology, University of Ulm (Universitätsklinikum Ulm), Ulm, Germany
| | - Wolfgang Janni
- Department of Obstetrics and Gynecology, University of Ulm (Universitätsklinikum Ulm), Ulm, Germany
| | - Katrina Kraft
- Department of Obstetrics and Gynecology, Munich Klinik Harlaching (München Klinik Harlaching), Munich, Germany.
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19
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Kim HB, Kim MK, Kim E, Ahn KS, Kim HS, Kim NK. Cushing syndrome in pregnancy, diagnosed after delivery. Yeungnam Univ J Med 2020; 38:60-64. [PMID: 32438534 PMCID: PMC7787896 DOI: 10.12701/yujm.2020.00290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/12/2020] [Indexed: 11/04/2022] Open
Abstract
Cushing syndrome (CS) is rare in pregnancy, and few cases have been reported to date. Women with untreated CS rarely become pregnant because of the ovulatory dysfunction induced by hypercortisolism. It is difficult to diagnose CS in pregnancy because of its very low incidence, the overlap between the clinical signs of hypercortisolism and the physiological changes that occur during pregnancy and the changes in hypothalamus-pituitary-adrenal axis activity that occur during pregnancy and limit the value of standard diagnostic testing. However, CS in pregnancy is associated with poor maternal and fetal outcomes; therefore, its early diagnosis and treatment are important. Here, we report two patients with CS that was not diagnosed during pregnancy, in whom maternal and fetal morbidity developed because of hypercortisolism.
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Affiliation(s)
- Han Byul Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Raphael Hospital, Daegu, Korea
| | - Mi Kyung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - El Kim
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Keun Soo Ahn
- Department of Surgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Hye Soon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Nam Kyung Kim
- Park Kyung Dae Clinic of Internal Medicine, Gyeongju, Korea
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20
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Gaujoux S, Hain É, Marcellin L, de Carbonnieres A, Goffinet F, Bertherat J, Dousset B. Adrenalectomy during pregnancy: A 15-year experience at a tertiary referral center. Surgery 2020; 168:335-339. [PMID: 32434659 DOI: 10.1016/j.surg.2020.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/18/2020] [Accepted: 03/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Adrenal lesions diagnosed during pregnancy remain rare, and their management is challenging because of maternal physiologic modifications, restricted imaging investigations, and contraindications to several treatments. Surgical issues of adrenalectomy during pregnancy and consequences on perinatal outcomes are poorly described. We therefore aimed to report maternal and fetal outcomes after adrenalectomy during pregnancy. METHODS All pregnant women who underwent adrenalectomy over a 15-year inclusion period were identified from a prospectively maintained database. Surgical management and maternal and fetal outcomes were reviewed. RESULTS From January 2003 to July 2018, a total of 12 women underwent adrenalectomy at a median gestation of 20 weeks. Of these women, 11 had hyper-secreting lesions, including 8 with cortisol oversecretion, and 11 had benign lesions, including cortisol-secreting adenoma (n = 5), pheochromocytoma (n = 2), primary pigmented, nodular adrenal disease (n = 1), severe Cushing's disease (n = 2), and hematoma (n = 1). A total of 3 patients with severe Cushing's disease (n = 2) and primary pigmented, nodular adrenal disease (n = 1) required bilateral adrenalectomy. One patient presented with a malignant adrenal Ewing sarcoma. Adrenalectomy during pregnancy was performed by the lateral laparoscopic transabdominal laparoscopic route in 9 patients. Postoperative morbidity occurred in 3 women. Maternal mortality was nil, but preterm birth occurred in 7 cases and intrauterine growth retardation was observed in 3 cases. Finally, among the 12 women, 10 had a child in good health. CONCLUSION During pregnancy, a lateral laparoscopic transabdominal approach is a feasible procedure. Maternal outcome is acceptable but fetal outcome is determined by the underlying disease, with a worse outcome when the adrenalectomy is indicated for malignant lesions or Cushing's syndrome.
