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Zimpfer A, Abel LM, Alozie A, Etz CD, Schneider B. Frequent protein kinase A regulatory subunit A1 mutations but no GNAS mutations as potential driver in sporadic cardiac myxomas. Cardiovasc Pathol 2024; 71:107632. [PMID: 38492686 DOI: 10.1016/j.carpath.2024.107632] [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: 10/13/2023] [Revised: 02/18/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
PURPOSE Cardiac myxomas (CMs) are the second most common benign primary cardiac tumors, mainly originating within the left atrium. Approximately 5% of CM cases are associated with Carney Complex (CNC), an autosomal dominant multiple neoplasia syndrome often caused by germline mutations in the protein kinase A regulatory subunit 1A (PRKAR1A). Data concerning PRKAR1A alterations in sporadic myxomas are variable and sparse, with PRKAR1A mutations reported to range from 0% to 87%. Therefore, we investigated the frequency of PRKAR1A mutations in sporadic CM using next-generation sequencing (NGS). Additionally, we explored mutations in the catalytic domain of the Protein Kinase A complex (PRKACA) and examined the presence of GNAS mutations as another potential driver. METHODS AND RESULTS This study retrospectively collected histological and clinical data from 27 patients with CM. First, we ruled out the possibility of underlying CNC through clinical evaluations and standardized interviews for each patient. Second, we performed PRKAR1A immunohistochemistry (IHC) analysis and graded the reactivity of myxoma cells semi-quantitatively. NGS was then applied to analyze the coding regions of PRKAR1A, PRKACA, and GNAS in all 27 cases. Of the 27 sporadic CM cases, 13 (48%) harbored mutations in PRKAR1A. Among these 13 mutant cases, six displayed more than one mutation in PRKAR1A. Most of the identified mutations resulted in premature stop codons or affected splicing. In PRKAR1A mutant CM cases, the loss of PRKAR1A protein expression was significantly more common. In two cases with missense mutations, protein expression remained preserved. Furthermore, a single mutation was detected in the catalytic domain of the protein kinase A complex, while no GNAS mutations were found. CONCLUSION We identified a relatively high frequency of PRKAR1A mutations in sporadic CM. These PRKAR1A mutations may also represent an important oncogenic mechanism in sporadic myxomas, as already known in CM cases associated with CNC.
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Affiliation(s)
- Annette Zimpfer
- Institute of Pathology, University Medical Center Rostock, Strempelstr. 14, Rostock, 18055 Germany.
| | - Liza M Abel
- Institute of Pathology, University Medical Center Rostock, Strempelstr. 14, Rostock, 18055 Germany
| | - Anthony Alozie
- Department of Cardiac Surgery, Rostock Heart Center, University Medical Center Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Christian D Etz
- Department of Cardiac Surgery, Rostock Heart Center, University Medical Center Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Björn Schneider
- Institute of Pathology, University Medical Center Rostock, Strempelstr. 14, Rostock, 18055 Germany
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Tizianel I, Barbot M, Ceccato F. Subtyping of Cushing's Syndrome: A Step Ahead. Exp Clin Endocrinol Diabetes 2024. [PMID: 38574761 DOI: 10.1055/a-2299-5065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Cushing's Syndrome (CS) is a rare disease due to chronic endogenous cortisol secretion. In recent years, new developments have broadened the spectrum of differential diagnosis, traditionally categorized as adrenocorticotropic hormone (ACTH)-dependent and ACTH-independent forms. Moreover, increased awareness of the detrimental effects of cortisol on cardiometabolic health and the risk of cardiovascular events lead to increased diagnosis of mild forms, especially in the context of adrenal incidentalomas.This review provides an up-to-date narrative of the most recent literature regarding the challenges of CS diagnosis. After the description of the diagnostic tools available, the functional non-neoplastic hypercortisolism (formerly known as pseudo-Cushing state) is characterized, followed by the subtyping of the different conditions of hypercortisolism, including the differential diagnosis of ACTH-dependent forms and the management of adrenal hypercortisolism, with peculiar attention to the new genetic classification of adrenal CS, mild autonomous cortisol secretion, and bilateral adrenal adenomas.
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Affiliation(s)
- Irene Tizianel
- 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
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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3
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Guarnotta V, Emanuele F, Salzillo R, Giordano C. Adrenal Cushing's syndrome in children. Front Endocrinol (Lausanne) 2023; 14:1329082. [PMID: 38192416 PMCID: PMC10773667 DOI: 10.3389/fendo.2023.1329082] [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: 10/27/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024] Open
Abstract
Adrenal Cushing's syndrome is a rare cause of endogenous hypercortisolism in neonatal and early childhood stages. The most common causes of adrenal CS are hyperfunctioning adrenal tumours, adenoma or carcinoma. Rarer causes are primary bilateral macronodular adrenal hyperplasia (PBAMH), primary pigmented adrenocortical disease (PPNAD) and McCune Albright syndrome. The diagnosis represents a challenge for clinicians. In cases of clinical suspicion, confirmatory tests of hypercortisolism should be performed, similarly to those performed in adults. Radiological imaging should be always combined with biochemical confirmatory tests, for the differential diagnosis of adrenal CS causes. Treatment strategies for adrenal CS include surgery and in specific cases medical drugs. An adequate treatment is associated to an improvement of growth, bone health, reproduction and body composition from childhood into and during adult life. After cure, lifelong glucocorticoid replacement therapy and endocrine follow-up are required, notably in patients with Carney's complex disease.
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Affiliation(s)
- Valentina Guarnotta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Endocrinology, University of Palermo, Palermo, Italy
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Reis BO, Leal CTS, Ezequiel DGA, Dos Santos Ribeiro Simões Juliano AC, de Macedo Veloso FL, da Silva LM, Ferreira LV, Ferreira M, De Oliveira Souza GZ. Severe osteoporosis in a young man with bilateral Cushing's syndrome: a case report. J Med Case Rep 2023; 17:251. [PMID: 37328870 DOI: 10.1186/s13256-023-03968-0] [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: 06/22/2022] [Accepted: 05/01/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND The diagnosis of Cushing's syndrome is challenging; however, through the clinical picture and the search for secondary causes of osteoporosis, it was possible to reach the diagnosis of the case reported. There was an independent, symptomatic ACTH hypercortisolism manifested by typical phenotypic changes, severe secondary osteoporosis and arterial hypertension in a young patient. CASE PRESENTATION A 20-year-old Brazilian man with low back pain for 8 months. Radiographs showed fragility fractures in the thoracolumbar spine, and bone densitometry showed osteoporosis, especially when evaluating the Z Score (- 5.6 in the lumbar spine). On physical examination, there were wide violaceous streaks on the upper limbs and abdomen, plethora and fat increase in the temporal facial region, hump, ecchymosis on limbs, hypotrophy of arms and thighs, central obesity and kyphoscoliosis. His blood pressure was 150 × 90 mmHg. Cortisol after 1 mg of dexamethasone (24.1 µg/dL) and after Liddle 1 (28 µg/dL) were not suppressed, despite normal cortisoluria. Tomography showed bilateral adrenal nodules with more severe characteristics. Unfortunately, through the catheterization of adrenal veins, it was not possible to differentiate the nodules due to the achievement of cortisol levels that exceeded the upper limit of the dilution method. Among the hypotheses for the differential diagnosis of bilateral adrenal hyperplasia are primary bilateral macronodular adrenal hyperplasia, McCune-Albright syndrome and isolated bilateral primary pigmented nodular hyperplasia or associated with Carney's complex. In this case, primary pigmented nodular hyperplasia or carcinoma became important etiological hypotheses when comparing the epidemiology in a young man and the clinical-laboratory-imaging findings of the differential diagnoses. After 6 months of drug inhibition of steroidogenesis, blood pressure control and anti-osteoporotic therapy, the levels and deleterious metabolic effects of hypercortisolism, which could also impair adrenalectomy in the short and long term, were reduced. Left adrenalectomy was chosen, given the possibility of malignancy in a young patient and to avoid unnecessary definitive surgical adrenal insufficiency if the adrenalectomy was bilateral. Anatomopathology of the left gland revealed expansion of the zona fasciculate with multiple nonencapsulated nodules. CONCLUSION The early identification of Cushing's syndrome, with measures based on the assessment of risks and benefits, remains the best way to prevent its progression and reduce the morbidity of the condition. Despite the unavailability of genetic analysis for a precise etiological definition, it is possible to take efficient measures to avoid future damage.
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Affiliation(s)
- Bárbara Oliveira Reis
- Serviço de Endocrinologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil.
| | - Christianne Toledo Sousa Leal
- Serviço de Endocrinologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | | | | | - Flávia Lopes de Macedo Veloso
- Serviço de Endocrinologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Leila Marcia da Silva
- Serviço de Endocrinologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Lize Vargas Ferreira
- Serviço de Endocrinologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Mariana Ferreira
- Serviço de Endocrinologia, Hospital Universitário da Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
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Abstract
Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of adrenocorticotropin hormone (ACTH)-independent Cushing's syndrome (CS), which mainly occurs in children and young adults. Treatment options with proven clinical efficacy for PPNAD include adrenalectomy (bilateral or unilateral adrenalectomy) and drug treatment to control hypercortisolemia. Previously, the main treatment of PPNAD is bilateral adrenal resection and long-term hormone replacement after surgery. In recent years, cases reports suggest that unilateral or subtotal adrenal resection can also lead to long-term remission in some patients without the need for long-term hormone replacement therapy. Medications for hypercortisolemia, such as Ketoconazole, Metyrapone and Mitotane et.al, have been reported as a preoperative transition for in some patients with severe hypercortisolism. In addition, tryptophan hydroxylase inhibitor, COX2 inhibitor Celecoxib, somatostatin and other drugs targeting the possible pathogenic mechanisms of the disease are under study, which are expected to be applied to the clinical treatment of PPNAD in the future. In this review, we summarize the recent progress on treatment of PPNAD, in which options of surgical methods, research results of drugs acting on possible pathogenic mechanisms, and the management during gestation are described in order to provide new ideas for clinical treatment.
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Affiliation(s)
- Xinming Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
| | - Siwen Zhang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
| | - Yunran Guo
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin
University, Changchun, China
- Correspondence Dr. Guixia Wang The First Hospital of Jilin
UniversityDepartment of Endocrinology and
MetabolismNO.1 Xinmin
Street130021
ChangchunChina+86 431
8878-2078+86 431 8878-6066
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Wan W, Zeng L, Jiang H, Xia Y, Xiong Y. Genetic and clinical phenotypic analysis of carney complex with external auditory canal myxoma. Front Genet 2022; 13:947305. [PMID: 36092889 PMCID: PMC9450949 DOI: 10.3389/fgene.2022.947305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/01/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Mutations in PRKAR1A gene can lead to Carney complex (CNC), and most CNC patients develop cardiac and cutaneous myxomas. In particular, cardiac myxomas are a common cause of mortality in CNC patients. Cutaneous myxomas of the external ear are extremely rare, and do not have any specific clinical features Methods: In this retrospective study, we analyzed the clinical and genetic data of the proband and his family and fifty whole blood control samples selected from the molecular genetic database of our hospital. Whole exome DNA sequencing analysis was used to detect the mutation in the peripheral blood samples. Results: The results of the clinical analysis showed the presence of spotty skin pigmentation and external auditory canal myxoma in the proband as well as in his sister and mother. Whole-exome DNA sequencing showed a novel heterozygous mutation in the PRKAR1A gene i.e., c.824_825delAG (p.Gln275Leufs*2), in the proband and his sister and mother. Conclusion: In conclusion, the family members had the same autosomal dominant PRKAR1A mutation. DNA sequencing revealed a novel c.824_825delAG in exon 9 of PRKAR1A. This pathogenic mutation has not been reported previously, and may be related to the occurrence of external auditory canal myxomas and spotty pigmentation. This study broadens the genotypic spectrum of PRKAR1A mutations in CNC.
