1
|
Manganiello CF, Di Berardino E, Schneider L, Callegari MS, Hoermann MR, Dotti FA. [Pseudo-ischemic electrocardiographic changes in the context of adrenal crisis]. Medicina (B Aires) 2024; 84:395. [PMID: 38683537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Affiliation(s)
- Carlos F Manganiello
- Servicio de Medicina Interna, Hospital de Bolívar Dr. Miguel Capredoni, Bolívar, Buenos Aires, Argentina. E-mail:
| | - Elvio Di Berardino
- Servicio de Medicina Interna, Hospital de Bolívar Dr. Miguel Capredoni, Bolívar, Buenos Aires, Argentina
| | - Luciano Schneider
- Servicio de Medicina Interna, Hospital de Bolívar Dr. Miguel Capredoni, Bolívar, Buenos Aires, Argentina
| | - Mariana S Callegari
- Servicio de Medicina Interna, Hospital de Bolívar Dr. Miguel Capredoni, Bolívar, Buenos Aires, Argentina
| | - Mariana R Hoermann
- Servicio de Medicina Interna, Hospital de Bolívar Dr. Miguel Capredoni, Bolívar, Buenos Aires, Argentina
| | - Flavia A Dotti
- Servicio de Medicina Interna, Hospital de Bolívar Dr. Miguel Capredoni, Bolívar, Buenos Aires, Argentina
| |
Collapse
|
2
|
Abstract
Disorders of Sex Development (DSD) are anomalies occurring in the process of fetal sexual differentiation that result in a discordance between the chromosomal sex and the sex of the gonads and/or the internal and/or external genitalia. Congenital disorders affecting adrenal function may be associated with DSD in both 46,XX and 46,XY individuals, but the pathogenic mechanisms differ. While in 46,XX cases, the adrenal steroidogenic disorder is responsible for the genital anomalies, in 46,XY patients DSD results from the associated testicular dysfunction. Primary adrenal insufficiency, characterized by a reduction in cortisol secretion and overproduction of ACTH, is the rule. In addition, patients may exhibit aldosterone deficiency leading to salt-wasting crises that may be life-threatening. The trophic effect of ACTH provokes congenital adrenal hyperplasia (CAH). Adrenal steroidogenic defects leading to 46,XX DSD are 21-hydroxylase deficiency, by far the most prevalent, and 11β-hydroxylase deficiency. Lipoid Congenital Adrenal Hyperplasia due to StAR defects, and cytochrome P450scc and P450c17 deficiencies cause DSD in 46,XY newborns. Mutations in SF1 may also result in combined adrenal and testicular failure leading to DSD in 46,XY individuals. Finally, impaired activities of 3βHSD2 or POR may lead to DSD in both 46,XX and 46,XY individuals. The pathophysiology, clinical presentation and management of the above-mentioned disorders are critically reviewed, with a special focus on the latest biomarkers and therapeutic development.
Collapse
Affiliation(s)
- Gabriela P. Finkielstain
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ignacio Bergadá
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Rodolfo A. Rey
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
- Universidad de Buenos Aires, Facultad de Medicina, Departamento de Biología Celular, Histología, Embriología y Genética, Buenos Aires, Argentina
| |
Collapse
|
3
|
Edo N, Morita K, Ishiwata C, Nakajima R, Sayama Y, Suzuki T, Sakamoto M, Okamoto K, Uchino T, Ozawa Y, Uno K, Uno K, Tsukamoto K, Ishikawa T. Diagnostic value of standard deviation score of log-transformed serum dehydroepiandrosterone sulfate in patients with hypothalamic-pituitary-adrenal axis insufficiency. Endocr J 2021; 68:1337-1345. [PMID: 34162776 DOI: 10.1507/endocrj.ej21-0140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Serum dehydroepiandrosterone sulfate (DHEA-S) levels reflect the state of adrenocorticotropic hormone (ACTH) secretion. However, it is difficult to use serum DHEA-S to diagnose hypothalamic-pituitary-adrenal (HPA) axis insufficiency due to its non-normal and highly skewed distribution. In this study, we focused on HPA insufficiency caused by hypothalamic and/or pituitary dysfunction and evaluated the usefulness of the standard deviation score of log-transformed DHEA-S (ln DHEA-S SD score), which was calculated from the established age- and sex-specific reference values. We retrospectively reviewed the medical records of 94 patients suspected of having HPA insufficiency, in whom serum DHEA-S measurement and the rapid ACTH stimulation test were performed, and included 65 patients who met our criteria in this study. The ln DHEA-S SD scores were distributed more normally than measured DHEA-S levels and were significantly higher in patients with a peak cortisol level ≥18 μg/dL than in those below this value, suggesting that this score is a legitimate and strong indicator of adrenocortical function. The optimal cut-off value for impaired HPA function was -0.853, with a sensitivity of 70.3% and a specificity of 100%. Among the 37 patients whose peak cortisol levels were below 18 μg/dL, 11 patients with ln DHEA-S scores ≥-0.853 exhibited significantly higher basal ACTH and basal and peak cortisol levels than the 26 patients with scores <-0.853. Thus, this score plays a supportive role in evaluating HPA axis function, particularly in patients with borderline cortisol responses to ACTH.
Collapse
Affiliation(s)
- Naoki Edo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
- Department of Clinical Research Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Koji Morita
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Chisato Ishiwata
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Rina Nakajima
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Yohei Sayama
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Takashi Suzuki
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Miki Sakamoto
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Kaori Okamoto
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Takuya Uchino
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Yuki Ozawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shin-Kuki General Hospital, Saitama 346-0021, Japan
| | - Kiyoko Uno
- Teikyo Academic Research Center, Teikyo University, Tokyo 173-8605, Japan
| | - Kenji Uno
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Kazuhisa Tsukamoto
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Toshio Ishikawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| |
Collapse
|
4
|
Nso N, Nassar M, Baraka B, Mbome Y, Alfishawy M. Adrenal Insufficiency in patients with cardiogenic shock: A meta-analysis. Diabetes Metab Syndr 2021; 15:102274. [PMID: 34628137 DOI: 10.1016/j.dsx.2021.102274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Adrenal Insufficiency (AI) is rarely observed in patients with cardiogenic shock (CS). We aimed to identify the prevalence of AI in patients with CS and its effect on their clinical outcomes. AIMS Our study aimed to determine the prevalence of AI in CS patients who underwent treatments for CS. METHODS The articles concerning AI in CS were extracted for review from PubMed/Medline, Science Direct, World Wide Science.org, and Pro-Quest. The research articles included patients with CS, post-cardiac-arrest shock, out-of-hospital cardiac arrest, and CS after acute myocardial infarction. RStudio (version 1.0.136) was used for analyzing AI in CS patients. RESULTS The search revealed 1463 unique publications, including 256 studies identified after screening the titles and the abstracts. Five observational cohort studies met the eligibility criteria for meta-analysis after the preliminary screening. The included studies reported a corticotropin stimulation test for AI diagnosis. The studies reportedly exhibited a low-to-fair quality. The random-effects pooled estimates indicated a 32% AI prevalence in the setting of CS [95% CI; 21%-45%; I2 = 81%]. The outcomes from the included studies were statistically significant for high heterogeneity (P = 0.001). The pooled results confirmed an 11%-51% AI prevalence in CS patients. CONCLUSIONS This meta-analysis revealed a moderate level prevalence of AI in CS patients.
Collapse
Affiliation(s)
- Nso Nso
- Internal Medicine Department, Icahn School of Medicine at Mount Sinai / NYC Health+Hospitals / Queens, New York, NY, USA.
| | - Mahmoud Nassar
- Internal Medicine Department, Icahn School of Medicine at Mount Sinai / NYC Health+Hospitals / Queens, New York, NY, USA.
| | - Bahaaeldin Baraka
- Clinical Oncology Department, Nottingham University Hospital, Nottingham, UK.
| | - Yolanda Mbome
- Internal Medicine Department, Richmond University Medical Center, New York, USA.
| | - Mostafa Alfishawy
- Infectious Diseases, Infectious Diseases Consultants and Academic Researchers of Egypt (IDCARE), Cairo, Egypt.
| |
Collapse
|
5
|
Patra S, Roy A, Mittal M, Shukla R. Use of dual-release hydrocortisone in adrenal insufficiency. Eur J Endocrinol 2021; 185:L9-L10. [PMID: 34243144 DOI: 10.1530/eje-21-0418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/14/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Shinjan Patra
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Ayan Roy
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Madhukar Mittal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Ravindra Shukla
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| |
Collapse
|
6
|
Čechová A, Honzík T, Edmondson AC, Ficicioglu C, Serrano M, Barone R, De Lonlay P, Schiff M, Witters P, Lam C, Patterson M, Janssen MCH, Correia J, Quelhas D, Sykut-Cegielska J, Plotkin H, Morava E, Sarafoglou K. Should patients with Phosphomannomutase 2-CDG (PMM2-CDG) be screened for adrenal insufficiency? Mol Genet Metab 2021; 133:397-399. [PMID: 34140212 PMCID: PMC8754259 DOI: 10.1016/j.ymgme.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/21/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
PMM2-CDG is the most common congenital disorder of glycosylation (CDG) accounting for almost 65% of known CDG cases affecting N-glycosylation. Abnormalities in N-glycosylation could have a negative impact on many endocrine axes. There is very little known on the effect of impaired N-glycosylation on the hypothalamic-pituitary-adrenal axis function and whether CDG patients are at risk of secondary adrenal insufficiency and decreased adrenal cortisol production. Cortisol and ACTH concentrations were simultaneously measured between 7:44 am to 1 pm in forty-three subjects (20 female, median age 12.8 years, range 0.1 to 48.6 years) participating in an ongoing international, multi-center Natural History study for PMM2-CDG (ClinicalTrials.gov Identifier: NCT03173300). Of the 43 subjects, 11 (25.6%) had cortisol below 5 μg/dl and low to normal ACTH levels, suggestive of secondary adrenal insufficiency. Two of the 11 subjects have confirmed central adrenal insufficiency and are on hydrocortisone replacement and/or stress dosing during illness; 3 had normal and 1 had subnormal cortisol response to ACTH low-dose stimulation test but has not yet been started on therapy; the remaining 5 have upcoming stimulation testing planned. Our findings suggest that patients with PMM2-CDG may be at risk for adrenal insufficiency. Monitoring of morning cortisol and ACTH levels should be part of the standard care in patients with PMM2-CDG.
Collapse
Affiliation(s)
- Anna Čechová
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Tomáš Honzík
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Andrew C Edmondson
- Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, USA
| | - Can Ficicioglu
- Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, USA
| | - Mercedes Serrano
- Pediatric Neurology Department, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain; U-703 Centre for Biomedical Research on Rare Diseases (CIBER-ER), Instituto de Salud Carlos III, Spain
| | - Rita Barone
- Child Neuropsychiatry Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pascale De Lonlay
- Necker Hospital, APHP, Reference Center for Inborn Errors of Metabolism, University of Paris, Paris, France; Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Manuel Schiff
- Necker Hospital, APHP, Reference Center for Inborn Errors of Metabolism, University of Paris, Paris, France
| | - Peter Witters
- Metabolic Center, Department of Pediatrics, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Christina Lam
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA 98101, USA; Division of Genetic Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Marc Patterson
- Department of Clinical Genomics-Department of Laboratory Medicine and Pathology, Mayo Clinic, MN, USA
| | - Mirian C H Janssen
- Radboud University Medical Centre, Department of Internal Medicine, Nijmegen, the Netherlands
| | - Joana Correia
- Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Dulce Quelhas
- Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Jolanta Sykut-Cegielska
- Department of Inborn Errors of Metabolism and Paediatrics, the Institute of Mother and Child, Warsaw, Poland
| | - Horacio Plotkin
- Glycomine, Inc, San Francisco, CA, USA; Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Eva Morava
- Department of Clinical Genomics-Department of Laboratory Medicine and Pathology, Mayo Clinic, MN, USA.