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Affiliation(s)
- Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France.
| | - Élisabeth Hain
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Louis Marcellin
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gynecology Obstetrics and Reproductive Medicine, University Hospital Cochin, Assistance Publique - Hôpitaux de Paris (AP- HP), Paris, France
| | - Anne de Carbonnieres
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - François Goffinet
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gynecology Obstetrics and Reproductive Medicine, University Hospital Cochin, Assistance Publique - Hôpitaux de Paris (AP- HP), Paris, France
| | - Jérôme Bertherat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France; Department of Endocrinology, Cochin Hospital, APHP, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France
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21
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Li S, Yang C, Fan J, Yao Y, Lv X, Guo Y, Zhang S. Pregnancy-induced Cushing's syndrome with an adrenocortical adenoma overexpressing LH/hCG receptors: a case report. BMC Endocr Disord 2020; 20:62. [PMID: 32393232 PMCID: PMC7216527 DOI: 10.1186/s12902-020-0539-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pregnancy-induced Cushing's syndrome (CS) with an adrenocortical adenoma overexpressing luteinizing hormone (LH)/human choriogonadotropin (hCG) receptors (LHCGR) has been rarely reported in the literatures. This peculiar condition challenges the canonical diagnosis and management of CS. CASE PRESENTATION A 27-year-old woman (G2P0A1) presented at 20 weeks gestational age (GA) with overt Cushingoid clinical features. Adrenocorticotropic hormone (ACTH)-independent CS was diagnosed based on undetectable ACTH and unsuppressed cortisol levels by dexamethasone. Magnetic resonance imaging (MRI) scanning without contrast revealed a left adrenal nodule while pituitary MRI scanning was normal. A conservative treatment strategy of controlling Cushingoid comorbidities was conducted. At 36 weeks GA, a caesarean operation was performed and a live female infant was delivered. At 8 weeks after parturition, our patient achieved normalization of blood pressure, blood glucose, serum potassium, and urinary cortisol level spontaneously. During non-pregnancy period, stimulation testing with exogenous hCG significantly evoked a cortisol increase. The woman underwent resection of the adrenal tumor at 6 months after parturition. Immunohistochemistry (IHC) showed the tumor tissue that stained positive for luteinizing hormone (LH)/human choriogonadotropin (hCG) receptor (LHCGR), whereas negative for both melanocortin 2 receptor (MC2R) and G protein-coupled receptor-1 (GPER-1). CONCLUSIONS Stimulation test with exogenous hCG after parturition is necessary for the diagnosis of pregnancy-induced CS. LHCGR plays an essential role in the pathogenesis of this rare condition.
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Affiliation(s)
- Shaohua Li
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Chen Yang
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Jing Fan
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Yao Yao
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Xiaomei Lv
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Ying Guo
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China
| | - Shaoling Zhang
- Department of Endocrinology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, 510120, China.
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22
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Ildefonso-Najarro SP, Plasencia-Dueñas EA, Benites-Moya CJ, Carrion-Rojas J, Concepción-Zavaleta MJ. Pregnancy during the course of Cushing's syndrome: a case report and literature review. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200022. [PMID: 32478666 PMCID: PMC7159255 DOI: 10.1530/edm-20-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 03/23/2020] [Indexed: 02/05/2023] Open
Abstract
SUMMARY Cushing's syndrome is an endocrine disorder that causes anovulatory infertility secondary to hypercortisolism; therefore, pregnancy rarely occurs during its course. We present the case of a 24-year-old, 16-week pregnant female with a 10-month history of unintentional weight gain, dorsal gibbus, nonpruritic comedones, hirsutism and hair loss. Initial biochemical, hormonal and ultrasound investigations revealed hypokalemia, increased nocturnal cortisolemia and a right adrenal mass. The patient had persistent high blood pressure, hyperglycemia and hypercortisolemia. She was initially treated with antihypertensive medications and insulin therapy. Endogenous Cushing's syndrome was confirmed by an abdominal MRI that demonstrated a right adrenal adenoma. The patient underwent right laparoscopic adrenalectomy and anatomopathological examination revealed an adrenal adenoma with areas of oncocytic changes. Finally, antihypertensive medication was progressively reduced and glycemic control and hypokalemia reversal were achieved. Long-term therapy consisted of low-dose daily prednisone. During follow-up, despite favorable outcomes regarding the patient's Cushing's syndrome, stillbirth was confirmed at 28 weeks of pregnancy. We discuss the importance of early diagnosis and treatment of Cushing's syndrome to prevent severe maternal and fetal complications. LEARNING POINTS Pregnancy can occur, though rarely, during the course of Cushing's syndrome. Pregnancy is a transient physiological state of hypercortisolism and it must be differentiated from Cushing's syndrome based on clinical manifestations and laboratory tests. The diagnosis of Cushing's syndrome during pregnancy may be challenging, particularly in the second and third trimesters because of the changes in the maternal hypothalamic-pituitary-adrenal axis. Pregnancy during the course of Cushing's syndrome is associated with severe maternal and fetal complications; therefore, its early diagnosis and treatment is critical.