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Affiliation(s)
- Wei Wan
- Department of Otolaryngology-Head and Neck Surgery, First Affiliated Hospital of Nangchang University, Jiangxi, China
| | - Liang Zeng
- Department of Otolaryngology-Head and Neck Surgery, First Affiliated Hospital of Nangchang University, Jiangxi, China
| | - Hongqun Jiang
- Department of Otolaryngology-Head and Neck Surgery, First Affiliated Hospital of Nangchang University, Jiangxi, China
- Jiangxi Institute of Otorhinolaryngology-Head and Neck Surgery, Jiangxi, China
- *Correspondence: Hongqun Jiang, ; Yunyan Xia,
| | - Yunyan Xia
- Department of Otolaryngology-Head and Neck Surgery, First Affiliated Hospital of Nangchang University, Jiangxi, China
- Jiangxi Institute of Otorhinolaryngology-Head and Neck Surgery, Jiangxi, China
- *Correspondence: Hongqun Jiang, ; Yunyan Xia,
| | - Yuanping Xiong
- Department of Otolaryngology-Head and Neck Surgery, First Affiliated Hospital of Nangchang University, Jiangxi, China
- Jiangxi Institute of Otorhinolaryngology-Head and Neck Surgery, Jiangxi, China
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7
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Oza CM, Mehta S, Khadilkar V, Khadilkar A. Primary pigmented nodular adrenal disease presenting as hypertensive crisis. BMJ Case Rep 2022; 15:e250023. [PMID: 35649622 PMCID: PMC9161052 DOI: 10.1136/bcr-2022-250023] [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] [Accepted: 05/11/2022] [Indexed: 11/03/2022] Open
Abstract
We present a case of a young girl who presented with hypertensive crisis and recent onset weight gain with hirsutism. On evaluation for Cushing syndrome (CS), her cortisol concentration was high, showed a paradoxical cortisol rise on dexamethasone suppression and the adrenocorticotropic hormone (ACTH) was low. Adrenal imaging showed normal adrenal morphology. Genetic diagnosis of primary pigmented nodular adrenal disease (PPNAD) was made. She was operated for bilateral adrenalectomy and histopathology confirmed the diagnosis of PPNAD. Our case highlights the rare aetiology of PPNAD as a cause of CS resulting in a hypertensive crisis. To the best of our knowledge, this is the youngest case of ACTH independent CS presenting as hypertensive encephalopathy.
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Affiliation(s)
- Chirantap Markand Oza
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
| | - Sajili Mehta
- Pediatric Endocrinology, Surya Mother and Child Care Super Speciality Hospital, Pune, Maharashtra, India
- Pediatric Endocrinology, MIMER, Pune, Maharashtra, India
| | - Vaman Khadilkar
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, Maharashtra, India
| | - Anuradha Khadilkar
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, Maharashtra, India
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8
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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9
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Wurth R, Rescigno M, Flippo C, Stratakis CA, Tatsi C. Inflammatory biomarkers in the evaluation of pediatric endogenous Cushing syndrome. Eur J Endocrinol 2022; 186:503-510. [PMID: 35171827 PMCID: PMC9059943 DOI: 10.1530/eje-21-1199] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/15/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Inflammatory biomarkers, such as absolute neutrophil and lymphocyte counts, neutrophil-to-lymphocyte ratio (NLR), platelet (PLT)-to-lymphocyte ratio (PLR) and monocyte-to-lymphocyte ratio (MLR), are associated with the progression and development of several disorders. Although patients with Cushing syndrome (CS) have immunosuppression with altered leucocyte counts, the profile of the inflammatory biomarkers in these patients has not been extensively studied. DESIGN We compared a panel of inflammatory biomarkers in patients with active endogenous CS (n of complete blood count (CBC) reports = 319) and eucortisolemic subjects of similar age, gender and BMI (n of CBC reports = 93). Patients were divided into two age groups (6-12 years at the time of CBC and >12 years at the time of CBC) based on age differences in normal reference ranges. RESULTS Patients with CS had higher NLR vs controls (6-12 years: 2.47 (1.86, 3.32) vs 1.35 (1.11, 2.27), P < 0.0001; >12 years: 3.00 (2.23-4.17) vs 1.80 (1.23-2.31), P < 0.0001). Similarly, absolute neutrophil and lymphocyte counts, MLR and PLR differed between patients with CS and controls. The inflammatory biomarkers correlated with indices of cortisol secretion, such as midnight serum cortisol, 24-h urinary free cortisol and morning cortisol. On receiver operating characteristic analysis, NLR showed high area under the curve (AUC) (6-12 years: cutoff of 1.72 had AUC: 0.77, >12 years: cutoff of 2.35 had AUC: 0.81). CONCLUSIONS We conclude that multiple inflammatory biomarkers differed between patients with CS and controls suggesting substantial effects of hypercortisolemia on the immune system.
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Affiliation(s)
- Rachel Wurth
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Megan Rescigno
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Chelsi Flippo
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Constantine A Stratakis
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
- Human Genetics & Precision Medicine, IMBB, FORTH, Heraklion, Crete, Greece
- Human Genetics & Precision Medicine, IMBB, FORTH, Heraklion, Crete, Greece
| | - Christina Tatsi
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
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Jacobson A, Koberlein E, Thomay A, Lombard CB, Adelanwa A, Lakhani DA, Smith KT. Congenital adrenal hyperplasia with associated giant adrenal myelolipoma, testicular adrenal rest tumors and primary pigmented nodular adrenocortical disease: A case report and brief review of the literature. Radiol Case Rep 2022; 17:710-716. [PMID: 35003466 PMCID: PMC8718818 DOI: 10.1016/j.radcr.2021.12.031] [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: 08/19/2021] [Revised: 12/06/2021] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
Congenital adrenal hyperplasia is an autosomal recessive disease most commonly associated with 21-hydroxylase deficiency, an enzyme integral in the biosynthesis of mineralocorticoids and glucocorticoids. We present a case of a 49-year-old male with congenital adrenal hyperplasia and commonly associated findings of adrenal myelolipoma, testicular adrenal rest tumors, as well as primary pigmented nodular adrenocortical disease. Adrenal myelolipoma is a rare, benign disease process associated with exogenous steroid treatment noncompliance in the setting of congenital adrenal hyperplasia. Testicular adrenal rest tumors are benign testicular tumors associated with congenital adrenal hyperplasia. Primary pigmented nodular adrenocortical disease is an ACTH-independent cortisol producing lesion. Our case emphasizes the association of congenital adrenal hyperplasia with adrenal myelolipoma and testicular adrenal rest tumors as well as the importance of familiarity with these associations to guide patient management.
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Affiliation(s)
- Aaron Jacobson
- Department of Radiology, West Virginia University, Morgantown, WV 26506, USA
| | - Elaine Koberlein
- West Virginia School of Osteopathic Medicine, Lewisburg, WV, 24901
| | - Alan Thomay
- Department of Surgical Oncology, West Virginia University, Morgantown, WV 26506, USA
| | - Cara B Lombard
- Department of Radiology, West Virginia University, Morgantown, WV 26506, USA
| | - Ayodele Adelanwa
- Department of Pathology, Anatomy and Laboratory Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - Dhairya A Lakhani
- Department of Radiology, West Virginia University, Morgantown, WV 26506, USA
| | - Kelly T Smith
- Department of Radiology, West Virginia University, Morgantown, WV 26506, USA
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11
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Araujo-Castro M, Marazuela M. Cushing´s syndrome due to bilateral adrenal cortical disease: Bilateral macronodular adrenal cortical disease and bilateral micronodular adrenal cortical disease. Front Endocrinol (Lausanne) 2022; 13:913253. [PMID: 35992106 PMCID: PMC9389040 DOI: 10.3389/fendo.2022.913253] [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: 04/05/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Cushing´s syndrome (CS) secondary to bilateral adrenal cortical disease may be caused by bilateral macronodular adrenal cortical disease (BMACD) or by bilateral micronodular adrenal cortical disease (miBACD). The size of adrenal nodules is a key factor for the differentiation between these two entities (>1cm, BMACD and <1cm; miBACD). BMACD can be associated with overt CS, but more commonly it presents with autonomous cortisol secretion (ACS). Surgical treatment of BMACD presenting with CS or with ACS and associated cardiometabolic comorbidities should be the resection of the largest adrenal gland, since it leads to hypercortisolism remission in up to 95% of the cases. Medical treatment focused on the blockade of aberrant receptors may lead to hypercortisolism control, although cortisol response is frequently transient. miBACD is mainly divided in primary pigmented nodular adrenocortical disease (PPNAD) and isolated micronodular adrenocortical disease (i-MAD). miBACD can present at an early age, representing one of the main causes of CS at a young age. The high-dose dexamethasone suppression test can be useful in identifying a paradoxical increase in 24h-urinary free cortisol, that is a quite specific in PPNAD. Bilateral adrenalectomy is generally the treatment of choice in patients with overt CS in miBACD, but unilateral adrenalectomy could be considered in cases with asymmetric disease and mild hypercortisolism. This article will discuss the clinical presentation, genetic background, hormonal and imaging features and treatment of the main causes of primary bilateral adrenal hyperplasia associated with hypercortisolism.
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Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Ramón y Cajal University Hospital, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
- Departament of Medicine, Alcalá University, Madrid, Spain
- *Correspondence: Marta Araujo-Castro,
| | - Mónica Marazuela
- Endocrinology & Nutrition Department, La Princesa University Hospital, Madrid, Spain
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12
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Chevalier B, Vantyghem MC, Espiard S. Bilateral Adrenal Hyperplasia: Pathogenesis and Treatment. Biomedicines 2021; 9:biomedicines9101397. [PMID: 34680514 PMCID: PMC8533142 DOI: 10.3390/biomedicines9101397] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 01/06/2023] Open
Abstract
Bilateral adrenal hyperplasia is a rare cause of Cushing’s syndrome. Micronodular adrenal hyperplasia, including the primary pigmented micronodular adrenal dysplasia (PPNAD) and the isolated micronodular adrenal hyperplasia (iMAD), can be distinguished from the primary bilateral macronodular adrenal hyperplasia (PBMAH) according to the size of the nodules. They both lead to overt or subclinical CS. In the latter case, PPNAD is usually diagnosed after a systematic screening in patients presenting with Carney complex, while for PBMAH, the diagnosis is often incidental on imaging. Identification of causal genes and genetic counseling also help in the diagnoses. This review discusses the last decades’ findings on genetic and molecular causes of bilateral adrenal hyperplasia, including the several mechanisms altering the PKA pathway, the recent discovery of ARMC5, and the role of the adrenal paracrine regulation. Finally, the treatment of bilateral adrenal hyperplasia will be discussed, focusing on current data on unilateral adrenalectomy.
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Affiliation(s)
- Benjamin Chevalier
- Department of Endocrinology, Diabetology, Metabolism and Nutrition, CHU Lille, F-59000 Lille, France; (B.C.); (M.-C.V.)
| | - Marie-Christine Vantyghem
- Department of Endocrinology, Diabetology, Metabolism and Nutrition, CHU Lille, F-59000 Lille, France; (B.C.); (M.-C.V.)
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1190, European Genomic Institute for Diabetes (EGID), CHU Lille, F-59000 Lille, France
| | - Stéphanie Espiard
- Department of Endocrinology, Diabetology, Metabolism and Nutrition, CHU Lille, F-59000 Lille, France; (B.C.); (M.-C.V.)
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1190, European Genomic Institute for Diabetes (EGID), CHU Lille, F-59000 Lille, France
- Correspondence:
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13
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Nakatake N, Hiraoka F, Yano S, Hara T, Matsubayashi S. Case of Cyclic Cushing's Disease with Improvement of Psoriatic Skin Lesions During a Period of Hypercortisolemia. J Endocr Soc 2021; 5:bvab058. [PMID: 34104844 PMCID: PMC8156988 DOI: 10.1210/jendso/bvab058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Indexed: 11/19/2022] Open
Abstract
Cushing's syndrome (CS) is known to involve periodic cortisol secretion in some patients. It has also been demonstrated that resolution of cortisol hypersecretion in CS may cause autoimmune-related disease to become apparent. At least 3 cases of psoriasis that became apparent after resolution of hypercortisolism in CS have been reported. We describe a 45-year-old man with cyclic Cushing's disease in whom psoriasis vulgaris, an autoimmune-related disease, was ameliorated during a period of hypercortisolemia. He had complained of intermittent sensations of "whole-body swelling" and improvement of his psoriatic skin lesions, which lasted 2 to 3 weeks at 2- to 3-month intervals over several years. During a 2-week hospitalization for endocrine investigations, an episode of hypercortisolemia appeared unexpectedly. During this time period, the peak serum cortisol level reached 75.7 µg/mL (adrenocorticotropic hormone level, 585 pg/mL) and 24-hour urinary free cortisol reached 10 500 µg/day. A diagnosis of Cushing's disease was made based on a markedly elevated urinary free cortisol level, an adequate increase in adrenocorticotropic hormone level in response to corticotropin-releasing hormone stimulation, and the presence of a giant pituitary tumor with a maximum diameter of approximately 4 cm. Interestingly, during this time period, there was a marked improvement in the psoriatic skin lesions and whole-body swelling sensations.