| | - Kyriakie Sarafoglou
- Dept. of Pediatrics - Divisions of Endocrinology and Genetics & Metabolism, Dept. of Experimental & Clinical Pharmacology, University of Minnesota, USA
| |
Collapse
|
7
|
Puglisi S, Rossini A, Tabaro I, Cannavò S, Ferrau' F, Ragonese M, Borretta G, Pellegrino M, Dughera F, Parisi A, Latina A, Pia A, Terzolo M, Reimondo G. What factors have impact on glucocorticoid replacement in adrenal insufficiency: a real-life study. J Endocrinol Invest 2021; 44:865-872. [PMID: 32779106 PMCID: PMC7946659 DOI: 10.1007/s40618-020-01386-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/02/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The impact of patient's characteristics on glucocorticoid (GC) replacement therapy in adrenal insufficiency (AI) is poorly evaluated. Aims of this study were to assess the influence of sex and body weight on GC dosing and to describe the choice of GC in AI of different etiologies. METHODS We retrospectively evaluated hydrocortisone (HC) equivalent total daily dose (HC-TDD) and per-kg-daily dose (HC-KDD) in 203 patients (104 primary AI [pAI], 99 secondary AI [sAI]) followed up for ≥ 12 months. They were treated with HC, modified-release HC (MRHC) or cortisone acetate (CA) and fludrocortisone acetate (FCA) in pAI. RESULTS At baseline, CA was preferred both in pAI and sAI; at last visit, MRHC was most used in pAI (49%) and CA in sAI (73.7%). Comparing the last visit with baseline, in pAI, HC-TDD and HC-KDD were significantly lower (p = 0.04 and p = 0.006, respectively), while FCA doses increased during follow-up (p = 0.02). The reduction of HC-TDD and HC-KDD was particularly relevant for pAI women (p = 0.04 and p = 0.002, respectively). In sAI patients, no change of HC-KDD and HC-TDD was observed, and we found a correlation between weight and HC-TDD in males (r 0.35, p = 0.02). CONCLUSIONS Our real-life study demonstrated the influence of etiology of AI on the type of GC used, a weight-based tailoring in sAI, a likely overdosage of GC treatment in pAI women at the start of treatment and the possibility to successfully increase FCA avoiding GC over-treatment. These observations could inform the usual clinical practice.
Collapse
Affiliation(s)
- S Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy.
| | - A Rossini
- Endocrinology and Diabetes Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - I Tabaro
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - S Cannavò
- Department of Human Pathology 'G.Barresi', University of Messina, Messina, Italy
| | - F Ferrau'
- Department of Human Pathology 'G.Barresi', University of Messina, Messina, Italy
| | - M Ragonese
- Department of Human Pathology 'G.Barresi', University of Messina, Messina, Italy
| | - G Borretta
- Division of Endocrinology, AO S. Croce E Carle, Cuneo, Italy
| | - M Pellegrino
- Division of Endocrinology, AO S. Croce E Carle, Cuneo, Italy
| | - F Dughera
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - A Parisi
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - A Latina
- Division of Endocrinology, AO S. Croce E Carle, Cuneo, Italy
| | - A Pia
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - M Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - G Reimondo
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| |
Collapse
|
8
|
Laugesen K, Broersen LHA, Hansen SB, Dekkers OM, Sørensen HT, Jorgensen JOL. MANAGEMENT OF ENDOCRINE DISEASE: Glucocorticoid-induced adrenal insufficiency: replace while we wait for evidence? Eur J Endocrinol 2021; 184:R111-R122. [PMID: 33449912 DOI: 10.1530/eje-20-1199] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/15/2021] [Indexed: 11/08/2022]
Abstract
Glucocorticoids are, besides non-steroidal anti-inflammatory drugs, the most widely used anti-inflammatory medications. Prevalence studies indicate substantial use of both systemic and locally acting agents. A recognised adverse effect of glucocorticoid treatment is adrenal insufficiency, which is highly prevalent based on biochemical testing, but its clinical implications are poorly understood. Current evidence, including randomised trials and observational studies, indicates substantial variation among patients in both risk and course of glucocorticoid-induced adrenal insufficiency, but both are currently unpredictable. Oral and intra-articular formulations, as well as long-term and high-dose treatments, carry the highest risk of glucocorticoid-induced adrenal insufficiency defined by biochemical tests. However, no route of administration, treatment duration, or dose can be considered without risk. More research is needed to estimate the risk and temporal pattern of glucocorticoid-induced adrenal insufficiency, to investigate its clinical implications, and to identify predictors of risk and prognosis. Randomized trials are required to evaluate whether hydrocortisone replacement therapy mitigates risk and symptoms of glucocorticoid-induced adrenal insufficiency in patients discontinuing glucocorticoid treatment. This review aims to provide an overview of the available evidence, pointing to knowledge gaps and unmet needs.
Collapse
Affiliation(s)
- Kristina Laugesen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Leonie H A Broersen
- Division of Endocrinology, Department of Medicine, Leiden University Medical Centre, ZA Leiden, the Netherlands
| | - Simon Bøggild Hansen
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Division of Endocrinology, Department of Medicine, Leiden University Medical Centre, ZA Leiden, the Netherlands
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Otto L Jorgensen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
9
|
Abstract
Adrenal insufficiency can arise from a primary adrenal disorder, secondary to adrenocorticotropic hormone deficiency, or by suppression of adrenocorticotropic hormone by exogenous glucocorticoid or opioid medications. Hallmark clinical features are unintentional weight loss, anorexia, postural hypotension, profound fatigue, muscle and abdominal pain, and hyponatraemia. Additionally, patients with primary adrenal insufficiency usually develop skin hyperpigmentation and crave salt. Diagnosis of adrenal insufficiency is usually delayed because the initial presentation is often non-specific; physician awareness must be improved to avoid adrenal crisis. Despite state-of-the-art steroid replacement therapy, reduced quality of life and work capacity, and increased mortality is reported in patients with primary or secondary adrenal insufficiency. Active and repeated patient education on managing adrenal insufficiency, including advice on how to increase medication during intercurrent illness, medical or dental procedures, and profound stress, is required to prevent adrenal crisis, which occurs in about 50% of patients with adrenal insufficiency after diagnosis. It is good practice for physicians to provide patients with a steroid card, parenteral hydrocortisone, and training for parenteral hydrocortisone administration, in case of vomiting or severe illness. New modes of glucocorticoid delivery could improve the quality of life in some patients with adrenal insufficiency, and further advances in oral and parenteral therapy will probably emerge in the next few years.
Collapse
Affiliation(s)
- Eystein S Husebye
- Department of Clinical Science and KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Simon H Pearce
- Department of Endocrinology, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nils P Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK; Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Olle Kämpe
- Department of Clinical Science and KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway; Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Center of Molecular Medicine, and Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
10
|
Dineen R, Martin-Grace J, Ahmed KMS, Frizelle I, Gunness A, Garrahy A, Hannon AM, O'Reilly MW, Smith D, McDermott J, Healy ML, Agha A, Pazderska A, Gibney J, Thompson CJ, Behan LA, Sherlock M. Cardiometabolic and psychological effects of dual-release hydrocortisone: a cross-over study. Eur J Endocrinol 2021; 184:253-265. [PMID: 33513125 DOI: 10.1530/eje-20-0642] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/16/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Adrenal insufficiency (AI) is associated with increased cardiovascular morbidity and mortality and reduced quality of life (QoL). Optimum glucocorticoid (GC) dosing and timing are crucial in the treatment of AI, yet the natural circadian secretion of cortisol is difficult to mimic. The once-daily dual-release hydrocortisone (DR-HC) preparation (Plenadren®), offers a more physiological cortisol profile and may address unmet needs. METHODS An investigator-initiated, prospective, cross-over study in patients with AI. Following baseline assessment of cardiometabolic risk factors and QoL, patients switched from their usual hydrocortisone regimen to a once-daily dose equivalent of DR-HC and were reassessed after 12 weeks of treatment. RESULTS Fifty-one patients (21 PAI/30 SAI) completed the study. Mean age was 41.6 years (s.d. 13), and 58% (n = 30) were male. The median daily HC dose before study entry was 20 mg (IQR 15-20 mg). After 3 months on DR-HC, the mean SBP decreased by 5.7 mmHg, P = 0.0019 and DBP decreased by 4.5 mmHg, P = 0.0011. There was also a significant reduction in mean body weight (-1.23 kg, P = 0.006) and BMI (-0.3 kg/m2, P = 0.003). In a sub-analysis, there was a greater reduction in SBP observed in patients with SAI when compared to PAI post-DR-HC. Patients reported significant improvements in QoL using three validated QoL questionnaires, with a greater improvement in PAI. CONCLUSION Dual-release hydrocortisone decreases BP, weight and BMI compared with conventional HC treatment, even at physiological GC replacement doses. Additionally, DR-HC confers significant improvements in QoL compared to immediate-release HC, particularly in patients with PAI, which is also reflected in the patient preference for DR-HC.
Collapse
Affiliation(s)
- Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital/RCSI
| | | | | | - Isolda Frizelle
- Robert Graves Institute of Endocrinology, Tallaght University Hospital
| | - Anjuli Gunness
- Robert Graves Institute of Endocrinology, Tallaght University Hospital
| | - Aoife Garrahy
- Academic Department of Endocrinology, Beaumont Hospital/RCSI
| | | | | | - Diarmuid Smith
- Academic Department of Endocrinology, Beaumont Hospital/RCSI
| | | | | | - Amar Agha
- Academic Department of Endocrinology, Beaumont Hospital/RCSI
| | | | - James Gibney
- Robert Graves Institute of Endocrinology, Tallaght University Hospital
| | | | - Lucy-Ann Behan
- Robert Graves Institute of Endocrinology, Tallaght University Hospital
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital/RCSI
| |
Collapse
|
11
|
Zeng J, Yan F, Chen Y, Zang L, Chen K, Lyu Z, Dou J, Mu Y, Lin M, Yang G. Primary Adrenal Lymphoma: Two Case Series From China. Front Endocrinol (Lausanne) 2021; 12:778984. [PMID: 35154000 PMCID: PMC8832485 DOI: 10.3389/fendo.2021.778984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/24/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Primary adrenal lymphoma (PAL) is a rare form of adrenal mass. We summarize our experience in its clinical presentation, biochemical indexes, radiological features, pathological information, therapy regimens, and outcomes. METHODS This was an institutional review board-approved retrospective review of medical records and surgical pathology specimens of patients with a diagnosis of PAL at the Chinese People's Liberation Army General Hospital and the First Affiliate Hospital of Xiamen University between July 2007 and July 2017. RESULTS Twenty-six patients were identified. The mean age at presentation was 60.84 ± 13.14 years with a male-to-female ratio of 2.25:1 (18:8). The most common presenting symptoms were loss of appetite (65%, 17/26), weight loss (62%, 16/26), abdominal pain (58%, 15/26), and fatigue (58%, 15/26). The levels of lactate dehydrogenase (75%, 15/20), β2-microglobulin (100%, 10/10), C-reactive protein (82%, 14/17), and ferritin (88%, 7/8) and the erythrocyte sedimentation rate (83%, 10/12) were elevated. Bilateral involvement was seen in 21 of 26 patients (81%); 12 of 19 evaluated patients with bilateral lesions (63%) were confirmed to have adrenal insufficiency. On computed tomography (CT), the mean tumor diameter was 7.31 ± 3.35 cm and the median Hounsfield density was 37.0 HU (range: 31.0-45.0 HU); 67% (10/15) and 27% (4/15) of lesions presented with mild and moderate enhancement after injection of contrast medium. 18F-fluorodeoxyglucose positron emission tomography (FDG PET)-CT revealed not only an adrenal tumor but also extra-adrenal lesions. Diffuse large B-cell lymphoma (DLBCL) was the most common phenotype (92%, 24/26). Ninety-two percent (24/26) of patients received chemotherapy while 8% (2/26) received unilateral adrenalectomy plus chemotherapy. The prognosis of PAL was poor, with a general survival time of 7.20 ± 5.18 months. CONCLUSION PAL is a rare disease. The clinical characteristics of PAL include loss of appetite and weight loss. Endocrine evaluation should be performed to determine whether patients have adrenal insufficiency, especially patients with bilateral lesions. FDG-PET appears to be more accurate than other imaging modalities in revealing extra-adrenal sites. Better therapy is required to improve the poor prognosis of PAL.