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Affiliation(s)
| | | | | | - Jose Carrion-Rojas
- Metabolism and Reproduction Unit, Division of Endocrinology, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
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Pofi R, Tomlinson JW. Glucocorticoids in pregnancy. Obstet Med 2019; 13:62-69. [PMID: 32714437 DOI: 10.1177/1753495x19847832] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/08/2019] [Indexed: 12/18/2022] Open
Abstract
The physiological changes that occur during pregnancy include altered regulation of the hypothalamo-pituitary-adrenal axis. The fetoplacental unit plays a major role in this, together with alteration of circulating cortisol-binding globulin levels, with a net effect to increase both total and free cortisol levels. Importantly, there are several pathological conditions that require steroid treatment or replacement during pregnancy, and optimizing therapy is clearly crucial. The potential for acute and chronic adverse effects that can impact upon both the mother and the fetus makes the decision of how and when to instigate steroid therapy particularly challenging. In this review, we describe the physio-pathological changes to the hypothalamo-pituitary-adrenal axis that occur during pregnancy, tools to assess endogenous glucocorticoid reserve as well as discuss treatment strategies and the potential for the development of adverse events.
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Affiliation(s)
- Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.,Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
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St-Jean M, MacKenzie-Feder J, Bourdeau I, Lacroix A. Exacerbation of Cushing's syndrome during pregnancy: stimulation of a cortisol-secreting adrenocortical adenoma by ACTH originating from the foeto-placental unit. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180115. [PMID: 30738017 PMCID: PMC6373782 DOI: 10.1530/edm-18-0115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/16/2019] [Indexed: 02/02/2023] Open
Abstract
A 29-year-old G4A3 woman presented at 25 weeks of pregnancy with progressive signs of Cushing's syndrome (CS), gestational diabetes requiring insulin and hypertension. A 3.4 × 3.3 cm right adrenal adenoma was identified during abdominal ultrasound imaging for nephrolithiasis. Investigation revealed elevated levels of plasma cortisol, 24 h urinary free cortisol (UFC) and late-night salivary cortisol (LNSC). Serum ACTH levels were not fully suppressed (4 and 5 pmol/L (N: 2-11)). One month post-partum, CS regressed, 24-h UFC had normalised while ACTH levels were now less than 2 pmol/L; however, dexamethasone failed to suppress cortisol levels. Tests performed in vivo 6 weeks post-partum to identify aberrant hormone receptors showed no cortisol stimulation by various tests (including 300 IU hLH i.v.) except after administration of 250 µg i.v. Cosyntropin 1-24. Right adrenalectomy demonstrated an adrenocortical adenoma and atrophy of adjacent cortex. Quantitative RT-PCR analysis of the adenoma revealed the presence of ACTH (MC2) receptor mRNA, while LHCG receptor mRNA was almost undetectable. This case reveals that CS exacerbation in the context of pregnancy can result from the placental-derived ACTH stimulation of MC2 receptors on the adrenocortical adenoma. Possible contribution of other placental-derived factors such as oestrogens, CRH or CRH-like peptides cannot be ruled out. Learning points: Diagnosis of Cushing's syndrome during pregnancy is complicated by several physiological alterations in hypothalamic-pituitary-adrenal axis regulation occurring in normal pregnancy. Cushing's syndrome (CS) exacerbation during pregnancy can be associated with aberrant expression of LHCG receptor on primary adrenocortical tumour or hyperplasia in some cases, but not in this patient. Placental-derived ACTH, which is not subject to glucocorticoid negative feedback, stimulated cortisol secretion from this adrenal adenoma causing transient CS exacerbation during pregnancy. Following delivery and tumour removal, suppression of HPA axis can require several months to recover and requires glucocorticoid replacement therapy.