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Affiliation(s)
- Nobuhiro Nakatake
- Department of Psychosomatic Medicine and Endocrinology, Fukuoka Tokushukai Hospital, Fukuoka 816-0864, Japan
| | - Fumihiro Hiraoka
- Department of Neurosurgical, Fukuoka Neurosurgical Hospital, Fukuoka 811-1313, Japan
| | - Shigetoshi Yano
- Department of Neurosurgical, Fukuoka Neurosurgical Hospital, Fukuoka 811-1313, Japan
| | - Takeshi Hara
- Department of Psychosomatic Medicine and Endocrinology, Fukuoka Tokushukai Hospital, Fukuoka 816-0864, Japan
| | - Sunao Matsubayashi
- Department of Psychosomatic Medicine and Endocrinology, Fukuoka Tokushukai Hospital, Fukuoka 816-0864, Japan
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14
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Tóth M. Cushing Disease with Glucocorticoid-induced Positive Feedback-A New Subtype of Pituitary Corticotropinomas? J Endocr Soc 2021; 5:bvab079. [PMID: 34061123 PMCID: PMC8143653 DOI: 10.1210/jendso/bvab079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Miklós Tóth
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, H-1083 Budapest, Hungary, European Reference Network on Rare Endocrine Conditions (Endo-ERN)
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15
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Ghazi AA, Mandegar MH, Abazari M, Behzadnia N, Sadeghian T, Torbaghan SS, Amirbaigloo A. A novel mutation in PRKAR1A gene in a patient with Carney complex presenting with pituitary macroadenoma, acromegaly, Cushing's syndrome and recurrent atrial myxoma. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:376-380. [PMID: 33939912 DOI: 10.20945/2359-3997000000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Carney complex (CNC) is a rare syndrome of multiple endocrine and non-endocrine tumors. In this paper we present a 23-year-old Iranian woman with CNC who harbored a novel mutation (c.642dupT) in PRKAR1A gene. This patient presented with pituitary macroadenoma, acromegaly, recurrent atrial myxoma, Cushing's syndrome secondary to primary pigmented nodular adrenocortical disease and pigmented schwanoma of the skin. PRKAR1A gene was PCR amplified using genomic DNA and analyzed for sequence variants which revealed the novel mutation resulting in substitution of amino acid cysteine instead of the naturally occurring valine in the peptide chain and a premature stop codon at position 18 (V215CfsX18). This change leads to development of tumors in different organs due to lack of tumor suppressive activity secondary to failure of synthesis of the related protein.
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Affiliation(s)
- Ali A Ghazi
- Endocrine Research Center, Research Institute for Endocrine Sciences (RIES), Shahid Beheshti University of Medical Sciences, Tehran, Iran,
| | | | - Mohammad Abazari
- Section of Cardiovascular Disorders, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Neda Behzadnia
- Lung Transplantation Research Center, National Institute of Tuberculosis and Lung Disease (NRILTD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Taraneh Sadeghian
- Section of Dermatology, Azad University of Medical Sciences; Consultant Dermatologist at Kasra General Hospital, Tehran, Iran
| | - Siamak Shariat Torbaghan
- Department of Pathology, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Kamilaris CDC, Faucz FR, Andriessen VC, Nilubol N, Lee CCR, Ahlman MA, Hannah-Shmouni F, Stratakis CA. First Somatic PRKAR1A Defect Associated With Mosaicism for Another PRKAR1A Mutation in a Patient With Cushing Syndrome. J Endocr Soc 2021; 5:bvab007. [PMID: 33644619 DOI: 10.1210/jendso/bvab007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Indexed: 11/19/2022] Open
Abstract
Context Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of ACTH-independent Cushing syndrome (CS) associated mostly with Carney complex (CNC), a rare autosomal dominant multiple neoplasia syndrome. More than two-thirds of familial cases and approximately one-third of sporadic cases of CNC harbor germline inactivating PRKAR1A defects. Increasingly sensitive technologies for the detection of genetic defects such as next-generation sequencing (NGS) have further highlighted the importance of mosaicism in human disease. Case Description A 33-year-old woman was diagnosed with ACTH-independent CS with abdominal computed tomography showing bilateral micronodular adrenal hyperplasia with a left adrenal adenoma. She underwent left adrenalectomy with pathology demonstrating PPNAD with a 1.5-cm pigmented adenoma. DNA analysis by Sanger sequencing revealed 2 different PRKAR1A variants in the adenoma that were absent from DNA extracted from blood and saliva: c.682C > T and c.974-2A > G. "Deep" NGS revealed that 0.31% of DNA copies extracted from blood and saliva did in fact carry the c.682C > T variant, suggesting low-level mosaicism for this defect. Conclusions We present a case of PPNAD due to low-level mosaicism for a PRKAR1A defect which led to the formation of an adenoma due to a second, adrenal-specific, somatic PRKAR1A mutation. The identification of mosaicism for PRKAR1A, depending on the number and distribution of cells affected has implications for genetic counseling and tumor surveillance. This is the first recorded case of a patient with PRKAR1A mosaicism, PPNAD, and an adenoma forming due to complete inactivation of PRKAR1A in adrenal tissue from a second, somatic-only, PRKAR1A coding sequence mutation.
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Affiliation(s)
- Crystal D C Kamilaris
- Section on Endocrinology and Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Fabio R Faucz
- Section on Endocrinology and Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Victoria C Andriessen
- Section on Endocrinology and Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Naris Nilubol
- Endocrine Surgery Section, Surgical Oncology Program, National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Chyi-Chia Richard Lee
- Laboratory of Pathology, National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Mark A Ahlman
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Fady Hannah-Shmouni
- Section on Endocrinology and Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
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Levy I, Szarek E, Maria AG, Starrost M, De La Luz Sierra M, Faucz FR, Stratakis CA. A phosphodiesterase 11 (Pde11a) knockout mouse expressed functional but reduced Pde11a: Phenotype and impact on adrenocortical function. Mol Cell Endocrinol 2021; 520:111071. [PMID: 33127481 PMCID: PMC7771190 DOI: 10.1016/j.mce.2020.111071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 01/23/2023]
Abstract
Phosphodiesterases catalyze the hydrolysis of cyclic nucleotides and maintain physiologic levels of intracellular concentrations of cyclic adenosine and guanosine mono-phosphate (cAMP and cGMP, respectively). Increased cAMP signaling has been associated with adrenocortical tumors and Cushing syndrome. Genetic defects in phosphodiesterase 11A (PDE11A) may lead to increased cAMP signaling and have been found to predispose to the development of adrenocortical, prostate, and testicular tumors. A previously reported Pde11a knockout (Pde11a-/-) mouse line was studied and found to express PDE11A mRNA and protein still, albeit at reduced levels; functional studies in various tissues showed increased cAMP levels and reduced PDE11A activity. Since patients with PDE11A defects and Cushing syndrome have PDE11A haploinsufficiency, it was particularly pertinent to study this hypomorphic mouse line. Indeed, Pde11a-/- mice failed to suppress corticosterone secretion in response to low dose dexamethasone, and in addition exhibited adrenal subcapsular hyperplasia with predominant fetal-like features in the inner adrenal cortex, mimicking other mouse models of increased cAMP signaling in the adrenal cortex. We conclude that a previously reported Pde11a-/- mouse showed continuing expression and function of PDE11A in most tissues. Nevertheless, Pde11a partial inactivation in mice led to an adrenocortical phenotype that was consistent with what we see in patients with PDE11A haploinsufficiency.
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Affiliation(s)
- Isaac Levy
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA; Endocrine and Diabetes Unit. Edmond and Lily Safra Children's Hospital, Tel-Hashomer. Ramat Gan. Sackler School of Medicine, Ramat-aviv, Israel
| | - Eva Szarek
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA
| | - Andrea Gutierrez Maria
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA
| | - Matthew Starrost
- Division of Veterinary Resources, National Institutes of Health (NIH), Bethesda, MD, 20892, USA
| | - Maria De La Luz Sierra
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA
| | - Fabio R Faucz
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA.
| | - Constantine A Stratakis
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA.
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Esparza-Salazar FJ, Hernández-González JA, Lezama-Toledo AR, Incontri-Abraham D, Corral A, Armenta-Moreno JI, Vargas-Abonce VP, Cuevas-Ramos D, Gómez-Pérez FJ, Gómez-Sámano MA. Nelson Syndrome: A Case Report and Literature Review. AACE Clin Case Rep 2020; 7:141-144. [PMID: 34095473 PMCID: PMC8053620 DOI: 10.1016/j.aace.2020.11.034] [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] [Indexed: 11/04/2022] Open
Abstract
Objective Nelson syndrome (NS) is a rare clinical disorder that can occur after total bilateral adrenalectomy (TBA), performed as a treatment for Cushing disease. NS is defined as the accelerated growth of an adrenocorticotropic hormone-producing pituitary adenoma. Our objective is to describe a case of NS and discuss it based on existing knowledge of this syndrome. Methods We describe the case of a woman diagnosed with NS at our facility in the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran and review published cases of NS. Results The patient, a 35-year-old woman with Cushing disease, had been diagnosed in 2006 at the endocrinology department in the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran. In 2007, a laparoscopic TBA was performed, and 2 years later, she presented with hyperpigmentation and adrenocorticotropic hormone levels of up to 11 846 pg/mL. NS was suspected, and as magnetic resonance imaging showed macroadenoma, transsphenoidal surgery was performed. The patient remained asymptomatic until 2012, when she presented with a right hemicranial headache, photophobia, and phonophobia. A fresh magnetic resonance imaging was performed, which documented tumor growth. She was referred to the Instituto Nacional de Neurologia y Neurocirugia, where she underwent surgery. Conclusion NS develops as a complication of TBA, which is used as a treatment of Cushing disease. The main treatment is surgery and radiotherapy.
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Affiliation(s)
| | | | | | | | - Armando Corral
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
| | | | - Valerie P Vargas-Abonce
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
| | - Daniel Cuevas-Ramos
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
| | - Francisco J Gómez-Pérez
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
| | - Miguel A Gómez-Sámano
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico
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Majumder S, Chakraborty PP, Ghosh PC, Bera M. Cushing’s syndrome in early infancy due to isolated sporadic bilateral micronodular adrenocortical disease associated with myosin heavy chain 8 mutation: diagnostic challenges, too many! BMJ Case Rep 2020; 13:13/10/e236850. [DOI: 10.1136/bcr-2020-236850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Endogenous Cushing’s syndrome (CS) is rare in infancy. Bilateral micronodular adrenocortical disease (BMAD), either primary pigmented nodular adrenocortical disease or the non-pigmented isolated micronodular adrenocortical disease is an important aetiology of CS in this age group, which requires bilateral adrenalectomy for cure. BMAD may be isolated, or a component of Carney complex. Isolated sporadic BMAD without other systemic manifestations poses a diagnostic challenge. Paradoxical cortisol response to dexamethasone suggests, while adrenal histopathology and mutational analysis of the culprit genes confirm BMAD. BMAD was suspected in 6-year-old infant with midnormal adrenocorticotrophic hormone, inconclusive adrenal and pituitary imaging and paradoxical increase in cortisol following high dose of dexamethasone. Exome sequencing revealed heterozygous c.354+1G>C (5′ splice site) variant in the myosin heavy chain gene (MYH8), located in chromosome 17. This particular variant has not been reported in the literature. In view of suspected phenotype and its absence in the population databases, the variant was classified as pathogenic.