Collapse
MESH Headings
- Abdominal Pain/physiopathology
- Adrenal Gland Neoplasms/diagnostic imaging
- Adrenal Gland Neoplasms/metabolism
- Adrenal Gland Neoplasms/physiopathology
- Adrenal Gland Neoplasms/therapy
- Adrenal Insufficiency/physiopathology
- Adrenalectomy
- Adult
- Aged
- Aged, 80 and over
- Anorexia/physiopathology
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Asparaginase/administration & dosage
- Blood Sedimentation
- C-Reactive Protein/metabolism
- China
- Cyclophosphamide/therapeutic use
- Dexamethasone/administration & dosage
- Dimethoate/administration & dosage
- Doxorubicin/therapeutic use
- Etoposide/administration & dosage
- Fatigue/physiopathology
- Female
- Ferritins/metabolism
- Humans
- L-Lactate Dehydrogenase/metabolism
- Lymphoma, Extranodal NK-T-Cell/diagnostic imaging
- Lymphoma, Extranodal NK-T-Cell/metabolism
- Lymphoma, Extranodal NK-T-Cell/physiopathology
- Lymphoma, Extranodal NK-T-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnostic imaging
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/therapy
- Male
- Methotrexate/administration & dosage
- Middle Aged
- Positron Emission Tomography Computed Tomography
- Prednisone/therapeutic use
- Rituximab/therapeutic use
- Survival Rate
- Tomography, X-Ray Computed
- Vincristine/therapeutic use
- Weight Loss
- beta 2-Microglobulin/metabolism
Collapse
Affiliation(s)
- Jinyang Zeng
- Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Department of Endocrinology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Fangfang Yan
- Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Department of Endocrinology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yulong Chen
- Department of Endocrinology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Li Zang
- Department of Endocrinology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Kang Chen
- Department of Endocrinology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhaohui Lyu
- Department of Endocrinology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yiming Mu
- Department of Endocrinology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Mingzhu Lin
- Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Guoqing Yang
- Department of Endocrinology, Hainan Branch of People's Liberation Army (PLA) General Hospital, Sanya, China
- *Correspondence: Guoqing Yang,
| |
Collapse
|
12
|
Loggini A, Tangonan R, El Ammar F, Mansour A, Kramer CL, Lazaridis C, Goldenberg FD. Neuroendocrine Dysfunction in the Acute Setting of Penetrating Brain Injury: A Systematic Review. World Neurosurg 2020; 147:172-180.e1. [PMID: 33346052 DOI: 10.1016/j.wneu.2020.12.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Data on neuroendocrine dysfunction (NED) in the acute setting of penetrating brain injury (PBI) are scarce, and the clinical approach to diagnosis and treatment remains extrapolated from the literature on blunt head trauma. METHODS Three databases were searched (PubMed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale, or the methodological quality of case series and case reports, as indicated. This systematic review was registered in PROSPERO (42020172163). RESULTS Six relevant studies involving 58 patients with PBI were included. Two studies were prospective cohort analyses, whereas 4 were case reports. The onset of NED was acute in all studies, by the first postinjury day. Risk factors for NED included worse injury severity and the presence of cerebral edema on imaging. Dysfunction of the anterior hypophysis involved the hypothalamic-pituitary-thyroid axis, treated with hormonal replacement, and hypocortisolism, treated with hydrocortisone. The prevalence of central diabetes insipidus was up to 41%. Most patients showed persistent NED months after injury. In separate reports, diabetes insipidus and hypocortisolism showed an association with higher mortality. The available literature for this review is poor, and the studies included had overall low quality with high risk of bias. CONCLUSIONS NED seems to be prevalent in the acute phase of PBI, equally involving both anterior and posterior hypophysis. Despite a potential association between NED and mortality, data on the optimal management of NED are limited. This situation defines the need for prospective studies to better characterize the clinical features and optimal therapeutic interventions for NED in PBI.
Collapse
Affiliation(s)
- Andrea Loggini
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA.
| | - Ruth Tangonan
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Faten El Ammar
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Ali Mansour
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Christopher L Kramer
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Christos Lazaridis
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Fernando D Goldenberg
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| |
Collapse
|
13
|
Bornstein SR, Malyukov M, Heller C, Ziegler CG, Ruiz-Babot G, Schedl A, Ludwig B, Steenblock C. New Horizons: Novel Adrenal Regenerative Therapies. J Clin Endocrinol Metab 2020; 105:5868096. [PMID: 32629476 PMCID: PMC7398608 DOI: 10.1210/clinem/dgaa438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/02/2020] [Indexed: 11/23/2022]
Abstract
Adrenal insufficiency requires lifelong corticoid replacement therapies. However, current therapies are not able to replace the physiological circadian pattern of the adrenal cortex and are associated with many metabolic, vascular, neuroendocrine, and mental perturbations. Therefore, regenerative and more curative strategies would be desirable. In the current perspective, we describe emerging new regenerative therapies for the treatment of adrenal insufficiency. In particular, we discuss gene therapy and cell replacement strategies. Furthermore, we discuss how adrenal cells might be used as a source for regenerative therapies of nonadrenal neurodegenerative diseases such as Parkinson disease.
Collapse
Affiliation(s)
- Stefan R Bornstein
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Diabetes and Nutritional Sciences Division, King’s College London, London, UK
- Correspondence and Reprint Requests: Stefan R. Bornstein, Department of Internal Medicine III, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany. E-mail:
| | - Maria Malyukov
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Carolin Heller
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden (PLID) of the Helmholtz Center Munich, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- DFG-Center for Regenerative Therapies Dresden, Technische Universität Dresden, Dresden, Germany
| | - Christian G Ziegler
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gerard Ruiz-Babot
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Barbara Ludwig
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden (PLID) of the Helmholtz Center Munich, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- DFG-Center for Regenerative Therapies Dresden, Technische Universität Dresden, Dresden, Germany
- Department of Endocrinology and Diabetology, University Hospital Zurich, Zurich, Switzerland
| | - Charlotte Steenblock
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
14
|
Rosenberg AGW, Pellikaan K, Poitou C, Goldstone AP, Høybye C, Markovic T, Grugni G, Crinò A, Caixàs A, Coupaye M, Van Den Berg SAA, Van Der Lely AJ, De Graaff LCG. Central Adrenal Insufficiency Is Rare in Adults With Prader-Willi Syndrome. J Clin Endocrinol Metab 2020; 105:5813913. [PMID: 32232324 PMCID: PMC7211032 DOI: 10.1210/clinem/dgaa168] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/27/2020] [Indexed: 01/25/2023]
Abstract
CONTEXT Prader-Willi syndrome (PWS) is associated with several hypothalamic-pituitary hormone deficiencies. There is no agreement on the prevalence of central adrenal insufficiency (CAI) in adults with PWS. In some countries, it is general practice to prescribe stress-dose hydrocortisone during physical or psychological stress in patients with PWS. Side effects of frequent hydrocortisone use are weight gain, osteoporosis, diabetes mellitus, and hypertension-already major problems in adults with PWS. However, undertreatment of CAI can cause significant morbidity-or even mortality. OBJECTIVE To prevent both over- and undertreatment with hydrocortisone, we assessed the prevalence of CAI in a large international cohort of adults with PWS. As the synacthen test shows variable results in PWS, we only use the metyrapone test (MTP) and insulin tolerance test (ITT). DESIGN Metyrapone test or ITT in adults with PWS (N = 82) and review of medical files for symptoms of hypocortisolism related to surgery (N = 645). SETTING Outpatient clinic. PATIENTS OR OTHER PARTICIPANTS Eighty-two adults with genetically confirmed PWS. MAIN OUTCOME MEASURE For MTP, 11-deoxycortisol > 230 nmol/L was considered sufficient. For ITT, cortisol > 500 nmol/L (Dutch, French, and Swedish patients) or > 450 nmol/L (British patients) was considered sufficient. RESULTS Central adrenal insufficiency was excluded in 81 of 82 patients. Among the 645 patients whose medical files were reviewed, 200 had undergone surgery without perioperative hydrocortisone treatment. None of them had displayed any features of hypocortisolism. CONCLUSIONS Central adrenal insufficiency is rare (1.2%) in adults with PWS. Based on these results, we recommend against routinely prescribing hydrocortisone stress-doses in adults with PWS.
Collapse
Affiliation(s)
- Anna G W Rosenberg
- Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karlijn Pellikaan
- Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Christine Poitou
- Assistance Publique-Hopitaux de Paris, Nutrition Department, Institute of Cardiometabolism and Nutrition, Pitie-Salpetriere Hospital, Sorbonne Universite, Paris, France
- International Network for Research, Management & Education on Adults with PWS
- European Reference Network on Rare Endocrine Conditions
| | - Anthony P Goldstone
- International Network for Research, Management & Education on Adults with PWS
- PsychoNeuroEndocrinology Research Group, Neuropsychopharmacology Unit, Division of Psychiatry, Computational, Cognitive and Clinical Neuroimaging Laboratory, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Charlotte Høybye
- International Network for Research, Management & Education on Adults with PWS
- European Reference Network on Rare Endocrine Conditions
- Department of Molecular Medicine and Surgery, Patient Area Endocrinology and Nephrology, Inflammation and Infection Theme, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Tania Markovic
- International Network for Research, Management & Education on Adults with PWS
- Metabolism & Obesity Services, Royal Prince Alfred Hospital, Camperdown, Australia
- Boden Collaboration, University of Sydney, Sydney, Australia
| | - Graziano Grugni
- International Network for Research, Management & Education on Adults with PWS
- European Reference Network on Rare Endocrine Conditions
- Divison of Auxology, Italian Auxological Institute, IRCCS, Piancavallo, Italy
| | - Antonino Crinò
- International Network for Research, Management & Education on Adults with PWS
- Reference Center for Prader–Willi Syndrome, Bambino Gesu Hospital, Research Institute, Palidoro (Rome), Italy
| | - Assumpta Caixàs
- International Network for Research, Management & Education on Adults with PWS
- Department of Endocrinology and Nutrition, Hospital Universitari Parc Taulí (UAB), Institut d’Investigacio i Innovacio Parc Taulí (I3PT), Sabadell, Spain
| | - Muriel Coupaye
- Assistance Publique-Hopitaux de Paris, Nutrition Department, Institute of Cardiometabolism and Nutrition, Pitie-Salpetriere Hospital, Sorbonne Universite, Paris, France
- International Network for Research, Management & Education on Adults with PWS
| | - Sjoerd A A Van Den Berg
- Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Aart Jan Van Der Lely
- Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- European Reference Network on Rare Endocrine Conditions
| | - Laura C G De Graaff
- Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- International Network for Research, Management & Education on Adults with PWS
- European Reference Network on Rare Endocrine Conditions
- Academic Center for Growth, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Correspondence and Reprint Requests: Laura de Graaff, MD, PhD, Department of Internal Medicine-Endocrinology, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands. E-mail:
| |
Collapse
|
15
|
Prete A, Taylor AE, Bancos I, Smith DJ, Foster MA, Kohler S, Fazal-Sanderson V, Komninos J, O’Neil DM, Vassiliadi DA, Mowatt CJ, Mihai R, Fallowfield JL, Annane D, Lord JM, Keevil BG, Wass JAH, Karavitaki N, Arlt W. Prevention of Adrenal Crisis: Cortisol Responses to Major Stress Compared to Stress Dose Hydrocortisone Delivery. J Clin Endocrinol Metab 2020; 105:5805157. [PMID: 32170323 PMCID: PMC7241266 DOI: 10.1210/clinem/dgaa133] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/09/2020] [Indexed: 01/16/2023]
Abstract
CONTEXT Patients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid a life-threatening adrenal crisis. However, current treatment recommendations are not evidence-based. OBJECTIVE To identify the most appropriate mode of hydrocortisone delivery in patients with adrenal insufficiency who are exposed to major stress. DESIGN AND PARTICIPANTS Cross-sectional study: 122 unstressed healthy subjects and 288 subjects exposed to different stressors (major trauma [N = 83], sepsis [N = 100], and combat stress [N = 105]). Longitudinal study: 22 patients with preserved adrenal function undergoing elective surgery. Pharmacokinetic study: 10 patients with primary adrenal insufficiency undergoing administration of 200 mg hydrocortisone over 24 hours in 4 different delivery modes (continuous intravenous infusion; 6-hourly oral, intramuscular or intravenous bolus administration). MAIN OUTCOME MEASURE We measured total serum cortisol and cortisone, free serum cortisol, and urinary glucocorticoid metabolite excretion by mass spectrometry. Linear pharmacokinetic modeling was used to determine the most appropriate mode and dose of hydrocortisone administration in patients with adrenal insufficiency exposed to major stress. RESULTS Serum cortisol was increased in all stress conditions, with the highest values observed in surgery and sepsis. Continuous intravenous hydrocortisone was the only administration mode persistently achieving median cortisol concentrations in the range observed during major stress. Linear pharmacokinetic modeling identified continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, as best suited for maintaining cortisol concentrations in the required range. CONCLUSIONS Continuous intravenous hydrocortisone infusion should be favored over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress.