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Affiliation(s)
| | | | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre Hospitalier Universitaire de Montréal, Montréal, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre Hospitalier Universitaire de Montréal, Montréal, Québec, Canada
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Machado MC, Fragoso MCBV, Bronstein MD. Pregnancy in Patients with Cushing's Syndrome. Endocrinol Metab Clin North Am 2018; 47:441-449. [PMID: 29754643 DOI: 10.1016/j.ecl.2018.02.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Progress in diagnosis and treatment of endocrine diseases has made pregnancy possible for women with endocrinopathies, including Cushing's syndrome (CS). The risk of maternal-fetal complications in patients who are not biochemically controlled, however, is substantial. Therefore, the surgical and/or medical control of hypercortisolism is mandatory prior to conceiving. A diagnosis of de novo CS during gestation is difficult due to changes in the hypothalamic-pituitary-adrenal axis during pregnancy, which may lead to some clinical features suggestive of CS along with abnormal laboratory tests. This review presents the diagnosis and management of CS during pregnancy.
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Affiliation(s)
- Marcio Carlos Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, Avenida Enéas de Carvalho Aguiar, n° 155, 8° andar, bloco 03, São Paulo, São Paulo 05403-000, Brazil; Endocrinology Service, AC Camargo Cancer Center, Rua Prof. Antonio Prudente n° 211, São Paulo, SP 01509-010, Brazil; Laboratory for Endocrinology Cellular and Molecular - LIM25, University of São Paulo Medical School, Av. Dr. Arnaldo, 455, 4° andar, São Paulo, SP 01246-903, Brazil
| | - Maria Candida Barisson Vilares Fragoso
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, Avenida Enéas de Carvalho Aguiar, n° 155, 8° andar, bloco 03, São Paulo, São Paulo 05403-000, Brazil
| | - Marcello Delano Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, Avenida Enéas de Carvalho Aguiar, n° 155, 8° andar, bloco 03, São Paulo, São Paulo 05403-000, Brazil.
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St-Jean M, Ghorayeb NE, Bourdeau I, Lacroix A. Aberrant G-protein coupled hormone receptor in adrenal diseases. Best Pract Res Clin Endocrinol Metab 2018; 32:165-187. [PMID: 29678284 DOI: 10.1016/j.beem.2018.01.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The regulation of cortisol or aldosterone production when ACTH of pituitary origin or the renin-angiotensin systems are suppressed in primary adrenal Cushing's syndrome or in primary aldosteronism is exerted by diverse genetic and molecular mechanisms. In addition to recently identified mutations in various genes implicated in the cyclic AMP or ion channel pathways, steroidogenesis is not really autonomous as it is frequently regulated by the aberrant adrenocortical expression of diverse hormone receptors, particularly G-protein coupled hormone receptors (GPCR) which can substitute for the normal function of ACTH or angiotensin-II. In addition, paracrine or autocrine production of ligands for the aberrant GPCR such as ACTH or serotonin is found in some adrenal tumors or hyperplasias and participates in a complex regulatory loop causing steroid excess. Targeted therapies to block the aberrant ligands or their receptors could become useful in the future, particularly for patients with bilateral source of steroid excess.
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Affiliation(s)
- Matthieu St-Jean
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
| | - Nada El Ghorayeb
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
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