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20
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Maillet M, Bourdeau I, Lacroix A. Update on primary micronodular bilateral adrenocortical diseases. Curr Opin Endocrinol Diabetes Obes 2020; 27:132-139. [PMID: 32209819 DOI: 10.1097/med.0000000000000538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Primary micronodular bilateral adrenocortical hyperplasias (MiBAH) are rare challenging diseases. Important progress in understanding its pathophysiology and genetics occurred in the last two decades. We summarize those progress and recent data on investigation and therapy of MiBAH focusing on primary pigmented nodular adrenocortical disease (PPNAD). RECENT FINDINGS Larger recent cohorts of PPNAD patients from various countries have confirmed their variable Cushing's syndrome phenotypes. Age of onset is earlier than other ACTH-independent Cushing's syndrome causes and the youngest case have now occurred at 15 months. Two retrospective studies identified an increased risk of osteoporotic fractures in PPNAD as compared with other Cushing's syndrome causes. The utility of 6-day oral dexamethasone test to produce a paradoxical increase of urinary-free cortisol in PPNAD was confirmed but the mean fold of increase was of 48%, less than previously suggested. Several new genetic variants of the PRKAR1A gene have been reported in PPNAD or Carney complex (CNC). Remission of Cushing's syndrome with unilateral adrenalectomy was reported in a few patients with PPNAD. SUMMARY MiBAH, PPNAD and CNC are rare challenging diseases, but with combined expert clinical and genetic approaches a comprehensive investigation and prevention strategy can be offered to affected patients and families.
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Affiliation(s)
- Michel Maillet
- Division of Endocrinology, Department of Medicine, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Québec, Canada
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21
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Abstract
Adrenocortical hyperplasia may develop in different contexts. Primary adrenal hyperplasia may be secondary to primary bilateral macronodular adrenocortical hyperplasia (PBMAH) or micronodular bilateral adrenal hyperplasia (MiBAH) which may be divided in primary pigmented nodular adrenocortical disease (PPNAD) and isolated micronodular adrenocortical disease (i-MAD). Both lead to oversecretion of cortisol and potentially to Cushing's syndrome. Moreover, adrenocortical hyperplasia may be secondary to longstanding ACTH stimulation in ACTH oversecretion as in Cushing's disease, ectopic ACTH secretion or glucocorticoid resistance syndrome and congenital adrenal hyperplasia secondary to various enzymatic defects within the cortex. Finally, idiopathic bilateral adrenal hyperplasia is the most common cause of primary aldosteronism. We will discuss recent findings on the multifaceted forms of adrenocortical hyperplasia.
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Affiliation(s)
- Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada.
| | - Stéfanie Parisien-La Salle
- Division of Endocrinology, Department of Medicine, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada.
| | - André Lacroix
- Division of Endocrinology, Department of Medicine, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montréal, Canada.
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22
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Abstract
Cushing syndrome (CS) describes the signs and symptoms caused by exogenous or endogenous hypercortisolemia. Endogenous CS is caused by either ACTH-dependent sources (pituitary or ectopic) or ACTH-independent (adrenal) hypercortisolemia. Several genes are currently known to contribute to the pathogenesis of CS. Germline gene defects, such as MEN1, AIP, PRKAR1A and others, often present in patients with pituitary or adrenal involvement as part of a genetic syndrome. Somatic defects in genes, such as USP8, TP53, and others, are also involved in the development of pituitary or adrenal tumors in a large percentage of patients with CS, and give insight in pathways involved in pituitary or adrenal tumorigenesis.
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Affiliation(s)
- Christina Tatsi
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, 20892, MD, USA.
| | - Chelsi Flippo
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, 20892, MD, USA.
| | - Constantine A Stratakis
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, 20892, MD, USA.
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Espiard S, Vantyghem MC, Assié G, Cardot-Bauters C, Raverot G, Brucker-Davis F, Archambeaud-Mouveroux F, Lefebvre H, Nunes ML, Tabarin A, Lienhardt A, Chabre O, Houang M, Bottineau M, Stroër S, Groussin L, Guignat L, Cabanes L, Feydy A, Bonnet F, North MO, Dupin N, Grabar S, Duboc D, Bertherat J. Frequency and Incidence of Carney Complex Manifestations: A Prospective Multicenter Study With a Three-Year Follow-Up. J Clin Endocrinol Metab 2020; 105:5698168. [PMID: 31912137 DOI: 10.1210/clinem/dgaa002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/03/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Carney Complex (CNC) is a rare multiple endocrine and nonendocrine neoplasia syndrome. Manifestations and genotype-phenotype correlations have been described by retrospective studies, but no prospective study evaluating the occurrence of the different manifestations has been available so far. METHODS This multicenter national prospective study included patients with CNC, primary pigmented nodular adrenal disease (PPNAD), or a pathogenic PRKAR1A mutation; after a full initial workup, participants were followed for 3 years with annual standardized evaluation. RESULTS The cohort included 70 patients (50 female/20 male, mean age 35.4 ± 16.7 years, 81% carrying PRKAR1A mutation). The initial investigations allowed identification of several manifestations. At the end of the 3-year follow-up, the newly diagnosed manifestations of the disease were subclinical acromegaly in 6 patients, bilateral testicular calcifications in 1 patient, and cardiac myxomas in 2 patients. Recurrences of cardiac myxomas were diagnosed in 4 patients during the 3-year follow-up study period. Asymptomatic abnormalities of the corticotroph and somatotroph axis that did not meet criteria of PPNAD and acromegaly were observed in 11.4% and 30% of the patients, respectively. Patients carrying the PRKAR1A c.709-7del6 mutation had a mild phenotype. CONCLUSION This study underlines the importance of a systematic follow-up of the CNC manifestations, especially a biannual screening for cardiac myxoma. By contrast, regular screening for the other manifestations after a first extensive workup could be spread out, leading to a lighter and more acceptable follow-up schedule for patients. These are important results for recommendations for long-term management of CNC patients.
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Affiliation(s)
- Stéphanie Espiard
- INSERM U1016, CNRS UMR8104, Institut Cochin, Université Paris Descartes, Paris
- Service d'Endocrinologie, Centre de référence des maladies rares de la surrénale, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
- Service d'endocrinologie, diabétologie, métabolisme et nutrition, CHR-U de Lille, Hôpital Huriez, Lille, France
| | - Marie-Christine Vantyghem
- Service d'endocrinologie, diabétologie, métabolisme et nutrition, CHR-U de Lille, Hôpital Huriez, Lille, France
| | - Guillaume Assié
- INSERM U1016, CNRS UMR8104, Institut Cochin, Université Paris Descartes, Paris
- Service d'Endocrinologie, Centre de référence des maladies rares de la surrénale, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Catherine Cardot-Bauters
- Service d'endocrinologie, diabétologie, métabolisme et nutrition, CHR-U de Lille, Hôpital Huriez, Lille, France
| | - Gerald Raverot
- Fédération d'endocrinologie, groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Françoise Brucker-Davis
- Service d'endocrinologie, diabétologie et médecine de la reproduction, CHU de Nice, Nice, France
| | | | - Hervé Lefebvre
- Service d'endocrinologie, diabète et maladie métabolique, CHU de Rouen, Rouen, France
| | - Marie-Laure Nunes
- Service d'endocrinologie, diabétologie et maladies métaboliques, Faculté de médecine Bordeaux-Victor-Ségalen, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Antoine Tabarin
- Service d'endocrinologie, diabétologie et maladies métaboliques, Faculté de médecine Bordeaux-Victor-Ségalen, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | | | - Olivier Chabre
- Service d'Endocrinologie, CHU Grenoble Alpes and Université Grenoble Alpes, Grenoble, France
| | - Muriel Houang
- Service d'endocrinologie pédiatrique, CHU Paris Est, Hôpital d'Enfants Armand-Trousseau, Paris, France
| | - Muriel Bottineau
- Université Paris Descartes, Sorbonne Paris Cité AP-HP, Unité de Biostatistique et Epidémiologie, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Paris, France
| | - Sebastian Stroër
- Service de Radiologie B, AP-HP, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, Paris, France
| | - Lionel Groussin
- INSERM U1016, CNRS UMR8104, Institut Cochin, Université Paris Descartes, Paris
- Service d'Endocrinologie, Centre de référence des maladies rares de la surrénale, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Laurence Guignat
- Service d'Endocrinologie, Centre de référence des maladies rares de la surrénale, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Laure Cabanes
- Service de Cardiologie, Hôpital Cochin, APHP, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Antoine Feydy
- Service de Radiologie B, AP-HP, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, Paris, France
| | - Fidéline Bonnet
- Service d'Hormonologie, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Marie Odile North
- Service d'Oncogénétique, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Nicolas Dupin
- Service de Dermatologie, Hôpital Cochin, Assistance publique - Hôpitaux de Paris, Paris, France
| | - Sophie Grabar
- Université Paris Descartes, Sorbonne Paris Cité AP-HP, Unité de Biostatistique et Epidémiologie, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Paris, France
| | - Denis Duboc
- Service de Cardiologie, Hôpital Cochin, APHP, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Jérôme Bertherat
- INSERM U1016, CNRS UMR8104, Institut Cochin, Université Paris Descartes, Paris
- Service d'Endocrinologie, Centre de référence des maladies rares de la surrénale, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
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Bavadiya G, Roy A, Sarkar KK, Shekhda KM, Chatterjee A, Shah C, Chakrabarty A. PRIMARY PIGMENTED NODULAR ADRENOCORTICAL DISEASE (PPNAD) PRESENTING AS CUSHING SYNDROME IN A CHILD AND REVIEW OF LITERATURE. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 16:362-365. [PMID: 33363661 DOI: 10.4183/aeb.2020.362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cushing syndrome in the paediatric age group is very difficult to diagnose due to atypical presenting features in children. Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of ACTH-independent Cushing syndrome in children and it has characteristic gross and microscopic pathologic features. We report a case of PPNAD in a 16-year-old boy who was evaluated in our hospital with chief complaints of poor height velocity and rapid weight gain for 2-3 years before presentation. Proper evaluation showed ACTH-independent Cushing syndrome with normal imaging. Total bilateral adrenalectomy was performed followed by hormones replacement. 6 months after surgery, significant acceleration of height velocity was noticed. Patient also lost body weight and developed secondary sexual characteristics.
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Affiliation(s)
- G Bavadiya
- Vivekananda Institute of Medical Sciences - Urology, West Bengal, India
| | - A Roy
- Vivekananda Institute of Medical Sciences - Diabetes and Endocrinology, West Bengal, India
| | - K K Sarkar
- Vivekananda Institute of Medical Sciences - Urology, West Bengal, India
| | - K M Shekhda
- Southend University Hospital NHS Foundation Trust - Diabetes and Endocrinology, Prittlewell chase, Westcliff-on-Sea, United Kingdom of Great Britain and Northern Ireland
| | - A Chatterjee
- Vivekananda Institute of Medical Sciences - General Medicine, Kolkata, West Bengal, India
| | - C Shah
- Vivekananda Institute of Medical Sciences - Urology, West Bengal, India
| | - A Chakrabarty
- Vivekananda Institute of Medical Sciences - Urology, West Bengal, India
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Memon SS, Thakkar K, Patil V, Jadhav S, Lila AR, Fernandes G, Bandgar TR, Shah NS. Primary pigmented nodular adrenocortical disease (PPNAD): single centre experience. J Pediatr Endocrinol Metab 2019; 32:391-397. [PMID: 30875328 DOI: 10.1515/jpem-2018-0413] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/30/2019] [Indexed: 12/21/2022]
Abstract
Background Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of Cushing's syndrome (CS) in childhood. We describe a case series of patients presenting at our centre along with a review of the literature. Methods A retrospective analysis of six index cases and one family were done for demographic features, hormonal profile, imaging findings, genetic mutation status, histopathologic findings and follow-up details. Diagnosis was based on biochemistry and confirmed with histopathology and or genetic mutation. All patients had suppressed 8 am adrenocorticotropic hormone (ACTH) (<10 pg/mL) despite evidence of hypercortisolism. Results The mean age in our cohort was 8.2 years (range 15 months to 20 years). All patients presented with overt CS, including one patient with cyclic Cushing's. Three patients had additional features of Carney complex (CNC). Imaging did not reveal any obvious mass lesions on computed tomography (CT), the classical beaded appearance was present in only two of the patients. Mutation analysis was positive in three patients. Five patients underwent bilateral adrenalectomy and had features of PPNAD on histopathology. Conclusions PPNAD is a rare cause of ACTH-independent CS in childhood and may signal underlying CNC. Patients with younger age of onset with overt CS may still have a mutation in the PRKAR1A gene and warrant genetic testing.