Collapse
Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - David J Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- School of Mathematics, University of Birmingham, Birmingham, UK
| | - Mark A Foster
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Sibylle Kohler
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Violet Fazal-Sanderson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - John Komninos
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Donna M O’Neil
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Christopher J Mowatt
- Department of Anaesthesiology, Royal Shrewsbury Hospital, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford, UK
| | | | - Djillali Annane
- Critical Care Department, Hôpital Raymond-Poincaré, Laboratory of Infection & Inflammation U1173 INSERM/University Paris Saclay-UVSQ, Garches, France
| | - Janet M Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - John A H Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Correspondence and Reprint Requests: Wiebke Arlt, MD, DSc, FRCP, FMedSci, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK. E-mail:
| |
Collapse
|
16
|
Isidori AM, Pofi R, Hasenmajer V, Lenzi A, Pivonello R. Use of glucocorticoids in patients with adrenal insufficiency and COVID-19 infection. Lancet Diabetes Endocrinol 2020; 8:472-473. [PMID: 32334645 PMCID: PMC7180011 DOI: 10.1016/s2213-8587(20)30149-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/15/2020] [Indexed: 01/20/2023]
Affiliation(s)
- Andrea M Isidori
- Policlinico Umberto I, COVID Hospital, Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy.
| | - Riccardo Pofi
- Policlinico Umberto I, COVID Hospital, Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Valeria Hasenmajer
- Policlinico Umberto I, COVID Hospital, Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Andrea Lenzi
- Policlinico Umberto I, COVID Hospital, Department of Experimental Medicine, Sapienza University of Rome, Rome 00161, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| |
Collapse
|
17
|
Naggirinya AB, Mujugira A, Meya DB, Biraro IA, Mupere E, Worodria W, Manabe YC. Functional adrenal insufficiency among tuberculosis-human immunodeficiency virus co-infected patients: a cross-sectional study in Uganda. BMC Res Notes 2020; 13:224. [PMID: 32307006 PMCID: PMC7169013 DOI: 10.1186/s13104-020-05064-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 04/07/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Tuberculosis (TB) is the leading cause of adrenal insufficiency in resource-limited settings. The adrenal gland is the most commonly affected endocrine organ in TB infection. We assessed factors associated with functional adrenal insufficiency (FAI) among TB-HIV patients with and without drug-resistance in Uganda. Patients with drug-sensitive and drug-resistant TB were enrolled and examined for clinical signs and symptoms of FAI with an early morning serum cortisol level obtained. FAI was defined as early morning serum cortisol < 414 nmol//L. Associations with FAI were modeled using multivariable logistic regression. RESULTS We screened 311 TB patients and enrolled 272. Of these, 117 (43%) had drug-resistant TB. Median age was 32 years (IQR 18-66) and 66% were men. The proportion with FAI was 59.8%. Mean cortisol levels were lower in participants with drug-resistant than susceptible TB (317.4 versus 488.5 nmol/L; p < 0.001). In multivariable analyses, drug-resistant TB (aOR 4.61; 95% CI 2.3-9.1; p < 0.001), treatment duration > 1 month (aOR 2.86; 95% CI 1.4-5.5; p = 0.002) and abdominal pain (aOR 2.06; 95% CI 1.04-4.09; p = 0.038) were significantly associated with FAI. Early morning serum cortisol levels should be quantified in TB-HIV co-infected patients with drug-resistant TB.
Collapse
Affiliation(s)
- Agnes Bwanika Naggirinya
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David B. Meya
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Irene Andia Biraro
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Immodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Ezekiel Mupere
- Department of Pediatrics, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Worodria
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yukari C. Manabe
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD USA
| |
Collapse
|
18
|
Manosroi W, Phimphilai M, Khorana J, Atthakomol P, Pipanmekaporn T. Predictive Factors of Adrenal Insufficiency in Outpatients with Indeterminate Serum Cortisol Levels: A Retrospective Study. ACTA ACUST UNITED AC 2020; 56:medicina56010023. [PMID: 31936335 PMCID: PMC7022503 DOI: 10.3390/medicina56010023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/26/2019] [Accepted: 01/06/2020] [Indexed: 11/17/2022]
Abstract
Background and Objectives: To diagnose adrenal insufficiency (AI), adrenocorticotropic hormone (ACTH) stimulation tests may need to be performed, but those tests may not be available in some institutions. In addition, they may not be necessary for some patients. The objective of this study was to identify clinical and biochemical factors that could facilitate AI diagnosis in outpatient departments and decrease the number of unnecessary dynamic tests. Materials and Methods: This seven-year retrospective study was performed in a tertiary care medical center. A total of 517 patients who had undergone ACTH stimulation tests in the outpatient department were identified. AI was described as a peak serum cortisol level of <18 µg/dL at 30 or 60 min after stimulation. The associations between clinical factors, biochemical factors, and AI were analyzed using the Poisson regression model and reported by the risk ratio (RR). Results: AI was identified in 128 patients (24.7%). Significant predictive factors for the diagnosis of AI were chronic kidney disease (RR = 2.52, p < 0.001), Cushingoid appearance (RR = 3.44, p < 0.001), nausea and/or vomiting (RR = 1.84, p = 0.003), fatigue (RR = 1.23, p < 0.001), serum basal cortisol <9 µg/dL (RR = 3.36, p < 0.001), serum cholesterol <150 mg/dL (RR = 1.26, p < 0.001), and serum sodium <135 mEq/L (RR = 1.09, p = 0.001). The predictive ability of the model was 83% based on the area under the curve. Conclusion: The easy-to-obtain clinical and biochemical factors identified may facilitate AI diagnosis and help identify patients with suspected AI. Using these factors in clinical practice may also reduce the number of nonessential dynamic tests for AI.
Collapse
Affiliation(s)
- Worapaka Manosroi
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (W.M.); (M.P.)
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Mattabhorn Phimphilai
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (W.M.); (M.P.)
| | - Jiraporn Khorana
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Pichitchai Atthakomol
- Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Tanyong Pipanmekaporn
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
- Correspondence: ; Tel.: +66-53-936453
| |
Collapse
|
19
|
Ebrahimi F, Widmer A, Wagner U, Mueller B, Schuetz P, Christ-Crain M, Kutz A. Association of adrenal insufficiency with patient-oriented health-care outcomes in adult medical inpatients. Eur J Endocrinol 2019; 181:701-709. [PMID: 31581127 PMCID: PMC6977938 DOI: 10.1530/eje-19-0469] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/03/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Adrenal insufficiency in the outpatient setting is associated with excess morbidity, mortality, and impaired quality of life. Evidence on its health-care burden in medical inpatients is scarce. The aim of this study was to assess the health-care burden of primary adrenal insufficiency (PAI) and secondary adrenal insufficiency (SAI) among hospitalized inpatients. DESIGN AND METHODS In this nationwide cohort study, adult medical patients with either PAI or SAI hospitalized between 2011 and 2015 were compared with propensity-matched (1:1) medical controls, respectively. The primary outcome was 30-day all-cause in-hospital mortality. Main secondary outcomes included ICU admission rate, length-of-hospital stay, 30-day and 1-year all-cause readmission rates. RESULTS In total, 594 hospitalized cases with PAI and 4880 cases with SAI were included. Compared with matched controls, in-hospital mortality was not increased among PAI or SAI patients, respectively. Patients with adrenal insufficiency were more likely to be admitted to ICU (PAI: OR 1.9 (95% CI, 1.27 to 2.72) and SAI: OR 1.5 (95% CI, 1.35 to 1.75)). Length of hospital stay was prolonged by 1.0 days in PAI patients (8.9 vs 7.9 days (95% CI, 0.06 to 1.93)), and by 3.3 days in SAI patients (12.1 vs 8.8 days (95% CI, 2.82 to 3.71)), when compared with matched controls. Patients with SAI were found to have higher 30-day and 1-year readmission rates (14.1 vs 12.1% and 50.0 vs 40.7%; P < 0.001) than matched controls. CONCLUSIONS While no difference in in-hospital mortality was found, adrenal insufficiency was associated with prolonged length of hospital stay, and substantially higher rates of ICU admission and hospital readmission.
Collapse
Affiliation(s)
- Fahim Ebrahimi
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Andrea Widmer
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Ulrich Wagner
- Division of Health and Social Affairs, Section Health, Swiss Federal Office for Statistics, Neuchâtel, Switzerland
- Foundation National Institute for Cancer Epidemiology and Registration (NICER), University of Zurich, Zurich, Switzerland
| | - Beat Mueller
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Division of Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Division of Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Mirjam Christ-Crain
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Alexander Kutz
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Correspondence should be addressed to A Kutz;
| |
Collapse
|
20
|
Violante-Cumpa JR, Pérez-Arredondo LA, Treviño-Castro MA. Buccal Mucosa Hyperpigmentation as a Differential Diagnosis in a Patient With Undifferentiated Shock. J Emerg Med 2019; 57:e119-e121. [PMID: 31492591 DOI: 10.1016/j.jemermed.2019.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/19/2019] [Accepted: 06/22/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Jorge Rafael Violante-Cumpa
- Internal Medicine Department, Hospital Universitario, Dr. José Eleuterio González, Universidad Autónoma de Nuevo León Monterrey, Nuevo León, Mexico
| | - Luis Alberto Pérez-Arredondo
- Internal Medicine Department, Hospital Universitario, Dr. José Eleuterio González, Universidad Autónoma de Nuevo León Monterrey, Nuevo León, Mexico
| | - Mario Alberto Treviño-Castro
- Internal Medicine Department, Hospital Universitario, Dr. José Eleuterio González, Universidad Autónoma de Nuevo León Monterrey, Nuevo León, Mexico
| |
Collapse
|
21
|
Affiliation(s)
- R Louise Rushworth
- From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) - all in Australia; and the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (H.F.)
| | - David J Torpy
- From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) - all in Australia; and the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (H.F.)
| | - Henrik Falhammar
- From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) - all in Australia; and the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (H.F.)
| |
Collapse
|
22
|
Abstract
Critical illnesses are characterized by increased systemic cortisol availability, which is a vital part of the stress response. Relative adrenal failure (later termed critical-illness-related corticosteroid insufficiency (CIRCI)) is a condition in which the systemic availability of cortisol is assumed to be insufficiently high to face the stress of the illness and is most typically thought to occur in the acute phase of septic shock. Researchers suggested that CIRCI could be diagnosed by a suppressed incremental cortisol response to an injection of adrenocorticotropic hormone, irrespective of the baseline plasma cortisol. This concept triggered several randomized clinical trials on the impact of large stress doses of hydrocortisone to treat CIRCI, which gave conflicting results. Recent novel insights into the response of the hypothalamic-pituitary-adrenal axis to acute and prolonged critical illnesses challenge the concept of CIRCI, as currently defined, as well as the current practice guidelines for diagnosis and treatment. In this Review, these novel insights are integrated within a novel conceptual framework that can be used to re-appreciate adrenocortical function and dysfunction in the context of critical illness. This framework opens new avenues for further research and for preventive and/or therapeutic innovations.
Collapse
Affiliation(s)
- Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Bram Peeters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium.
| |
Collapse
|
23
|
Rotvig DH, Bauer JØ, Eller NH, Jørgensen MB. [Work-related stress and the hypothalamic-pituitary-adrenal axis]. Ugeskr Laeger 2019; 181:V03180206. [PMID: 30777591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This is a review on the topic of work-related stress (WRS), and how difficulities with differential diagnostics often arise because of overlapping symptoms between WRS and depression. Investigation into the hypothalamic-pituitary-adrenal (HPA) axis deviations seems to reveal the HPA axis as a promising biomarker, since studies have shown, that patients with melancholic type depression exhibit hyper-cortisolism, while patients with WRS exhibit hypocortisolism. More studies of better quality are needed, before anything conclusive can be said. Consensus regarding definition and a development of diagnostic criteria for WRS, e.g. the Swedish "exhaustion disorder", could enable a better differentiation and contribute to more accurate treatment and research.