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Affiliation(s)
- Saba Samad Memon
- Department of Endocrinology and Metabolism, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
| | - Kunal Thakkar
- Department of Endocrinology and Metabolism, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
| | - Virendra Patil
- Department of Endocrinology and Metabolism, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
| | - Swati Jadhav
- Department of Endocrinology and Metabolism, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
| | - Anurag R Lila
- Department of Endocrinology and Metabolism, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
| | - Gwendolyn Fernandes
- Department of Pathology, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
| | - Tushar R Bandgar
- Department of Endocrinology and Metabolism, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
| | - Nalini S Shah
- Department of Endocrinology and Metabolism, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
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Zhang CD, Pichurin PN, Bobr A, Lyden ML, Young WF, Bancos I. Cushing syndrome: uncovering Carney complex due to novel PRKAR1A mutation. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180150. [PMID: 30897549 PMCID: PMC6432981 DOI: 10.1530/edm-18-0150] [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: 01/20/2019] [Accepted: 03/04/2019] [Indexed: 11/24/2022] Open
Abstract
Carney complex (CNC) is a rare multiple neoplasia syndrome characterized by spotty pigmentation of the skin and mucosa in association with various non-endocrine and endocrine tumors, including primary pigmented nodular adrenocortical disease (PPNAD). A 20-year-old woman was referred for suspected Cushing syndrome. She had signs of cortisol excess as well as skin lentigines on physical examination. Biochemical investigation was suggestive of corticotropin (ACTH)-independent Cushing syndrome. Unenhanced computed tomography scan of the abdomen did not reveal an obvious adrenal mass. She subsequently underwent bilateral laparoscopic adrenalectomy, and histopathology was consistent with PPNAD. Genetic testing revealed a novel frameshift pathogenic variant c.488delC/p.Thr163MetfsX2 (ClinVar Variation ID: 424516) in the PRKAR1A gene, consistent with clinical suspicion for CNC. Evaluation for other clinical features of the complex was unrevealing. We present a case of PPNAD-associated Cushing syndrome leading to the diagnosis of CNC due to a novel PRKAR1A pathogenic variant. Learning points: PPNAD should be considered in the differential for ACTH-independent Cushing syndrome, especially when adrenal imaging appears normal. The diagnosis of PPNAD should prompt screening for CNC. CNC is a rare multiple neoplasia syndrome caused by inactivating pathogenic variants in the PRKAR1A gene. Timely diagnosis of CNC and careful surveillance can help prevent potentially fatal complications of the disease.
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Affiliation(s)
- Catherine D Zhang
- Departments of Internal Medicine, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Pavel N Pichurin
- Departments of Clinical Genomics, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Aleh Bobr
- Departments of Laboratory Medicine and Pathology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Melanie L Lyden
- Departments of Surgery, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - William F Young
- Departments of Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Irina Bancos
- Departments of Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Sakaguchi C, Ashida K, Kohashi K, Ohe K, Fujii Y, Yano S, Matsuda Y, Sakamoto S, Sakamoto R, Oda Y, Nomura M, Ogawa Y. A case of autonomous cortisol secretion in a patient with subclinical Cushing's syndrome, GNAS mutation, and paradoxical cortisol response to dexamethasone. BMC Endocr Disord 2019; 19:13. [PMID: 30670014 PMCID: PMC6343241 DOI: 10.1186/s12902-019-0345-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/19/2018] [Accepted: 01/16/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Increased urinary free cortisol in response to the oral administration of dexamethasone is a paradoxical reaction mainly reported in patients with primary pigmented nodular adrenocortical disease. Here, we describe the first case of subclinical Cushing's syndrome represented by autonomous cortisol secretion and paradoxical response to oral dexamethasone administration, harboring an activating mutation in the α subunit of the stimulatory G protein (GNAS). CASE PRESENTATION A 65-year-old woman was diagnosed with subclinical Cushing's syndrome during an evaluation for bilateral adrenal masses. Tumors of unknown origin were found in the heart, brain, thyroid gland, colon, pancreas, and both adrenal glands. Adenocarcinoma of the sigmoid colon and systemic brown-patchy skin pigmentation were also present. Her urinary cortisol levels increased in response to oral dexamethasone, while serum dehydroepiandrosterone-sulfate was not suppressed. After right adrenalectomy, genetic analysis of the resected tumor revealed the somatic GNAS activating mutation, p.R201H. Paradoxical urinary cortisol response persisted even after unilateral adrenal resection, although serum and urinary cortisol levels were attenuated. CONCLUSIONS This patient harbored a GNAS activating mutation, and presented with a mild cortisol- and androgen-producing adrenal adenoma. Administration of oral dexamethasone paradoxically increased cortisol levels, possibly via the stimulation of the cyclic adenosine monophosphate-dependent protein kinase A signaling pathway, which is seen in patients with pigmented nodular adrenocortical disease or Carney complex. GNAS mutations may provide clues to the mechanisms of hyper-function and tumorigenesis in the adrenal cortex, especially in bilateral adrenal masses accompanied by multiple systemic tumors. Examining GNAS mutations could help physicians detect extra-adrenal malignancies, which may contribute to an improved prognosis for patients with this type of Cushing's syndrome.
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Affiliation(s)
- Chihiro Sakaguchi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ashida
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume-city, Fukuoka, 830-0011 Japan
| | - Kenichi Kohashi
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ohe
- Faculty of Pharmaceutical Sciences, Fukuoka University, Fukuoka, Japan
| | - Yoichi Fujii
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Seiichi Yano
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yayoi Matsuda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shohei Sakamoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryuichi Sakamoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masatoshi Nomura
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume-city, Fukuoka, 830-0011 Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Pineyro MM, Redes L, De Mattos S, Sanchez L, Brignardello E, Bianchi V, Ems V, Centurión D, Viola M. Factitious Cushing's Syndrome: A Diagnosis to Consider When Evaluating Hypercortisolism. Front Endocrinol (Lausanne) 2019; 10:129. [PMID: 30886602 PMCID: PMC6409302 DOI: 10.3389/fendo.2019.00129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/12/2019] [Indexed: 11/23/2022] Open
Abstract
Factitious Cushing's syndrome is exceptionally rare. The diagnosis is challenging due to the interference of exogenous corticosteroids with cortisol immunoassays. We present a case of a 26 year old female that presented with clinical and biochemical features of Cushing's syndrome. She denied any exogenous corticosteroid use. She had a suppressed ACTH level with normal adrenal glands on CT scans. There was a paradoxical increase of cortisol with a 100% rise in 24 h urinary free cortisol (UFC) during the Liddle's test suggestive of primary pigmented nodular adrenocortical disease (PPNAD). However, basal UFC levels were within normal values, interpreted as an intermittent variation of cortisol secretion maybe due to cyclic Cushing's. At this point a synthetic glucocorticoid serum screening was ordered, which was denied by the administrators because the test was not available in our hospital. A positron emission tomography (PET)-CT using 18 F-Flurodeoxyglucose did not show any uptake in the adrenal glands. With the diagnosis of probable primary pigmented nodular adrenocortical disease a unilateral right adrenelectomy was performed. Histopathological examination revealed normal adrenal gland. A synthetic glucocorticoid serum screen by liquid chromatography-tandem mass spectrometry (LC-MS/MS) sent to Mayo Clinic lab revealed high levels of serum prednisone and prednisolone. In conclusion, factitious Cushing's syndrome is an important diagnosis to consider in patients being evaluated for hypercortisolism. Discordant hormonal test results as well as normal findings on adrenal glands on CT scan should raise suspicion of this entity, and prompt measurement of synthetic corticosteroids using LC-MS/MS.
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Affiliation(s)
- Maria M. Pineyro
- Clínica de Endocrinología y Metabolismo, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
- *Correspondence: Maria M. Pineyro orcid.org/0000-0003-2083-7839
| | - Lia Redes
- Clínica Psiquiátrica, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Sylvana De Mattos
- Clínica Psiquiátrica, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Luciana Sanchez
- Clínica de Endocrinología y Metabolismo, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Estefania Brignardello
- Clínica de Endocrinología y Metabolismo, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Virginia Bianchi
- Clínica Psiquiátrica, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Vanessa Ems
- Clínica Psiquiátrica, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Dardo Centurión
- Departamento de Anatomía Patológica, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Marcelo Viola
- Clínica Quirúrgica 1, Facultad de Medicina, Hospital Pasteur, Universidad de la República, Montevideo, Uruguay
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Cyranska-Chyrek E, Filipowicz D, Szczepanek-Parulska E, Nowaczyk M, Ambroziak U, Toutounchi S, Koperski Ł, Bednarczuk T, Meczekalski B, Ruchała M. Primary pigmented nodular adrenocortical disease (PPNAD) as an underlying cause of symptoms in a patient presenting with hirsutism and secondary amenorrhea: case report and literature review. Gynecol Endocrinol 2018; 34:1022-1026. [PMID: 30129786 DOI: 10.1080/09513590.2018.1493101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Hypercortisolemia in females may lead to menstrual cycle disturbances, infertility, hirsutism and acne. Herewith, we present a 18-year-old patient, who was diagnosed due to weight gain, secondary amenorrhea, slowly progressing hirsutism, acne and hot flashes. Thorough diagnostics lead to a conclusion, that the symptoms was the first manifestation of primary pigmented nodular adrenocortical disease (PPNAD). All symptoms of Cushing syndrome including hirsutism and menstrual disturbances resolved after bilateral adrenalectomy. Our report indicates that oligo- or amenorrhea, hirsutism, acne in combination with weight gain, growth failure, hypertension and slightly expressed cushingoid features in a young woman requires diagnostics towards hypercortisolemia. Despite PPNAD is a very rare cause of ACTH-independent Cushing syndrome, it has to be taken into consideration, especially when adrenal glands appear to be normal on imaging and paradoxical rise in cortisol level in high-dose dexamethasone test is observed. Unlike in our patient, in vast majority of patients, PPNAD is associated with Carney complex (CC). Therefore, these patients and their first-degree relatives should be always carefully screened for symptoms of PPNAD, CC and genetic mutations of PRKAR1A, PDE11A, and PDE8B genes.
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Affiliation(s)
- Ewa Cyranska-Chyrek
- a Department of Endocrinology, Metabolism and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Dorota Filipowicz
- a Department of Endocrinology, Metabolism and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Ewelina Szczepanek-Parulska
- a Department of Endocrinology, Metabolism and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Marta Nowaczyk
- a Department of Endocrinology, Metabolism and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
| | - Urszula Ambroziak
- b Department of Internal Medicine and Endocrinology , Medical University of Warsaw , Warsaw , Poland
| | - Sadegh Toutounchi
- c Department of General and Endocrine Surgery , Medical University of Warsaw , Warsaw , Poland
| | - Łukasz Koperski
- d Department of Pathology , Medical University of Warsaw , Warsaw , Poland
| | - Tomasz Bednarczuk
- b Department of Internal Medicine and Endocrinology , Medical University of Warsaw , Warsaw , Poland
| | - Blazej Meczekalski
- e Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | - Marek Ruchała
- a Department of Endocrinology, Metabolism and Internal Medicine , Poznan University of Medical Sciences , Poznan , Poland
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Kiriakopoulos A, Linos D. Carney Syndrome Presented as a Pathological Spine Fracture in a 35-Year-Old Male. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1366-1369. [PMID: 30442879 PMCID: PMC6251001 DOI: 10.12659/ajcr.911962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Patient: Male, 35 Final Diagnosis: Carney syndrome Symptoms: Pain at the spine Medication: — Clinical Procedure: Retroperitoneal adrenalectomy Specialty: Surgery
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Affiliation(s)
- Andreas Kiriakopoulos
- Fifth Surgical Clinic, Department of Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Dimitrios Linos
- Fifth Surgical Clinic, Department of Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Pasternak-Pietrzak K, Stratakis CA, Moszczyńska E, Lecka-Ambroziak A, Staniszewski M, Wątrobińska U, Lyssikatos C, Prokop-Piotrkowska M, Grajkowska W, Pronicki M, Szalecki M. Detection of new potentially pathogenic mutations in two patients with primary pigmented nodular adrenocortical disease (PPNAD) - case reports with literature review. ENDOKRYNOLOGIA POLSKA 2018; 69:675-681. [PMID: 30259502 DOI: 10.5603/ep.a2018.0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/27/2018] [Accepted: 04/29/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Primary pigmented nodular adrenocortical disease (PPNAD) is a rare form of ACTH-independent Cushing's syndrome (CS). Half of patients with PPNAD are sporadic cases and the other half familial. MATERIAL AND METHODS We present two patients with PPNAD confirmed by genetic analysis. RESULTS In both patients there were no abnormal findings on diagnostic imaging of both adrenals and heart. Patients underwent bilateral two-stage adrenalectomy. Histopathological examination confirmed PPNAD. Genetic testing showed the following mutations in the PRKAR1A gene coding for the regulatory subunit type 1A of the protein kinase A enzyme: c.125dupG (patient 1) and c.15dupT (patient 2). Both these defects lead to inactivation of the PRKAR1A protein and are consequently causative of PPNAD in these patients. CONCLUSIONS The novel mutations presented in this article are considered to be pathogenic for PPNAD.