Collapse
|
24
|
Serban AL, Sala E, Carosi G, Del Sindaco G, Giavoli C, Locatelli M, Arosio M, Mantovani G, Ferrante E. Recovery of Adrenal Function after Pituitary Surgery in Patients with Cushing Disease: Persistent Remission or Recurrence? Neuroendocrinology 2019; 108:211-218. [PMID: 30636245 DOI: 10.1159/000496846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/12/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cushing disease (CD) represents the principal cause of endogenous hypercortisolism. The first-line therapy of CD is surgical removal of the ACTH-secreting pituitary adenoma, which is generally followed by adrenal insufficiency (AI). OBJECTIVE To analyze the recovery of AI in patients with CD after pituitary surgery in relation with recurrence and persistent remission of CD. PATIENTS AND METHODS We performed a retrospective analysis of patients with CD who met the following inclusion criteria: adult age, presence of AI 2 months after the surgical intervention, and a minimum follow-up of 3 years after the surgical intervention. RESULTS Sixty-one patients were followed for a median of 6 years. Ten (16.4%) patients recurred during follow-up. The patients who restored adrenal function did so after a median time of 19 months, with a significantly shorter time in the recurrence group (12.5 vs. 25 months, p = 0.008). All 10 patients who recurred recovered their adrenal function within 22 months. The recovery rate of AI in the persistent remission group was 37.3% (19/51) at 3 years and 55.8% (24/43) at 5 years. In all patients the duration of AI was negatively associated with disease recurrence. CONCLUSION The duration of postsurgical AI in patients with recurrent CD is significantly shorter than that in patients with persistently remitted CD, and this parameter may be a useful predictor of recurrence. Patients showing a normal pituitary-adrenal axis within 2 years after surgery should be strictly monitored as they are at higher risk of disease relapse.
Collapse
Affiliation(s)
- Andreea Liliana Serban
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy,
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy,
| | - Elisa Sala
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giulia Carosi
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giulia Del Sindaco
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Claudia Giavoli
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Marco Locatelli
- Neurosurgery Division, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| |
Collapse
|
25
|
Younas A, Ali A, Nawaz MA, Asif N, Khadim MT. Comparative evaluation of 30 and 60 minutes cortisol Levels During Short Synacthen Test for diagnosis of Adrenal Insufficiency. J PAK MED ASSOC 2019; 69:1628-1631. [PMID: 31740868 DOI: 10.5455/jpma.299484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Alveena Younas
- Department of Pathology, Armed Forces Institute Of Pathology, Rawalpindi, Pakistan
| | - Asif Ali
- Department of Pathology, Armed Forces Institute Of Pathology, Rawalpindi, Pakistan
| | - Muhammad Asif Nawaz
- Department of Pathology, Armed Forces Institute Of Pathology, Rawalpindi, Pakistan
| | - Naveed Asif
- Department of Pathology, Armed Forces Institute Of Pathology, Rawalpindi, Pakistan
| | | |
Collapse
|
26
|
Ohara N, Hirokawa M, Kobayashi M, Ikeda Y, Yoneoka Y, Seki Y, Akiyama K, Tani T, Terajima K, Ozawa T. Reversible Non-parkinsonian Bradykinesia with Impaired Frontal Lobe Function as the Predominant Manifestation of Adrenal Insufficiency. Intern Med 2018; 57:3399-3406. [PMID: 30101905 PMCID: PMC6306535 DOI: 10.2169/internalmedicine.1101-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A 69-year-old Japanese man with a history of suprasellar surgery and irradiation developed bradykinesia and mild fatigue without muscle weakness, myalgia, pyramidal or extrapyramidal signs, parkinsonian symptoms, or ataxia. An endocrinological work-up revealed anterior hypopituitarism associated with secondary adrenal insufficiency. Higher brain function tests indicated an impaired frontal lobe function. The patient's bradykinesia, fatigue, and frontal lobe dysfunction improved within 2 weeks after the initiation of corticosteroid replacement therapy. To our knowledge, this is the first reported case of adrenal insufficiency manifesting as non-parkinsonian bradykinesia. Physicians should consider reversible non-parkinsonian bradykinesia associated with frontal lobe dysfunction as an unusual manifestation of adrenal insufficiency.
Collapse
Affiliation(s)
- Nobumasa Ohara
- Department of Endocrinology and Metabolism, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Mayuko Hirokawa
- Department of Endocrinology and Metabolism, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Michi Kobayashi
- Department of Endocrinology and Metabolism, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Yohei Ikeda
- Department of Radiology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Yuichiro Yoneoka
- Department of Neurosurgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Yasuhiro Seki
- Department of Neurosurgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Katsuhiko Akiyama
- Department of Neurosurgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Takashi Tani
- Department of Neurology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Kenshi Terajima
- Department of Neurology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Tetsutaro Ozawa
- Department of Neurology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| |
Collapse
|
27
|
Senthilkumaran S, Menezes RG, Hussain SA, Luis SA, Thirumalaikolundusubramanian P. Russell's Viper Envenomation-Associated Addisonian Crisis. Wilderness Environ Med 2018; 29:504-507. [PMID: 30309826 DOI: 10.1016/j.wem.2018.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/30/2018] [Accepted: 06/04/2018] [Indexed: 11/18/2022]
Abstract
Snakebite envenomation is an important public health problem in tropical countries. We report a case of bilateral adrenal hemorrhage in a 28-y-old man with Russell's viper bite that occurred in the Sathyamangalam forest range in the Indian state of Tamil Nadu. In this case, a combination of early bite recognition, hospital-based supportive care, corticosteroid therapy, and timely administration of polyvalent antivenom resulted in a favorable clinical outcome.
Collapse
Affiliation(s)
| | - Ritesh G Menezes
- Forensic Medicine Division, Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia (Prof Menezes).
| | - Syed Ather Hussain
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan (Dr Hussain)
| | - Sushil Allen Luis
- School of Medicine, The University of Queensland, Brisbane, Australia (Dr Luis)
| | - Ponniah Thirumalaikolundusubramanian
- Department of Internal Medicine, Trichy SRM Medical College Hospital and Research Center, Irungalur, Trichy, India (Prof Thirumalaikolundusubramanian)
| |
Collapse
|
28
|
Alkhateeb M, Alsakkal M, Alfauri MN, Alasmar D. Reversible dilated cardiomyopathy as a complication of adrenal cortex insufficiency: a case report. J Med Case Rep 2018; 12:345. [PMID: 30458836 PMCID: PMC6247618 DOI: 10.1186/s13256-018-1899-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular manifestations associated with Addison's disease are previously documented. We described a case of an 11-year-old girl who developed dilated cardiomyopathy as a complication to Addison's disease. Glucocorticoid replacement therapy resulted in near-complete recovery of cardiac function. It is the first reported case of reversible cardiomyopathy as a complication of primary adrenal insufficiency in Syria. CASE PRESENTATION An 11-year-old Caucasian girl with no significant past medical history presented with abdominal pain, vomiting after meals, and a low-grade fever. A physical examination and laboratory evaluation suggested primary adrenal insufficiency. An echocardiogram showed changes consistent with dilated cardiomyopathy. Causes of primary adrenal insufficiency other than autoimmune were excluded. CONCLUSIONS Dilated cardiomyopathy is a rare complication of primary adrenal insufficiency. Proper treatment of adrenal insufficiency with glucocorticoid replacement therapy resulted in restoration of normal cardiac function.
Collapse
|
29
|
Yamamoto M, Ben-Shlomo A, Kameda H, Fukuoka H, Deng N, Ding Y, Melmed S. Somatostatin receptor subtype 5 modifies hypothalamic-pituitary-adrenal axis stress function. JCI Insight 2018; 3:122932. [PMID: 30282821 PMCID: PMC6237446 DOI: 10.1172/jci.insight.122932] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 08/29/2018] [Indexed: 11/17/2022] Open
Abstract
Pituitary corticotroph somatostatin receptor subtype 5 (SSTR5) signals to inhibit adrenocorticotrophin (ACTH) secretion. As ACTH deficiency results in attenuated adrenal cortisol production and an impaired stress response, we sought to clarify the role of SSTR5 in modifying the hypothalamic/pituitary/adrenal (HPA) axis. We generated Tg HP5 mice overexpressing SSTR5 in pituitary corticotrophs that produce the ACTH precursor proopiomelanocortin (POMC). Basal ACTH and corticosterone were similar in HP5 and WT mice, while HP5 mice showed attenuated ACTH and corticosterone responses to corticotrophin releasing hormone (CRH). HP5 mice exhibited attenuated corticosterone responses upon a restraint stress test and inflammatory stress following LPS injection, as well as increased anxiety-like and depressive-like behavior on open field and forced swim tests. Pituitary corticotroph CRH receptor subtype 1 (CRHR1) mRNA expression and ACTH responses to CRH were also attenuated in HP5 mice. In AtT20 cells stably overexpressing SSTR5, CRHR1 expression and cAMP response to CRH were reduced, whereas both were increased after SSTR5 KO. In elucidating mechanisms for these observations, we show that SSTR5-induced miR-449c suppresses both CRHR1 expression and function. We conclude that corticotroph SSTR5 attenuates HPA axis responses via CRHR1 downregulation, suggesting a role for SSTR5 in the pathogenesis of secondary adrenal insufficiency.
Collapse
Affiliation(s)
| | | | | | | | - Nan Deng
- Biostatistics and Bioinformatics Research Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yan Ding
- Pituitary Center, Department of Medicine, and
| | | |
Collapse
|
30
|
Papadimitriou DT, Bothou C, Zarganis D, Karantza M, Papadimitriou A. Heterozygous mutations in the cholesterol side-chain cleavage enzyme gene (CYP11A1) can cause transient adrenal insufficiency and life-threatening failure to thrive. Hormones (Athens) 2018; 17:419-421. [PMID: 29995203 DOI: 10.1007/s42000-018-0048-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 04/30/2018] [Indexed: 10/28/2022]
Abstract
The first and rate-limited step of steroidogenesis in all steroidogenic tissues is the conversion of cholesterol to pregnenolone, catalysed by P450scc side-chain cleavage enzyme (CYP11A1 gene-SCC). SCC deficiency has been characterised as an autosomal recessive disorder, although it may also be inherited as an autosomal dominant trait in humans. Here, we describe a family of three members carrying the same novel heterozygous CYP11A1 mutation, a c.235G > A missense variant in exon 1: pVal79Ile. A 46 XY boy (P1) was presented at the age of 3 months with early onset adrenal insufficiency and life-threatening failure to thrive, with low adrenal androgens but normal external genitalia. Five years later, the parents had twin girls, one of whom (P2) presented acute adrenal crisis a few hours after birth. The father (P3), born at term, was reported as having suffered from failure to thrive during the neonatal period, though not his only male sibling. This report of severe early adrenal insufficiency caused by a heterozygous mutation of the CYP11A1 gene clearly demonstrates that SCC deficiency may be inherited as an autosomal dominant trait in humans.
Collapse
Affiliation(s)
- Dimitrios T Papadimitriou
- Department of Pediatric-Adolescent Endocrinology & Diabetes, Athens Medical Center, 58 Kifissias Ave., 15125, Marousi, Athens, Greece.
- Division of Pediatric Endocrinology, Third Department of Pediatrics, Attikon University Hospital, Haidari, Athens, Greece.
| | - Christina Bothou
- Department of Pediatric-Adolescent Endocrinology & Diabetes, Athens Medical Center, 58 Kifissias Ave., 15125, Marousi, Athens, Greece
| | | | - Maria Karantza
- Department of Pediatric Endocrinology, Mitera Children's Hospital, Athens, Greece
| | - Anastasios Papadimitriou
- Division of Pediatric Endocrinology, Third Department of Pediatrics, Attikon University Hospital, Haidari, Athens, Greece
| |
Collapse
|
31
|
Abstract
In 1855, Thomas Addison described an illness now known as Addison disease (AD) caused by damage to the adrenal cortex and manifesting in weakness, weight loss, hypotension, gastrointestinal disturbances, and brownish pigmentation of the skin and mucous membranes. Corticosteroid supplementation, corticotropin (adrenocorticotropic hormone [ACTH] of medicinal use) test, and anti-adrenal auto-antibodies (AA) have come into use in the 100 years since Addison's death. Following the methodological innovations, 4 disorders which share impaired response to corticotropin in common have been discovered (i.e., partial AD, apigmented adrenal insufficiency [AI], subclinical AI, and the AA-positive state exclusively in subjects proven to have an impaired response to corticotropin). As they are hidden, potentially serious conditions, these disorders are bound together as latent AI (LAI). Diagnosis of AD is often delayed, which may lead to adrenal crisis. If LAI were widely recognized, such delays would not exist and crises would be averted. The 3 existing guidelines do not refer much to LAI patients outside those in acute situations. To address this, information relevant to clinical manifestations and diagnostic tests of LAI was sought in the literature. Signs and symptoms that are useful clues to begin a diagnostic workup are presented for endocrinologists to identify patients with suspected LAI. The utility of 2 corticotropin test protocols is reviewed. To endorse LAI shown by the corticotropin test, monitoring items following corticosteroid supplementation are cited from the guidelines and supplemented with the author's observations. ABBREVIATIONS AA = anti-adrenal auto-antibodies; Ab = antibodies; ACA = AA detected by immunofluorescence; ACTH = adrenocorticotropic hormone; AD = Addison disease; AI = adrenal insufficiency; DHEA = dehydroepiandrosterone; GC = glucocorticoid; IFA = immunofluorescence assay; LAI = latent AI; LDT = low-dose test; MC = mineralocorticoid; 21OHAb = anti-21-hydroxylase Ab; ST = standard test; URI = upper respiratory infection.
Collapse
|
32
|
Pofi R, Feliciano C, Sbardella E, Argese N, Woods CP, Grossman AB, Jafar-Mohammadi B, Gleeson H, Lenzi A, Isidori AM, Tomlinson JW. The Short Synacthen (Corticotropin) Test Can Be Used to Predict Recovery of Hypothalamo-Pituitary-Adrenal Axis Function. J Clin Endocrinol Metab 2018; 103:3050-3059. [PMID: 29846658 DOI: 10.1210/jc.2018-00529] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/22/2018] [Indexed: 12/11/2022]
Abstract
CONTEXT The 250-μg short Synacthen (corticotropin) test (SST) is the most commonly used tool to assess hypothalamo-pituitary-adrenal (HPA) axis function. There are many potentially reversible causes of adrenal insufficiency (AI), but no data to guide clinicians as to the frequency of repeat testing or likelihood of HPA axis recovery. OBJECTIVE To use the SST results to predict adrenal recovery. DESIGN A retrospective analysis of 1912 SSTs data. PATIENTS Seven hundred seventy-six patients with reversible causes of AI were identified who had at least two SSTs performed. A subgroup analysis was performed on individuals previously treated with suppressive doses of glucocorticoids (n = 110). MAIN OUTCOME MEASURES Recovery of HPA axis function. RESULTS SST 30-minute cortisol levels above or below 350 nmol/L (12.7 μg/dL) best predicted HPA axis recovery [area under the curve (AUC) receiver operating curve (ROC) = 0.85; median recovery time: 334 vs 1368 days, P = 8.5 × 10-13]: 99% of patients with a 30-minute cortisol >350 nmol/L recovered adrenal function within 4 years, compared with 49% in those with cortisol levels <350 nmol/L. In the subgroup analysis, delta cortisol (30-minute-basal) best predicted the recovery (AUC ROC = 0.77; median recovery time: 262 vs 974 days, P = 7.0 × 10-6). No patient with a delta cortisol <100 nmol (3.6 μg/dL) and a subsequent 1-year random cortisol <200 nmol/L (7.3 μg/dL) recovered HPA axis function. CONCLUSIONS Cortisol levels across an SST can be used to predict recovery of AI and may guide the frequency of repeat testing and inform both clinicians and patients as to the likelihood of restoration of HPA axis function.
Collapse
Affiliation(s)
- Riccardo Pofi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism and National Institute for Health Research Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Chona Feliciano
- Centre for Endocrinology, Diabetes, and Metabolism, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Nicola Argese
- Department of Endocrinology, S.S. Annunziata Hospital, Taranto, Italy
| | - Conor P Woods
- Department of Endocrinology, Naas General Hospital, Kildare and Tallaght Hospital, Dublin, Ireland
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism and National Institute for Health Research Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Bahram Jafar-Mohammadi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism and National Institute for Health Research Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Helena Gleeson
- Centre for Endocrinology, Diabetes, and Metabolism, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Jeremy W Tomlinson
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism and National Institute for Health Research Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
33
|
Abstract
Central adrenal insufficiency (CAI) is a life-threatening condition caused by either pituitary disease (secondary adrenal insufficiency) or impaired hypothalamic function with inadequate CRH production (tertiary adrenal insufficiency). ACTH deficiency may be isolated or, more frequently, occur in conjunction with other pituitary hormone deficiencies and midline defects. Genetic mutations of the TBX19 causing isolated CAI are rare but a number of genes encoding transcription factors involved in hypothalamic-pituitary gland development, as well as other genes including POMC and PC1, are associated with ACTH deficiency. CAI is frequently identified in congenital, malformative, genetic, and epigenetic syndromes as well as in several acquired conditions of different etiologies. The signs and symptoms vary considerably and depend on the age of onset and the number and severity of associated pituitary defects. They may include hypoglycemia, lethargy, apnea, poor feeding, prolonged cholestatic jaundice, jitteriness, seizures, and sepsis in the neonate, or nonspecific signs such as fatigue, hypotension, vomiting and hyponatremia without hyperkalemia in children. The diagnosis of CAI relies on the measurement of morning cortisol concentrations along with dynamic test for cortisol release with different stimulating agents. Early recognition of CAI and its correct management are mandatory in order to avoid both morbidity and mortality in affected neonates, children and adolescents.
Collapse
Affiliation(s)
- Giuseppa Patti
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Chiara Guzzeti
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao", AO Brotzu, Cagliari, Italy
| | - Natascia Di Iorgi
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | | | - Flavia Napoli
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Sandro Loche
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao", AO Brotzu, Cagliari, Italy
| | - Mohamad Maghnie
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy.
| |
Collapse
|
34
|
Abstract
OBJECTIVE Prolonged exposure to glucocorticoids lead to hypothalamic-pituitary-adrenal (HPA) axis suppression that recovers after cessation of treatment. We aimed to identify the predictive factors for HPA axis recovery after prolonged glucocorticoid use. METHODS Retrospective review of patients who had undergone first short Synacthen test (SST) to assess HPA axis recovery after prolonged use of glucocorticoids. RESULTS A total of 61% (20/33) of patients had adequate SST response at a median time of 2 years after diagnosis of adrenal insufficiency. Those who had adequate response during SST had higher ambulatory early morning cortisol ( P<.01), shorter duration of exposure to glucocorticoids ( P = .01), and lower final cumulative hydrocortisone replacement dose ( P = .03). Age, gender, body mass index, indications for glucocorticoid use, and basal adrenocorticotropic hormone levels were not predictive of HPA axis recovery. On multivariate analysis, ambulatory early morning cortisol was the only independent predictor of adequate SST response (odds ratio, 1.02; 95% confidence interval, 1.01 to 1.04; P = .02). Using receiver operating characteristic curve analysis, ambulatory early morning cortisol of 8.8 μg/dL predicted a positive SST response with a sensitivity of 70% and specificity of 93%. CONCLUSION Early morning ambulatory cortisol could be used to decide on timely SST in order to prevent complications from unnecessary replacement with glucocorticoids. ABBREVIATIONS ACTH = adrenocorticotropic hormone; BMI = body mass index; CV = coefficient of variation; HPA = hypothalamic-pituitary-adrenal; SST = short Synacthen test.
Collapse
|
35
|
Quinkler M, Ekman B, Zhang P, Isidori AM, Murray RD. Mortality data from the European Adrenal Insufficiency Registry-Patient characterization and associations. Clin Endocrinol (Oxf) 2018; 89:30-35. [PMID: 29682773 DOI: 10.1111/cen.13609] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/23/2018] [Accepted: 03/29/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Mortality from primary and secondary adrenal insufficiency (AI; PAI and SAI, respectively) is 2-3-fold higher than in the general population. Mortality relates to cardiovascular disease, acute adrenal crisis (AC), cancer and infections; however, there has been little further characterization of patients who have died. DESIGN/METHODS We analysed real-world data from 2034 patients (801 PAI, 1233 SAI) in the European Adrenal Insufficiency Registry (EU-AIR; NCT01661387). Baseline clinical and biochemical data of patients who subsequently died were compared with those who remained alive. RESULTS From August 2012 to June 2017, 26 deaths occurred (8 PAI, 18 SAI) from cardiovascular disease (n = 9), infection (n = 4), suicide (n = 2), drug-induced hepatitis (n = 2), and renal failure, brain tumour, cachexia and AC (each n = 1); cause of death was unclear in 5 patients. Patients who died were significantly older at baseline than alive patients. Causes of AI were representative of patients with SAI; however, 3-quarters of deceased patients with PAI had undergone bilateral adrenalectomy (3 with uncontrolled Cushing's disease, 3 with metastatic renal cell cancer). There were no significant differences in body mass index, blood pressure, low-density lipoprotein cholesterol, total cholesterol or electrolytes between deceased and alive patients. Deceased patients with SAI were more frequently male individuals, were receiving higher daily doses of hydrocortisone (24.0 ± 7.6 vs 19.3 ± 5.7 mg, P = .0016) and experienced more frequent ACs (11.1 vs 2.49/100 patient-years, P = .0389) than alive patients. CONCLUSIONS This is the first study to provide detailed characteristics of deceased patients with AI. Older, male patients with SAI and frequent AC had a high mortality risk.
Collapse
Affiliation(s)
| | - Bertil Ekman
- Department of Endocrinology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | | | - Robert D Murray
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| |
Collapse
|
36
|
Kalenyak K, Heilmann RM. [Canine hypoadrenocorticism - an update on pathogenesis, diagnosis and treatment]. Tierarztl Prax Ausg K Kleintiere Heimtiere 2018; 46:163-175. [PMID: 29898478 DOI: 10.15654/tpk-180351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Canine hypoadrenocorticism (HoAC) results from a loss of functional adrenal cortex, the most common etiology of which is an immune-mediated destruction leading to an inadequate production of glucocorticoids and mineralocorticoids. The term "atypical" HoAC is used for a subgroup of dogs with either an isolated glucocorticoid deficiency or a combined glucocorticoid and mineralocorticoid deficiency but normal electrolytes. Dogs with HoAC can present with a large variety of clinical signs, ranging from shaking, weakness, and mild gastrointestinal signs to seizures, hypovolemic shock, and collapse. Routine clinicopathologic and diagnostic imaging findings are usually nonspecific and frequently mimic those of other common diseases. However, the absence of a stress leukogram, eosinophilia, hyponatremia, hyperkalemia, and azotemia and small adrenal glands on abdominal ultrasound are characteristic findings in dogs with HoAC. The ACTH stimulation test is currently the gold standard method for diagnosing HoAC. Other endocrine laboratory diagnostics, including the quantification of endogenous ACTH, basal and ACTH-stimulated aldosterone levels, cortisol:ACTH ratio, and aldosterone:renin ratio, may further aid in differentiating between primary, secondary, and "atypical" HoAC. Aggressive intravenous fluid therapy is the cornerstone of treatment in paients with an acute Addisonian crisis because it restores normovolemia and normal blood electrolytes. Maintenance therapy consists of glucocorticoid (e.g., prednisolone) and mineralocorticoid (e.g., des- oxycortone pivalate) supplementation and aims for stable electrolyte concentrations and a clinically well dog. The optimal dose of desoxy- cortone pivalate for a specific dog is determined based on blood so- dium and potassium concentrations by using a standardized protocol. Regular reevaluation of blood electrolytes is required for early identifi- cation of a mineralocorticoid deficiency in dogs with "atypical" HoAC. The long-term prognosis for dogs with HoAC is excellent provided that patients receive adequate treatment and there is good owner com- pliance.