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Tirosh A, Valdés N, Stratakis CA. Genetics of micronodular adrenal hyperplasia and Carney complex. Presse Med 2018; 47:e127-e137. [PMID: 30093212 DOI: 10.1016/j.lpm.2018.07.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Micronodular bilateral adrenal hyperplasia (MiBAH) is a rare cause of adrenal Cushing syndrome (CS). The investigations carried out on this disorder during the last two decades suggested that it could be divided into at least two entities: primary pigmented nodular adrenocortical disease (PPNAD) and isolated micronodular adrenocortical disease (i-MAD). The most common presentation of MiBAH is familial PPNAD as part of Carney complex (CNC) (cPPNAD). CNC, associated with multiple endocrine and non-endocrine neoplasias, was first described in 1985 in 40 patients, 10 of whom were familial cases. In 2000, we identified inactivating germline mutations of the PRKAR1A gene, encoding the regulatory subunit type 1α (RIα) of protein kinase A (PKA), in the majority of patients with CNC and PPNAD. PRKAR1A mutations causing CNC lead to increased PKA activity. Since then, additional genetic alterations in the cAMP/PKA signaling pathway leading to increased PKA activity have been described in association with MiBAH. This review summarizes older and recent findings on the genetics and pathophysiology of MiBAH, PPNAD, and related disorders.
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Affiliation(s)
- Amit Tirosh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Section on Endocrinology and Genetics, Bethesda, MD 20892, USA; Tel-Aviv University, Sackler Faculty of Medicine, 6997801 Tel Aviv-Yafo, Israel
| | - Nuria Valdés
- Hospital Universitario Central de Asturias, Department of Endocrinology and Nutrition, Avenida de Roma s/n, 33011 Oviedo, Asturias, Spain
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Section on Endocrinology and Genetics, Bethesda, MD 20892, USA.
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Fu J, Lai F, Chen Y, Wan X, Wei G, Li Y, Xiao H, Cao X. A novel splice site mutation of the PRKAR1A gene, C.440+5 G>C, in a Chinese family with Carney complex. J Endocrinol Invest 2018; 41:909-917. [PMID: 29318463 DOI: 10.1007/s40618-017-0817-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/24/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Carney complex (CNC) is an extremely rare, multiple endocrine neoplasia syndrome that occurs in an autosomal dominant manner. Mutations in PRKAR1A have been reported to be a common genetic cause of CNC. METHODS In this study, we reported a Chinese pedigree of CNC that manifests mainly as spotty skin pigmentation and primary pigmented nodular adrenocortical disease. Whole blood samples of this pedigree were collected for DNA/RNA analysis. Polymerase chain reaction (PCR) and reverse-transcription polymerase chain reaction analyses were performed to amplify the 11 exons and adjacent introns of PRKAR1A. Direct sequencing was used to detect the mutation, and DNA from 70 Han Chinese people was extracted and sequenced as a control to estimate the frequency of the identified mutation. RESULTS Within the pedigree, ten patients with CNC were identified, and a novel heterozygous mutation (c.440+5 G>C in intron 4a) was identified in the PRKAR1A gene. PCR amplification of cDNA from the control subjects and patients was performed. Agarose gel electrophoresis showed only one wild-type band in the cDNA corresponding to the former group, whereas an extra band was present in samples from the latter group corresponding to the skipping of exon 4a; this confirms that the variant affects PRKAR1A splicing. CONCLUSION In conclusion, the c.440+5 G>C mutation is a new splice site mutation that has not been reported and has the potential to broaden the mutational spectrum of PRKAR1A that is associated with CNC, which would facilitate genetic diagnosis and counseling for CNC.
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Affiliation(s)
- J Fu
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou, 510080, Guangdong, China
| | - F Lai
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou, 510080, Guangdong, China
| | - Y Chen
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou, 510080, Guangdong, China
| | - X Wan
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou, 510080, Guangdong, China
| | - G Wei
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou, 510080, Guangdong, China
| | - Y Li
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou, 510080, Guangdong, China
| | - H Xiao
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou, 510080, Guangdong, China
| | - X Cao
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd., Guangzhou, 510080, Guangdong, China.
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Weigand I. Pathogenesis of benign unilateral adrenocortical tumors: focus on cAMP/PKA pathway. MINERVA ENDOCRINOL 2018; 44:25-32. [PMID: 29963826 DOI: 10.23736/s0391-1977.18.02874-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Somatic mutations affecting genes in the cAMP/PKA (protein kinase A) signaling pathway have been described as causative for the pathogenesis of benign unilateral adrenocortical adenomas associated with cortisol over secretion. These include predominantly somatic mutations in the PRKACA gene which encodes the catalytic subunit α of PKA. In addition, mutations in the GNAS gene, coding for the stimulatory G protein α, have been observed in approximately 10% of cortisol producing adenomas (CPA). The mutations render PKA signaling constitutively active and are therefore involved in cortisol over secretion of these tumors. Despite the prominent role of the cAMP/PKA pathway in the pathogenesis of unilateral CPA, also mutations in the CTNNB1 gene, encoding β-catenin, were identified in CPA. However, mutations in β-catenin are not limited to CPA and are not associated with cortisol secretion since they were predominantly found in endocrine-inactive adenomas (EIA) and might hence contribute to tumorigenesis in adrenocortical tissues. In this review, recent findings in the pathogenesis of benign adrenocortical tumors with a particular focus on the cAMP/PKA signaling pathway are summarized.
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Affiliation(s)
- Isabel Weigand
- Unit of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Wuerzburg, Wuerzburg, Germany -
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Abstract
The knowledge on the molecular and genetic causes of Cushing's syndrome (CS) has greatly increased in the recent years. Somatic mutations leading to overactive 3',5'-cyclic adenosine monophosphate/protein kinase A and wingless-type MMTV integration site family/beta-catenin pathways are the main molecular mechanisms underlying adrenocortical tumorigenesis. Corticotropinomas are characterized by resistance to glucocorticoid negative feedback, impaired cell cycle control and overexpression of pathways sustaining ACTH secretion. Recognizing the genetic defects behind corticotroph and adrenocortical tumorigenesis proves crucial for tailoring the clinical management of CS patients and for designing strategies for genetic counseling and clinical screening to be applied in routine medical practice.
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Affiliation(s)
- Laura C Hernández-Ramírez
- Section on Endocrinology and Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), 10 Center Drive, CRC, Room 1E-3216, Bethesda, MD 20892-1862, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), 10 Center Drive, CRC, Room 1E-3216, Bethesda, MD 20892-1862, USA.
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Tatsi C, Stratakis CA. Neonatal Cushing Syndrome: A Rare but Potentially Devastating Disease. Clin Perinatol 2018; 45:103-118. [PMID: 29406000 PMCID: PMC5806137 DOI: 10.1016/j.clp.2017.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Neonatal Cushing syndrome (CS) is most commonly caused by exogenous administration of glucocorticoids and rarely by endogenous hypercortisolemia. CS owing to adrenal lesions is the most common cause of endogenous CS in neonates and infants, and adrenocortical tumors (ACTs) represent most cases. Many ACTs develop in the context of a TP53 gene mutation, which causes Li-Fraumeni syndrome. More rarely, neonatal CS presents as part of other syndromes such as McCune-Albright syndrome or Beckwith-Wiedemann syndrome. Management usually includes resection of the primary tumor with or without additional medical treatment, but manifestations may persist after resolution of hypercortisolemia.
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Affiliation(s)
- Christina Tatsi
- Section on Endocrinology & Genetics, Developmental Endocrine Oncology and Genetics Group, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD 20892, USA,Pediatric Endocrinology Inter-institute Training Program, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Constantine A. Stratakis
- Section on Endocrinology & Genetics, Developmental Endocrine Oncology and Genetics Group, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD 20892, USA,Pediatric Endocrinology Inter-institute Training Program, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD 20892, USA
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Hannah-Shmouni F, Moraitis AG, Romero VV, Faucz FR, Mastroyannis SA, Berthon A, Failor RA, Merino M, Demidowich AP, Stratakis CA. Successful Treatment of Estrogen Excess in Primary Bilateral Macronodular Adrenocortical Hyperplasia with Leuprolide Acetate. Horm Metab Res 2018; 50:124-132. [PMID: 29183089 PMCID: PMC6343127 DOI: 10.1055/s-0043-122074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Primary bilateral macronodular adrenocortical hyperplasia (PBMAH) is an uncommon cause of adrenal Cushing syndrome (CS) in which cortisol and occasionally other steroid hormones can be secreted under the influence of aberrantly expressed G-protein coupled receptors (GPCRs) in the adrenal cortex. We describe the unique case of a 64-year-old postmenopausal female with PBMAH whose adrenal lesions expressed luteinizing hormone receptors (LHr). She presented initially with CS and underwent right adrenalectomy; a few years later she presented with macromastia and mastodynia, possibly due to estrogen excess from her remaining left adrenocortical masses. Testing before and after treatment with quarterly leuprolide acetate therapy and immunohistochemistry on tissue and targeted sequencing of the genes of interest were performed. Tissue from the patient's right adrenal was tested for P450 aromatase (CYP19A1) and LHr expression; both were expressed throughout the hyperplastic cortex, although expression was more intense in the adenomatous areas. Targeted sequencing revealed a pathogenic PDE11A mutation, as well as variants in the ARMC5 and INHA genes. PDE11A expression was decreased in the adenoma but there was no loss of heterozygosity for the PDE11A locus. Because of the clinical presentation and LHr expression, quarterly leuprolide acetate therapy was started. Shortly after initiation of therapy, the patient reported decreased breast size and pain; she remains well controlled to date, after 10 years of treatment. This is the first description of a patient with PBMAH presenting with severe macromastia and mastodynia from what appears to be excess estrogen production from her adrenal tumor. The patient had a long-lasting response to chronic leuprolide acetate treatment, showing that drug therapy exploiting the aberrant receptor expression in PBMAH is possible even in the absence of cortisol overproduction.
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Affiliation(s)
- Fady Hannah-Shmouni
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Andreas G. Moraitis
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
- Corcept Therapeutics Incorporated, Drug Research and Development, MI, USA (Current address)
| | | | - Fabio R. Faucz
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Spyridon A. Mastroyannis
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Annabel Berthon
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Richard A. Failor
- Division of Endocrinology, Metabolism, & Nutrition University of Washington, Seattle, WA, USA
| | - Maria Merino
- Laboratory of Pathology, National Cancer Institute (NCI), NIH, Bethesda, MD, USA
| | - Andrew P. Demidowich
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Constantine A. Stratakis
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
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Chen S, Li R, Lu L, Duan L, Zhang X, Tong A, Pan H, Zhu H, Lu Z. Efficacy of dexamethasone suppression test during the diagnosis of primary pigmented nodular adrenocortical disease in Chinese adrenocorticotropic hormone-independent Cushing syndrome. Endocrine 2018; 59:183-190. [PMID: 29094256 PMCID: PMC5765188 DOI: 10.1007/s12020-017-1436-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 09/20/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the cut-off value of the ratio of 24 h urinary free cortisol (24 h UFC) levels post-dexamethasone to prior-dexamethasone in dexamethasone suppression test (DST) during the diagnosis of primary pigmented nodular adrenocortical disease in Chinese adrenocorticotropic hormone-independent Cushing syndrome. DESIGN Retrospective study. PARTICIPANTS The patients diagnosed with primary pigmented nodular adrenocortical disease (PPNAD, n = 25), bilateral macronodular adrenal hyperplasia (BMAH, n = 27), and adrenocortical adenoma (ADA, n = 84) were admitted to the Peking Union Medical College Hospital from 2001 to 2016. ESTIMATIONS Serum cortisol, adrenocorticotropic hormone (ACTH), and 24 h UFC were measured before and after low-dose dexamethasone suppression test (LDDST) and high-dose dexamethasone suppression test (HDDST). RESULTS After LDDST and HDDST, 24 h UFC elevated in patients with PPNAD (paired t-test, P = 0.007 and P = 0.001), while it remained unchanged in the BMAH group (paired t-test, P = 0.471 and P = 0.414) and decreased in the ADA group (paired t-test, P = 0.002 and P = 0.004). The 24 h UFC level after LDDST was higher in PPNAD and BMAH as compared to ADA (P < 0.017), while no significant difference was observed between PPNAD and BMAH. After HDDST, 24 h UFC was higher in patients with PPNAD as compared to that of ADA and BMAH (P < 0.017). The cut-off value of 24 h UFC (Post-L-Dex)/(Pre-L-Dex) was 1.16 with 64.0% sensitivity and 77.9% specificity, and the cut-off value of 24 h UFC (Post-H-Dex)/(Pre-H-Dex) was 1.08 with 84.0% sensitivity and 75.6% specificity. CONCLUSION The ratio of post-dexamethasone to prior-dexamethasone had a unique advantage in distinguishing PPNAD from BMAH and ADA.