Collapse
|
37
|
Abstract
PURPOSE OF REVIEW Monogenic disorders play significant roles in the pathogenesis of childhood-onset primary adrenal insufficiency (PAI). The most common form of PAI is congenital adrenal hyperplasia (CAH), which includes the enzymatic defects of the steroidogenic pathway. This review focuses on less common forms of monogenic PAI (i.e. non-CAH monogenic PAI) with particular attention on their cause, clinical phenotypes and genetic epidemiology. RECENT FINDINGS Non-CAH monogenic PAI can be classified into three major categories: first, adrenocorticotropic hormone resistance, second, impaired adrenal redox homeostasis and third, defective organogenesis of the adrenal glands. The clinical phenotypes of the mutation-carrying patients vary depending on the responsible gene, and they are partially explained by the tissue RNA expression patterns. Genetic epidemiology studies conducted in Turkey and Japan showed that about 80% of PAI of unknown cause was monogenic. SUMMARY Genetic basis of non-CAH monogenic PAI had been less clearly understood than CAH; however, significant advances have been made with use of new research techniques such as next-generation sequencing. Understanding of these rare forms of PAI may contribute to clarifying the physiology and pathology of the adrenal glands.
Collapse
Affiliation(s)
- Satoshi Narumi
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| |
Collapse
|
38
|
Ortiz-Flores AE, Santacruz E, Jiménez-Mendiguchia L, García-Cano A, Nattero-Chávez L, Escobar-Morreale HF, Luque-Ramírez M. Role of sampling times and serum cortisol cut-off concentrations on the routine assessment of adrenal function using the standard cosyntropin test in an academic hospital from Spain: a retrospective chart review. BMJ Open 2018; 8:e019273. [PMID: 29730618 PMCID: PMC5942445 DOI: 10.1136/bmjopen-2017-019273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Aiming to validate the use of a single poststimulus sampling protocol for cosyntropin test short standard high-dose test (SST) in our institution, our primary objectives were (1) to determine the concordance between 30 and 60 min serum cortisol (SC) measurements during SST; and (2) to evaluate the diagnostic agreement between both sampling times when using classic or assay-specific and sex-specific SC cut-off values. The secondary objectives included (1) estimating the specificity and positive predictive value of 30 and 60 min sampling times while considering the suspected origin of adrenal insufficiency (AI); and (2) obtaining assay-specific cut-off values for SC after SST in a group of subjects with normal hypothalamic-pituitary-adrenal (HPA) axis. DESIGN AND SETTING This is a retrospective chart review study conducted at a Spanish academic hospital from 2011 to 2015. PARTICIPANTS AND INTERVENTIONS Two groups were evaluated: (1) a main study group including 370 patients in whom SC was measured at 30 and 60 min during SST; and (2) a confirmative group that included 150 women presenting with a normal HPA axis in whom SST was conducted to rule out late-onset congenital adrenal hyperplasia. Diagnostic agreement between both sampling times was assessed by considering both classic (500 nmol/L) and assay-specific SC cut-off concentrations. RESULTS Diagnostic agreement between both sampling times was greater when applying sex-specific and assay-specific cut-off values instead of the classic cut-off values. For suspected primary AI, 30 min SC determination was enough to establish a diagnosis in over 95% of cases, without missing any necessary treatment. When central AI is suspected, 60 min SC measurement was more specific, establishing a diagnosis in over 97% of cases. CONCLUSIONS Sex-specific and assay-specific SC cut-off values improve the diagnostic accuracy of SST. For primary disease, a subnormal SC response at 30 min is a reliable marker of adrenal dysfunction. On the contrary, when central AI is suspected, 60 min SC measurement improves the diagnostic accuracy of the test.
Collapse
Affiliation(s)
- Andrés E Ortiz-Flores
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal & Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Elisa Santacruz
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ana García-Cano
- Department of Clinical Biochemistry, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Lia Nattero-Chávez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal & Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Manuel Luque-Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal & Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| |
Collapse
|
39
|
Bouchentouf R. Mycobacterium fortuitum infection associated with achalasia. Tunis Med 2018; 96:311-313. [PMID: 30430507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The association achalasia and non tuberculous Mycobacteria lung infection is described in the literature. Most of the time Mycobacterium Fortuitum is responsible of aspiration pneumonia that didn't respond to usual antibiotic therapy. We report a new case about a 15 year-old woman with Allgrove's syndrome history. The chest imaging showed a right pulmonary condensation and the diagnosis was bacteriological. Mycobacterium Fortuitum resistant to Rifampicin, isoniazid, Pyrazinamide and ethamabutol was isolated. She was treated by cotrimoxazole, ciprofloxacin and clarithromycin for 12 months, with a good clinical, radiological and bacteriological evolution. With the purpose to prevent the relapse the patient was treated by cardiomyotomy.
Collapse
|
40
|
Roucher-Boulez F, Brac de la Perriere A, Jacquez A, Chau D, Guignat L, Vial C, Morel Y, Nicolino M, Raverot G, Pugeat M. Triple-A syndrome: a wide spectrum of adrenal dysfunction. Eur J Endocrinol 2018; 178:199-207. [PMID: 29237697 DOI: 10.1530/eje-17-0642] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/12/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Triple-A or Allgrove syndrome is an autosomal recessive disorder due to mutations in the AAAS gene, which encodes a nucleoporin named ALADIN. It is characterized by a classical clinical triad: alacrima, achalasia and adrenal insufficiency, the canonic symptoms that are associated with progressive peripheral neuropathy. Only a few cohorts have been reported. The objective of the present study was to characterize the various spectra of adrenal function in Triple-A patients. METHODS A retrospective clinical and biological monitoring of 14 patients (10 families) was done in a single multidisciplinary French center. All had AAAS gene sequenced and adrenal function evaluation. RESULTS Nine different AAAS mutations were found, including one new mutation: c.755G>C, p.(Trp252Ser). Regarding adrenal function, defects of the zona fasciculata and reticularis were demonstrated by increased basal ACTH levels and low DHEAS levels in all cases regardless of the degree of glucocorticoid deficiency. In contrast, mineralocorticoid function was always conserved: i.e., normal plasma renin level associated with normal aldosterone level. The main prognostic feature was exacerbation of neuropathy and cognitive disorders. CONCLUSIONS These data suggest that, in Triple-A patients, adrenal function can be deficient, insufficient or compensated. In our cohort after the first decade of life, there does not appear to be any degradation of adrenal function over time. However, patients with compensated adrenal function should be informed and educated to manage a glucocorticoid replacement therapy in case of stressful conditions, with no need for systematic long-term treatment.
Collapse
Affiliation(s)
- Florence Roucher-Boulez
- Laboratoire de Biochimie et Biologie Moléculaire Grand EstUM Pathologies Endocriniennes Rénales Musculaires et Mucoviscidose, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Univ LyonUniversité Claude Bernard Lyon 1, Lyon, France
- Centre de Référence du Développement Génital: du Fœtus à l'AdulteFilière Maladies Rares Endocriniennes, Bron, France
| | - Aude Brac de la Perriere
- Centre de Référence du Développement Génital: du Fœtus à l'AdulteFilière Maladies Rares Endocriniennes, Bron, France
- Fédération d'EndocrinologieGroupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Aude Jacquez
- Univ LyonUniversité Claude Bernard Lyon 1, Lyon, France
| | - Delphine Chau
- Univ LyonUniversité Claude Bernard Lyon 1, Lyon, France
| | - Laurence Guignat
- Service d'EndocrinologieCentre de Référence des Maladies Surrénaliennes Rares, Hôpital Cochin, Paris, France
| | - Christophe Vial
- Service d'Electroneuromyographie et Pathologies NeuromusculairesGroupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Yves Morel
- Laboratoire de Biochimie et Biologie Moléculaire Grand EstUM Pathologies Endocriniennes Rénales Musculaires et Mucoviscidose, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Univ LyonUniversité Claude Bernard Lyon 1, Lyon, France
- Centre de Référence du Développement Génital: du Fœtus à l'AdulteFilière Maladies Rares Endocriniennes, Bron, France
| | - Marc Nicolino
- Univ LyonUniversité Claude Bernard Lyon 1, Lyon, France
- Centre de Référence du Développement Génital: du Fœtus à l'AdulteFilière Maladies Rares Endocriniennes, Bron, France
- Service de Pédiatrie EndocrinologieGroupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Gerald Raverot
- Univ LyonUniversité Claude Bernard Lyon 1, Lyon, France
- Fédération d'EndocrinologieGroupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Michel Pugeat
- Univ LyonUniversité Claude Bernard Lyon 1, Lyon, France
- Fédération d'EndocrinologieGroupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| |
Collapse
|
41
|
Anand G, Beuschlein F. MANAGEMENT OF ENDOCRINE DISEASE: Fertility, pregnancy and lactation in women with adrenal insufficiency. Eur J Endocrinol 2018; 178:R45-R53. [PMID: 29191934 DOI: 10.1530/eje-17-0975] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 11/30/2017] [Accepted: 11/30/2017] [Indexed: 12/21/2022]
Abstract
With the introduction of hormonal substitution therapy in the 1950s, adrenal insufficiency (AI) has been turned into a manageable disease in pregnant women. In fact, in the light of glucocorticoid replacement therapy and improved obstetric care, it is realistic to expect good maternal and fetal outcomes in patients with AI. However, there are still a number of challenges such as establishing the diagnosis of AI in pregnant women and optimizing the treatment of AI and related comorbidities prior to as well as during pregnancy. Clinical and biochemical diagnoses of a new-onset AI may be challenging because of overlapping symptoms of normal pregnancy as well as pregnancy-induced changes in cortisol values. Physiological changes occurring during pregnancy should be taken into account while adjusting the substitution therapy. The high proportion of reported adrenal crisis in pregnant women with AI highlights persistent problems in this particular clinical situation. Due to the rarity of the disease, there is no prospective data-guiding management of pregnancy in patients with known AI. The aim of this review is to summarize the maternal and fetal outcomes based on recently published case reports in patients with AI and to suggest a practical approach to diagnose and manage AI in pregnancy.
Collapse
Affiliation(s)
- Gurpreet Anand
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| |
Collapse
|
42
|
Abstract
RATIONALE Late-onset transient adrenal insufficiency with circulatory collapse is a rare condition that occurs in preterm infants. Although the incidence of late-onset transient adrenal insufficiency in preterm infants has been reported in Japan, reports from Western countries are lacking. In addition, no study has investigated the effect of twin-to-twin transfusion syndrome (TTTS) in monozygotic twins. PATIENT CONCERNS A pair of extremely low birth weight twins presented with TTTS. DIAGNOSES Both twins developed late-onset adrenal insufficiency with oliguria, hypotension, hyponatremia, and pulmonary edema at a postnatal age of 24 days and 51 days, respectively. INTERVENTION Temporary administration of intravenous hydrocortisone was initiated. OUTCOMES Their symptoms improved dramatically and they survived the event without any neurologic sequelae after 3 years of follow-up. LESSONS Late-onset circulatory collapse may occur, especially in extremely preterm infants, even at 2 months after birth. Hydrocortisone therapy is an effective treatment to rescue circulatory collapse caused by adrenal insufficiency in preterm infants and may not affect long-term neuromotor and cognitive outcomes.
Collapse
Affiliation(s)
- Chin Yee Ho
- Department of Pediatrics, E-Da Hospita
- School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Zong-Rong He
- Department of Pediatrics, E-Da Hospita
- School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - San-Nan Yang
- Department of Pediatrics, E-Da Hospita
- School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yung-Ning Yang
- Department of Pediatrics, E-Da Hospita
- School of Medicine, I-Shou University, Kaohsiung, Taiwan
| |
Collapse
|
43
|
Abstract
The daily rhythm of the hypothalamo-pituitary-adrenal (HPA) axis is regulated by the central clock in the suprachiasmatic nucleus. Cortisol, a glucocorticoid, acts as a secondary messenger between the central clock and the peripheral tissues. Changes in clock time, as seen in shift workers, alters the HPA axis and results in metabolic disturbances associated with ill health. Depression, anorexia nervosa and obstructive sleep apnoea, are associated with cortisol rhythm phase shifts and increased cortisol exposure. Higher nocturnal cortisol exposure is observed in patients with Cushing's syndrome and adrenal incidentalomas with autonomous cortisol secretion and is associated with insulin resistance, and increased cardiovascular risk and mortality. A decrease in cortisol rhythm amplitude is seen in adrenal insufficiency, and despite replacement, patients have an impaired quality of life and increased mortality. Research on cortisol replacement has focused on replacing the cortisol daily rhythm by subcutaneous hydrocortisone infusions and oral modified release hydrocortisone formulations with the aim of improving disease control and quality of life.