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Affiliation(s)
- Shi Chen
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Ran Li
- Eight-year Program of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China.
| | - Lian Duan
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Xuebin Zhang
- Department of Urology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Anli Tong
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Hui Pan
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
| | - Zhaolin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Key Laboratory of Endocrinology of National Health and Family Planning Commission, Beijing, China
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Abstract
Cushing syndrome (CS) is caused by chronic exposure to excess glucocorticoids. Early recognition and treatment of hypercortisolemia can lead to decreased morbidity and mortality. The diagnosis of CS and thereafter, establishing the cause can often be difficult, especially in patients with mild and cyclic hypercortisolism. Surgical excision of the cause of excess glucocorticoids is the optimal treatment for CS. Medical therapy (steroidogenesis inhibitors, medications that decrease adrenocorticotropic hormone [ACTH] levels or glucocorticoid antagonists) and pituitary radiotherapy may be needed as adjunctive treatment modalities in patients with residual, recurrent or metastatic disease, in preparation for surgery, or when surgery is contraindicated. A multidisciplinary team approach, individualized treatment plan and long-term follow-up are important for optimal management of hypercortisolemia and the comorbidities associated with CS. ABBREVIATIONS ACTH = adrenocorticotropic hormone; BIPSS = bilateral inferior petrosal sinus sampling; CBG = corticosteroid-binding globulin; CD = Cushing disease; CRH = corticotropin-releasing hormone; CS = Cushing syndrome; Dex = dexamethasone; DST = dexamethasone suppression test; EAS = ectopic ACTH syndrome; FDA = U.S. Food & Drug Administration; HDDST = high-dose DST; IPS/P = inferior petrosal sinus to peripheral; MRI = magnetic resonance imaging; NET = neuroendocrine tumor; PET = positron emission tomography; UFC = urinary free cortisol.
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Jarial KDS, Walia R, Nahar U, Bhansali A. Primary bilateral adrenal nodular disease with Cushing's syndrome: varying aetiology. BMJ Case Rep 2017; 2017:bcr-2017-220154. [PMID: 28739615 DOI: 10.1136/bcr-2017-220154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Primary adrenal disorders contribute 20%â€"30% of patients with endogenous Cushing's syndrome. Most of the primary adrenal diseases are unilateral and include adenoma and adrenocortical carcinoma, whereas bilateral adrenal lesions are uncommon and include primary pigmented nodular adrenocortical disease, primary bilateral macronodular adrenocortical hyperplasia, isolated micronodular adrenocortical disease, bilateral adenomas or carcinomas, and rarely pituitary adrenocorticotropic hormone-dependent adrenal nodular disease. Cyclic adenosine monophosphate-dependent protein kinase A signalling is the major activator of cortisol secretion in primary adrenal nodular disorders. We report two cases of bilateral adrenal nodular disease with endogenous Cushing's syndrome, including one each of primary pigmented nodular adrenocortical disease and primary bilateral macronodular adrenocortical hyperplasia.
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Affiliation(s)
- Kush Dev Singh Jarial
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Uma Nahar
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Katanić D, Kafka D, Živojinov M, Vlaški J, Budakov Z, Knežević Pogančev M, Vorgučin I, Ćuk T. Primary pigmented nodular adrenocortical disease: literature review and case report of a 6-year-old boy. J Pediatr Endocrinol Metab 2017; 30:603-609. [PMID: 28391254 DOI: 10.1515/jpem-2016-0249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 03/06/2017] [Indexed: 12/24/2022]
Abstract
Cushing's syndrome is rare in childhood and is usually caused by a pituitary adenoma. Primary hyperfunction of adrenal glands is less frequent, particularly primary pigmented nodular adrenocortical disease (PPNAD). It occurs usually in children and adolescents, with female preponderance, while Cushing's disease has increased frequency in prepubertal males. A case of a 6-year-old boy is presented with isolated non-familiar PPNAD. The clinical pattern involved Cushingoid appearance, hypertension, virilization and depressive mood. Laboratory analyses showed loss of circadian rhythm of cortisol, undetectable adrenocorticotropic hormone (ACTH) level, impaired fasting glucose, polycythemia and elevated white blood count (WBC). Radiology investigation revealed a slightly enlarged medial branch of the left adrenal gland and a normal right one, so a unilateral adrenalectomy was performed. Pathohistology described multiple dark brownish pigmented nodules of various sizes confined to the cortex. Contralateral adrenalectomy was done 3 months later. Follow-up of 3 years was uneventful, except for one adrenal crisis during an intercurrent respiratory illness.
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Affiliation(s)
- Dragan Katanić
- Paediatrician-Endocrinologist, Faculty of Medicine, University Paediatric Clinic, Novi Sad
| | - Dejan Kafka
- University of Novi Sad, Faculty of Medicine, Novi Sad
| | | | - Jovan Vlaški
- University of Novi Sad, Faculty of Medicine, Novi Sad
| | | | | | | | - Tomislav Ćuk
- University of Novi Sad, Faculty of Medicine, Novi Sad
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Arlt W, Lang K, Sitch AJ, Dietz AS, Rhayem Y, Bancos I, Feuchtinger A, Chortis V, Gilligan LC, Ludwig P, Riester A, Asbach E, Hughes BA, O'Neil DM, Bidlingmaier M, Tomlinson JW, Hassan-Smith ZK, Rees DA, Adolf C, Hahner S, Quinkler M, Dekkers T, Deinum J, Biehl M, Keevil BG, Shackleton CH, Deeks JJ, Walch AK, Beuschlein F, Reincke M. Steroid metabolome analysis reveals prevalent glucocorticoid excess in primary aldosteronism. JCI Insight 2017; 2:93136. [PMID: 28422753 PMCID: PMC5396526 DOI: 10.1172/jci.insight.93136] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/14/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Adrenal aldosterone excess is the most common cause of secondary hypertension and is associated with increased cardiovascular morbidity. However, adverse metabolic risk in primary aldosteronism extends beyond hypertension, with increased rates of insulin resistance, type 2 diabetes, and osteoporosis, which cannot be easily explained by aldosterone excess. METHODS We performed mass spectrometry-based analysis of a 24-hour urine steroid metabolome in 174 newly diagnosed patients with primary aldosteronism (103 unilateral adenomas, 71 bilateral adrenal hyperplasias) in comparison to 162 healthy controls, 56 patients with endocrine inactive adrenal adenoma, 104 patients with mild subclinical, and 47 with clinically overt adrenal cortisol excess. We also analyzed the expression of cortisol-producing CYP11B1 and aldosterone-producing CYP11B2 enzymes in adenoma tissue from 57 patients with aldosterone-producing adenoma, employing immunohistochemistry with digital image analysis. RESULTS Primary aldosteronism patients had significantly increased cortisol and total glucocorticoid metabolite excretion (all P < 0.001), only exceeded by glucocorticoid output in patients with clinically overt adrenal Cushing syndrome. Several surrogate parameters of metabolic risk correlated significantly with glucocorticoid but not mineralocorticoid output. Intratumoral CYP11B1 expression was significantly associated with the corresponding in vivo glucocorticoid excretion. Unilateral adrenalectomy resolved both mineralocorticoid and glucocorticoid excess. Postoperative evidence of adrenal insufficiency was found in 13 (29%) of 45 consecutively tested patients. CONCLUSION Our data indicate that glucocorticoid cosecretion is frequently found in primary aldosteronism and contributes to associated metabolic risk. Mineralocorticoid receptor antagonist therapy alone may not be sufficient to counteract adverse metabolic risk in medically treated patients with primary aldosteronism. FUNDING Medical Research Council UK, Wellcome Trust, European Commission.
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Affiliation(s)
- Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Katharina Lang
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Alice J Sitch
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Anna S Dietz
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Yara Rhayem
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Annette Feuchtinger
- Research Unit Analytical Pathology, Helmholtz Zentrum Munich, Oberschleißheim, Germany
| | - Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Ludwig
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Evelyn Asbach
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Beverly A Hughes
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Donna M O'Neil
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Zaki K Hassan-Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - D Aled Rees
- Neurosciences and Mental Health Research Institute, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Christian Adolf
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stefanie Hahner
- Department of Medicine I, Endocrine and Diabetes Unit, University Hospital Würzburg, Würzburg, Germany
| | | | - Tanja Dekkers
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Michael Biehl
- Johann Bernoulli Institute for Mathematics and Computer Science, University of Groningen, Groningen, Netherlands
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital South Manchester, Manchester, United Kingdom
| | - Cedric Hl Shackleton
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,University of California at San Francisco Benioff Children's Hospital, Oakland, California, USA
| | - Jonathan J Deeks
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Axel K Walch
- Research Unit Analytical Pathology, Helmholtz Zentrum Munich, Oberschleißheim, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, Munich, Germany
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43
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Lyssikatos C, Pavithran PV, Tirosh A, Faucz FR, Vasukutty JR, Belyavskaya E, Ahamed A, Raygada M, Stratakis CA. Newly Diagnosed Carney Complex in 3 Young Adults with Primary Adrenal Cushing Syndrome – A Case Series and Review of the Literature. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161541.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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44
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Gourgari E, Lodish M, Keil M, Sinaii N, Turkbey E, Lyssikatos C, Nesterova M, de la Luz Sierra M, Xekouki P, Khurana D, Ten S, Dobs A, Stratakis CA. Bilateral Adrenal Hyperplasia as a Possible Mechanism for Hyperandrogenism in Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab 2016; 101:3353-60. [PMID: 27336356 PMCID: PMC5010568 DOI: 10.1210/jc.2015-4019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
CONTEXT Androgen excess may be adrenal and/or ovarian in origin; we hypothesized that a subgroup of patients with polycystic ovarian syndrome (PCOS) may have some degree of abnormal adrenocortical function. OBJECTIVE The objective of the study was to evaluate the pituitary adrenal axis with an oral low- and high-dose dexamethasone-suppression test (Liddle's test) in women with PCOS. DESIGN This was a case-control study. SETTING The study was conducted at the National Institutes of Health Clinical Center. PARTICIPANTS A total of 38 women with PCOS and 20 healthy volunteers (HV) aged 16-29 years participated in the study. MAIN OUTCOME MEASURES Urinary free cortisol (UFC) and 17-hydroxysteroids (17OHS) before and after low- and high-dose dexamethasone and assessment of adrenal volume by computed tomography scan were measured. RESULTS Twenty-four-hour urinary 17OHS and UFC were measured during day 1 to day 6 of the Liddle's test. Baseline UFC levels were not different between PCOS and HVs; on the day after the completion of high-dose dexamethasone administration (d 6), UFC was higher in the PCOS group (2.0 ± 0.7 μg/m(2)·d) than the HV group (1.5 ± 0.5) (P = .038). On day 5, 17OHS and UFC were negatively correlated with adrenal volumes (left side, rp = -0.47, P = .009, and rp = -0.61, P < .001, respectively). PCOS patients above the 75th percentile for UFC and/or 17OHS after high-dose dexamethasone (n = 15) had a significantly smaller total adrenal volume (6.9 ± 1.9 cm(3) vs 9.2 ± 1.8 cm(3), P = .003) when compared with the remaining PCOS patients (n = 22), but they did not have worse insulin resistance or hyperandrogenism. CONCLUSIONS In a subset of young women with PCOS, we detected a pattern of glucocorticoid secretion that mimicked that of patients with micronodular adrenocortical hyperplasia: they had smaller adrenal volumes and higher steroid hormone secretion after dexamethasone compared with the group of PCOS with appropriate response to dexamethasone.