Collapse
Affiliation(s)
| | - Richard Ross
- Oncology and Metabolism, University of Sheffield, Sheffield, S10 2RX, UK.
| | - Miguel Debono
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield, UK.
| |
Collapse
|
44
|
Cutright A, Ducey S, Barthold CL, Kim J. Recognizing and managing adrenal disorders in the emergency department [digest]. Emerg Med Pract 2017; 19:S1-S2. [PMID: 28933807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Primary and secondary adrenal insufficiency are underrecognized conditions among emergency department patients, affecting an estimated 10% to 20% of critically ill patients. The signs and symptoms of cortisol deficit can be nonspecific and wide-ranging, and identification and swift treatment with stress-dosing of hydrocortisone is vital to avoid life-threatening adrenal crisis. Laboratory evaluation focuses on identification of electrolyte abnormalities typical of adrenal insufficiency, and while additional testing may depend on the type and severity of symptoms, it should not delay corticosteroid replacement. This issue provides recommendations on effective management of patients presenting with adrenal insufficiency, with particular attention to the management of critically ill and septic patients, pregnant patients, and children. [Points & Pearls is a digest of Emergency Medicine Practice.].
Collapse
Affiliation(s)
- Amy Cutright
- Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Stephen Ducey
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Claudia L Barthold
- Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Jeremy Kim
- Emergency Physician, St. David's South Austin Medical Center, Austin, TX
| |
Collapse
|
45
|
Peechakara S, Bena J, Clarke NJ, McPhaul MJ, Reitz RE, Weil RJ, Recinos P, Kennedy L, Hamrahian AH. Total and free cortisol levels during 1 μg, 25 μg, and 250 μg cosyntropin stimulation tests compared to insulin tolerance test: results of a randomized, prospective, pilot study. Endocrine 2017; 57:388-393. [PMID: 28730418 DOI: 10.1007/s12020-017-1371-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 07/01/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The appropriate cosyntropin dose during cosyntropin stimulation tests remains uncertain. We conducted a prospective, randomized pilot study to compare 1 μg IV low dose cosyntropin test, 25 μg IM medium dose cosyntropin test, and 250 μg IM standard dose cosyntropin test to evaluate secondary adrenal insufficiency. Insulin tolerance test was used as the gold standard. METHOD The study included patients with hypothalamic/pituitary disease (n = 10) with at least one pituitary axis deficiency other than ACTH deficiency and controls (n = 12). All tests were done in random order. Sensitivity and specificity were calculated for total cortisol and serum free cortisol cut-off levels during cosyntropin stimulation tests. RESULTS The median (range) age and F/M sex ratios for patients and controls were 54 years (23-62), 2/8, and 33 years (21-51), 6/6, respectively. The best total cortisol cut-off during low dose cosyntropin test, medium dose cosyntropin test, 30 min and 60 min standard dose cosyntropin test were 14.6 μg/dL (100% sensitivity & specificity), 18.7 μg/dL (100% sensitivity, 88% specificity), 16.1 (100% sensitivity & specificity), and 19.5 μg/dL (100% sensitivity & specificity), respectively. There was no difference in the ROC curve for cortisol values between the cosyntropin stimulation tests (p > 0.41). Using a cortisol cut-off of 18 μg/dL during cosyntropin stimulation tests, only cortisol level at 30 min during standard dose cosyntropin test provided discrimination similar to insulin tolerance test. The best peak free cortisol cut-off levels were 1 μg/dL for insulin tolerance test, 0.9 μg/dL for low dose cosyntropin test, 0.9 μg/dL for medium dose cosyntropin test, and 0.9 μg/dL and 1.3 μg/dL for 30 min and 60 min standard dose cosyntropin test, respectively. CONCLUSION All cosyntropin stimulation tests had excellent correlations with insulin tolerance test, when appropriate cut-offs were used. This pilot study does not suggest an advantage in using 25 μg cosyntropin dose during the cosyntropin stimulation test. A serum free cortisol cut-off of 0.9 μg/dL may be used as pass criterion during low dose cosyntropin test, standard dose cosyntropin test cosyntropin test, and 30 min standard dose cosyntropin test.
Collapse
Affiliation(s)
- Seenia Peechakara
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA.
| | - James Bena
- Quantitative Health Sciences, Lerner Research Institute, Cleveland, OH, 44195, USA
| | - Nigel J Clarke
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 92675, USA
| | - Michael J McPhaul
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 92675, USA
| | - Richard E Reitz
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 92675, USA
| | - Robert J Weil
- Brain Tumor and Neuro-Oncology Center and Department of Neurosurgery, The Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Pablo Recinos
- Brain Tumor and Neuro-Oncology Center and Department of Neurosurgery, The Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Laurence Kennedy
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Amir H Hamrahian
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
- Department of Endocrinology, Medical Subspecialty Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| |
Collapse
|
46
|
Abstract
AbstractGreat heterogeneity seems to exist regarding diagnosis, therapy, and teaching of patients with secondary adrenal insufficiency (SAI) across Germany resulting in different diagnosis and treatment strategies. The aim of the work was to present the first national audit on diagnosis, treatment, and patient teaching of SAI reflecting common clinical practice in Germany. A self-designed questionnaire was sent via e-mail to all members of the German Endocrine Society (approx. 120 centers). Returned questionnaires (response rate 38.3%) were checked for duplicity of institutions and analyzed. Diagnostic testing focuses on those patients with relevant risk for adrenal insufficiency. Basal serum cortisol is mostly used as screening test. Short synacthen and CRH tests are the preferred confirmatory tests, however, cut-off values vary due to different assays used. Patients with radiation, second surgery, progressive disease or new symptoms are followed by serial re-testing. Perioperative management and frequency of postoperative re-evaluations differ among centers. Hydrocortisone is the preferred glucocorticoid for replacement therapy, but daily doses vary considerably (10–30 mg/day). Some centers perform hormone measurements for dose adjustment of glucocorticoid replacement therapy whereas others rely on clinical judgement. Patients’ teaching is done in 84% of centers, but only half of the centers include patients’ relatives. Homogeneity exists in patients’ teaching regarding intercurrent illnesses (fever, diarrhoea). Recommendations regarding dose adaptations in situations such as sport-activities, dental-procedures, or coughing are highly variable. This first national audit reveals great heterogeneity among German centers and could improve patients’ care in SAI, for example, by initiating new trials and developing clinical practice guidelines.
Collapse
Affiliation(s)
| | - Jürgen Honegger
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | | |
Collapse
|
47
|
Werumeus Buning J, Konopka KH, Brummelman P, Koerts J, Dullaart RPF, van den Berg G, van der Klauw MM, Tucha O, Wolffenbuttel BHR, van Beek AP. Somatosensory function in patients with secondary adrenal insufficiency treated with two different doses of hydrocortisone-Results from a randomized controlled trial. PLoS One 2017; 12:e0180326. [PMID: 28686664 PMCID: PMC5501533 DOI: 10.1371/journal.pone.0180326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 06/11/2017] [Indexed: 11/18/2022] Open
Abstract
Background Low cortisol levels are associated with several functional pain syndromes. In patients with secondary adrenal insufficiency (SAI), the lack in endogenous cortisol production is substituted by the administration of oral hydrocortisone (HC). Our previous study showed that a lower dose of HC led to an increase in reported subjective pain symptoms. Whether different doses of HC substitution alter somatosensory functioning in SAI patients has not been established yet. Methods In this randomized double blind cross-over trial, forty-six patients with SAI participated. Patients randomly received either first a lower dose (0.2–0.3 mg HC/kg body weight/day) for 10 weeks followed by a higher dose (0.4–0.6 mg HC/kg body weight/day) for another 10 weeks, or vice versa. After each treatment period, blood samples were drawn and somatosensory functioning was assessed by determining the mechanical detection threshold (MDT), mechanical pain threshold (MPT), mechanical pain sensitivity (MPS) and the pain pressure threshold (PPT), according to the Quantitative Sensory Testing (QST) battery by the German Network on Neuropathic Pain. Results The administration of the higher dose of HC resulted in significantly higher levels of cortisol (mean [SD] 748 [245] nmol/L) than the lower dose (537 [250] nmol/L, P<0.001). No differences were found in MDT, MPT, MPS and PPT z-scores between the two doses of HC. Furthermore, the number of patients showing sensory abnormalities did not differ between the two different doses. Conclusions The results suggest that the dose of HC has no impact on somatosensory functioning in response to mechanical stimuli in patients with SAI, despite previously found altered subjective pain reports.
Collapse
Affiliation(s)
- Jorien Werumeus Buning
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- * E-mail:
| | - Karl-Heinz Konopka
- Drug Discovery Science & Management-Europe, Astellas Pharma Europe B.V., Leiden, The Netherlands
| | - Pauline Brummelman
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Janneke Koerts
- Department of Clinical and Developmental Neuropsychology, University of Groningen, Groningen, The Netherlands
| | - Robin P. F. Dullaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerrit van den Berg
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Melanie M. van der Klauw
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Oliver Tucha
- Department of Clinical and Developmental Neuropsychology, University of Groningen, Groningen, The Netherlands
| | - Bruce H. R. Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - André P. van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
48
|
|
49
|
Chihaoui M, Chaker F, Yazidi M, Grira W, Ben Amor Z, Rejeb O, Slimane H. Ramadan fasting in patients with adrenal insufficiency. Endocrine 2017; 55:289-295. [PMID: 27878773 DOI: 10.1007/s12020-016-1186-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
Abstract
AIM The risks of fasting during Ramadan in patients with adrenal insufficiency are unknown. The aims of this study were to evaluate these risks in such patients, to determine the risk factors and finally to set some recommendations. METHODS It is a cross-sectional study about 180 patients with known and treated adrenal insufficiency. The patients responded to a 14-item questionnaire concerning their knowledge about the disease and fasting during the last month of Ramadan. RESULTS There were 132 women and 48 men. The mean age was 47.6 ± 15.0 years (14-79). One hundred and thirty eight patients (76.7 %) were advised by their physician not to fast. Ninety-one patients (50.5 %) tried to fast. Complications occurred in 61 cases (67.0 %): asthenia in 88.5 % of cases, intense thirst in 32.8 %, symptoms of dehydration in 49.2 % and symptoms of hypoglycaemia in 18 %. One patient was hospitalized. Fifty-five patients (60.4 %) were able to fast for the whole month. Age, gender, duration of the disease, its primary origin, associated hypothyroidism, diabetes mellitus, hypertension or diabetes insipidus and daily dose of hydrocortisone did not significantly differ between fasters and non-fasters, full-month-fasters and partial-month-fasters, and fasters with complications and fasters without complications. The frequency of adequate knowledge about the disease was significantly higher in full-month-fasters vs. partial-month-fasters, and in fasters without complications vs. those with complications. CONCLUSION In patients with adrenal insufficiency, fasting can cause complications especially if the level of knowledge about the disease is low.
Collapse
Affiliation(s)
- Mélika Chihaoui
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia.
| | - Fatma Chaker
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Zohra Ben Amor
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Ons Rejeb
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Hedia Slimane
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| |
Collapse
|
50
|
Foster C, Choudhary A. Severe malnutrition causing superior mesenteric artery syndrome in an adolescent with Triple A syndrome. J Pediatr Endocrinol Metab 2016; 29:1221-1224. [PMID: 27682707 DOI: 10.1515/jpem-2015-0373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 08/29/2016] [Indexed: 12/26/2022]
Abstract
Triple A syndrome, formerly known as Allgrove syndrome (AS), is characterized by achalasia, alacrima and adrenal insufficiency. Here we report an adolescent male with adrenal insufficiency who developed severe malnutrition secondary to a delayed diagnosis of achalasia. The severe malnutrition in our patient led to superior mesenteric artery (SMA) obstruction syndrome. Severe malnutrition to the point of SMA syndrome has not been previously described in the literature in Triple A syndrome.
Collapse
|