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Affiliation(s)
- Evgenia Gourgari
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Maya Lodish
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Meg Keil
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Ninet Sinaii
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Evrim Turkbey
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Charalampos Lyssikatos
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Maria Nesterova
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Maria de la Luz Sierra
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Paraskevi Xekouki
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Divya Khurana
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Svetlana Ten
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Adrian Dobs
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics (E.G., M.L., M.K., C.L., M.N., M.S., P.X., C.A.S.), and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Department of Radiology (E.T.), Clinical Center, National Institutes of Health, Bethesda, Maryland 20892; Division of Pediatric Endocrinology (E.G.), Georgetown University Medical Center, Washington, DC 20007; Biostatistics and Clinical Epidemiology Service (N.S.), National Institutes of Health Clinical Center, Bethesda, MD; Division of Pediatric Endocrinology (D.K., S.T.), Infants and Children's Hospital of Brooklyn at Maimonides and Children and Hospital at Downstate, State University of New York, Brooklyn, New York 11219. and Department of Endocrinology (A.D.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
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Abstract
Endogenous Cushing syndrome (CS) in pediatrics is rare; it may be caused by tumors that produce corticotropin in the pituitary gland or elsewhere, tumors that produce corticotropin-releasing hormone anywhere, and adrenocortical masses that produce cortisol. Adrenocortical cancer is a rare cause of CS in children but should be excluded first. CS in children is often caused by germline or somatic mutations with implications for patient prognosis and for their families. CS should be recognized early in children; otherwise, it can lead to significant morbidity and mortality. Patients with suspected CS should be referred to specialized clinical centers for workup.
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Affiliation(s)
- Constantine A Stratakis
- Section on Endocrinology & Genetics (SEGEN), NICHD, NIH, Building 10, CRC, East Laboratories, Room 1-3330, 10 Center Drive, Bethesda, MD 20892, USA.
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46
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Abstract
Primary adrenal Cushing syndrome is the result of cortisol hypersecretion mainly by adenomas and, rarely, by bilateral micronodular or macronodular adrenocortical hyperplasia. cAMP-dependent protein kinase A (PKA) signalling is the major activator of cortisol secretion in the adrenal cortex. Many adenomas and hyperplasias associated with primary hypercortisolism carry somatic or germline mutations in genes that encode constituents of the cAMP-PKA pathway. In this Review, we discuss Cushing syndrome and its linkage to dysregulated cAMP-PKA signalling, with a focus on genetic findings in the past few years. In addition, we discuss the presence of germline inactivating mutations in ARMC5 in patients with primary bilateral macronodular adrenocortical hyperplasia. This finding has implications for genetic counselling of affected patients; hitherto, most patients with this form of adrenal hyperplasia and Cushing syndrome were thought to have a sporadic and not a familial disorder.
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Affiliation(s)
- Maya Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health Clinical Research Center, 10 Center Drive, Building 10, Room 1-3330, MSC1103, Bethesda, Maryland 20892, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health Clinical Research Center, 31 Center Drive, Building 31, Room 2A46, MSC2425, Bethesda, Maryland 20892 USA
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47
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Chrysostomou PP, Lodish MB, Turkbey EB, Papadakis GZ, Stratakis CA. Use of 3-Dimensional Volumetric Modeling of Adrenal Gland Size in Patients with Primary Pigmented Nodular Adrenocortical Disease. Horm Metab Res 2016; 48:242-6. [PMID: 27065461 PMCID: PMC6300994 DOI: 10.1055/s-0042-103686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Primary pigmented nodular adrenocortical disease (PPNAD) is a rare type of bilateral adrenal hyperplasia leading to hypercortisolemia. Adrenal nodularity is often appreciable with computed tomography (CT); however, accurate radiologic characterization of adrenal size in PPNAD has not been studied well. We used 3-dimensional (3D) volumetric analysis to characterize and compare adrenal size in PPNAD patients, with and without Cushing's syndrome (CS). Patients diagnosed with PPNAD and their family members with known mutations in PRKAR1A were screened. CT scans were used to create 3D models of each adrenal. Criteria for biochemical diagnosis of CS included loss of diurnal variation and/or elevated midnight cortisol levels, and paradoxical increase in urinary free cortisol and/or urinary 17-hydroxysteroids after dexamethasone administration. Forty-five patients with PPNAD (24 females, 27.8±17.6 years) and 8 controls (19±3 years) were evaluated. 3D volumetric modeling of adrenal glands was performed in all. Thirty-eight patients out of 45 (84.4%) had CS. Their mean adrenal volume was 8.1 cc±4.1, 7.2 cc±4.5 (p=0.643) for non-CS, and 8.0cc±1.6 for controls. Mean values were corrected for body surface area; 4.7 cc/kg/m(2)±2.2 for CS, and 3.9 cc/kg/m(2)±1.3 for non-CS (p=0.189). Adrenal volume and midnight cortisol in both groups was positively correlated, r=0.35, p=0.03. We conclude that adrenal volume measured by 3D CT in patients with PPNAD and CS was similar to those without CS, confirming empirical CT imaging-based observations. However, the association between adrenal volume and midnight cortisol levels may be used as a marker of who among patients with PPNAD may develop CS, something that routine CT cannot do.
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Affiliation(s)
- Paola P. Chrysostomou
- Program on Developmental Endocrinology and Genetics, Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National, Institutes of Health (NIH), Bethesda, MD
| | - Maya B. Lodish
- Program on Developmental Endocrinology and Genetics, Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National, Institutes of Health (NIH), Bethesda, MD
| | - Evrim B. Turkbey
- Radiology and Imaging Sciences, Clinical Center, and National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, MD
| | - Georgios Z. Papadakis
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Constantine A. Stratakis
- Program on Developmental Endocrinology and Genetics, Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National, Institutes of Health (NIH), Bethesda, MD
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48
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Papanastasiou L, Fountoulakis S, Voulgaris N, Kounadi T, Choreftaki T, Kostopoulou A, Zografos G, Lyssikatos C, Stratakis CA, Piaditis G. Identification of a novel mutation of the PRKAR1A gene in a patient with Carney complex with significant osteoporosis and recurrent fractures. Hormones (Athens) 2016; 15:129-35. [PMID: 27377598 PMCID: PMC7427502 DOI: 10.14310/horm.2002.1627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 09/29/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Carney complex (CNC) is a rare autosomal dominant multiple neoplasia syndrome characterized by the presence of endocrine and non-endocrine tumors. More than 125 different germline mutations of the protein Kinase A type 1-α regulatory subunit (PRKAR1A) gene have been reported. We present a novel PRKAR1A gene germline mutation in a patient with severe osteoporosis and recurrent vertebral fractures. DESIGN Clinical case report. CASE REPORT A 53-year-old male with a medical history of surgically removed recurrent cardiac myxomas was evaluated for repeated low-pressure vertebral fractures and severe osteoporosis. Physical examination revealed spotty skin pigmentation of the lower extremities and papules in the nuchal and thoracic region. The presence of hypercortisolism due to micronodular adrenal disease and the history of cardiac myxomas suggested the diagnosis of CNC; the patient underwent detailed imaging investigation and genetic testing. METHODS Standard imaging and clinical testing; DNA was sequenced by the Sanger method. RESULTS Sequence analysis from peripheral lymphocytes DNA revealed a novel heterozygous point mutation at codon 172 of exon 2 (c.172G>T) of the PRKAR1A gene, resulting in early termination of the PRKAR1A transcript [p.Glu58Ter (E58X)]. CONCLUSION We report a novel point mutation of the PRKAR1A gene in a patient with CNC who presented with significant osteoporosis and fractures. Low bone mineral density along with recurrent myxomas should point to the diagnosis of CNC.
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Affiliation(s)
- Labrini Papanastasiou
- Department of Endocrinology and Diabetes Center, ‘G Gennimatas’ General Hospital, Athens, Greece
| | - Stelios Fountoulakis
- Department of Endocrinology and Diabetes Center, ‘G Gennimatas’ General Hospital, Athens, Greece
| | - Nikos Voulgaris
- Department of Endocrinology and Diabetes Center, ‘G Gennimatas’ General Hospital, Athens, Greece
| | - Theodora Kounadi
- Department of Endocrinology and Diabetes Center, ‘G Gennimatas’ General Hospital, Athens, Greece
| | | | - Akrivi Kostopoulou
- Department of Pathology, ‘G Gennimatas’ General Hospital, Athens, Greece
| | - George Zografos
- Department of Surgery, ‘G Gennimatas’ General Hospital, Athens, Greece
| | - Charalampos Lyssikatos
- Section on Endocrinology & Genetics, Program on Developmental Endocrinology & Genetics, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, USA
| | - Constantine A. Stratakis
- Section on Endocrinology & Genetics, Program on Developmental Endocrinology & Genetics, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, USA
| | - George Piaditis
- Department of Endocrinology and Diabetes Center, ‘G Gennimatas’ General Hospital, Athens, Greece
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49
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Schernthaner-Reiter MH, Trivellin G, Stratakis CA. MEN1, MEN4, and Carney Complex: Pathology and Molecular Genetics. Neuroendocrinology 2016; 103:18-31. [PMID: 25592387 PMCID: PMC4497946 DOI: 10.1159/000371819] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/31/2014] [Indexed: 12/17/2022]
Abstract
Pituitary adenomas are a common feature of a subset of endocrine neoplasia syndromes, which have otherwise highly variable disease manifestations. We provide here a review of the clinical features and human molecular genetics of multiple endocrine neoplasia (MEN) type 1 and 4 (MEN1 and MEN4, respectively) and Carney complex (CNC). MEN1, MEN4, and CNC are hereditary autosomal dominant syndromes that can present with pituitary adenomas. MEN1 is caused by inactivating mutations in the MEN1 gene, whose product menin is involved in multiple intracellular pathways contributing to transcriptional control and cell proliferation. MEN1 clinical features include primary hyperparathyroidism, pancreatic neuroendocrine tumours and prolactinomas as well as other pituitary adenomas. A subset of patients with pituitary adenomas and other MEN1 features have mutations in the CDKN1B gene; their disease has been called MEN4. Inactivating mutations in the type 1α regulatory subunit of protein kinase A (PKA; the PRKAR1A gene), that lead to dysregulation and activation of the PKA pathway, are the main genetic cause of CNC, which is clinically characterised by primary pigmented nodular adrenocortical disease, spotty skin pigmentation (lentigines), cardiac and other myxomas and acromegaly due to somatotropinomas or somatotrope hyperplasia.
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Affiliation(s)
- Marie Helene Schernthaner-Reiter
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md., USA
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50
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Mineo R, Tamba S, Yamada Y, Okita T, Kawachi Y, Mori R, Kyo M, Saisho K, Kuroda Y, Yamamoto K, Furuya A, Mukai T, Maekawa T, Nakamura Y, Sasano H, Matsuzawa Y. A Novel Mutation in the type Iα Regulatory Subunit of Protein Kinase A (PRKAR1A) in a Cushing's Syndrome Patient with Primary Pigmented Nodular Adrenocortical Disease. Intern Med 2016; 55:2433-8. [PMID: 27580546 DOI: 10.2169/internalmedicine.55.6605] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A 40-year-old man presented with Cushing's syndrome due to bilateral adrenal hyperplasia with multiple nodules. Computed tomography scan results were atypical demonstrating an enlargement of the bilateral adrenal glands harboring multiple small nodules, but the lesion was clinically diagnosed to be primary pigmented nodular adrenocortical disease (PPNAD) based on both endocrinological test results and his family history. We performed bilateral adrenalectomy and confirmed the diagnosis histologically. An analysis of the patient and his mother's genomic DNA identified a novel mutation in the type Iα regulatory subunit of protein kinase A (PRKAR1A) gene; p.E17X (c.49G>T). This confirmed the diagnosis of PPNAD which is associated with Carney Complex.
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Affiliation(s)
- Ryohei Mineo
- Department of Endocrinology and Metabolism, Sumitomo Hospital, Japan
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