Hormone secretion in alcohol-induced pseudo-Cushing's syndrome. Differential diagnosis with Cushing disease

Bone changes in alcoholic liver disease

Alcoholism has been associated with growth impairment, osteomalacia, delayed fracture healing, and aseptic necrosis (primarily necrosis of the femoral head), but the main alterations observed in the bones of alcoholic patients are osteoporosis and an increased risk of fractures. Decreased bone mass is a hallmark of osteoporosis, and it may be due either to decreased bone synthesis and/or to increased bone breakdown. Ethanol may affect both mechanisms. It is generally accepted that ethanol decreases bone synthesis, and most authors have reported decreased osteocalcin levels (a “marker” of bone synthesis), but some controversy exists regarding the effect of alcohol on bone breakdown, and, indeed, disparate results have been reported for telopeptide and other biochemical markers of bone resorption. In addition to the direct effect of ethanol, systemic alterations such as malnutrition, malabsorption, liver disease, increased levels of proinflammatory cytokines, alcoholic myopathy and neuropathy, low testosterone levels, and an increased risk of trauma, play contributory roles. The treatment of alcoholic bone disease should be aimed towards increasing bone formation and decreasing bone degradation. In this sense, vitamin D and calcium supplementation, together with biphosphonates are essential, but alcohol abstinence and nutritional improvement are equally important. In this review we study the pathogenesis of bone changes in alcoholic liver disease and discuss potential therapies.

Prognosis of osteopenia in chronic alcoholics

Osteoporosis is frequent among alcoholics all by a direct effect of ethanol, malnutrition, and liver failure. Therefore, it may be related to survival. The aim of this study was to assess bone mineral density (BMD), bone mineral content, hormonal status, and to determine prognostic value of these parameters in a total of 124 alcoholics followed up for a median period of 57 months. Several bone homeostasis-related hormones were measured in patients and age- and sex-matched controls. Whole-body densitometry was performed by a Hologic QDR-2000 (Waltham, MA) densitometer; nutritional status and liver function were assessed. Sixty patients underwent a second evaluation 6 months later. Patients showed lower serum insulin-like growth factor-1 (median=58, interquartile range [IQR]=33-135 vs. 135ng/mL, IQR=116-243ng/mL, P<.001), vitamin D (25.5, IQR=18.3-36.8 vs. 79.9pg/mL, IQR=59.2-107.8pg/mL, P<.001), and osteocalcin (2.1, IQR=1.1-4.5 vs. 6.5ng/mL, IQR=4.7-8.7ng/mL, P<.001) than controls, and lower BMD values, and lower Z- and T-scores at right and left legs and arms, thoracic and lumbar spine, pelvis, and right and left ribs. By multiple regression analysis, BMD mainly depends on nutritional parameters and liver function. Kaplan-Meier curves show that subtotal BMD and BMD at both arms and pelvis were significantly related with survival. Patients who had lost total hip BMD after 6 months showed a shorter survival than those who had not, but using Cox's regression, encephalopathy, ascites, and nutritional parameters displaced BMD as prognostic factor. Therefore, osteopenia ensues in chronic alcoholic patients. It mainly depends on poor nutrition and is related to survival, although surpassed in this sense by encephalopathy, ascites, and nutritional parameters.

Serum Total Prostate-Specific Antigen Assay in Women with Cushing’s Disease or Alcohol-Dependent Pseudo-Cushing’s State

BACKGROUND

The distinction between Cushing's disease (Cushing's syndrome dependent on adrenocorticotropic hormone (ACTH)-secreting tumors of pituitary origin) and pseudo-Cushing's states (Cushingoid features and hypercortisolism sometimes present in alcoholic, depressed or obese subjects) can present a diagnostic challenge in clinical endocrinology. Recently, the availability of a highly sensitive immunofluorometric assay for the measurement of total prostate-specific antigen (PSA) provided the possibility to measure serum PSA levels in women. Interestingly, PSA gene expression and protein production has been found to be upregulated by steroid hormones, such as androgens, glucocorticoids, mineral corticoids and progestins. In fact, serum total PSA concentrations appear to be higher in female patients with Cushing's disease than in normal women. We wondered whether a similar phenomenon also occurs in pseudo-Cushing's state.

METHODS

In order to answer this question, we compared the serum total PSA levels measured in 10 female subjects with alcohol-dependent pseudo-Cushing's state with those observed in 8 female patients with Cushing's disease and in 15 age-matched healthy women. Serum testosterone, ACTH and cortisol, and 24-hour urinary cortisol levels were measured; cortisol suppression after dexamethasone was also tested in all subjects.

RESULTS

The basal serum levels of ACTH and cortisol were significantly lower in normal subjects than in patients with Cushing's disease or pseudo-Cushing's state; these latter groups showed similar basal hormonal values. Dexamethasone administration was unable to suppress serum cortisol levels in 5 subjects with Cushing's disease and 6 subjects with pseudo-Cushing's state. Serum testosterone values in the group with Cushing's disease were higher than in the other groups. No differences were observed between pseudo-Cushing's and normal subjects. Serum total PSA levels were significantly higher in women with Cushing's disease than in subjects with pseudo-Cushing's state and normal controls; these latter groups showed similar PSA values. When serum total PSA and testosterone levels were considered together, a significant positive correlation was observed in the group with Cushing's disease, but not in the other groups.

CONCLUSIONS

These data indicate that the steroid milieu responsible for the elevation in serum PSA in women with Cushing's disease is not present in subjects with alcohol-dependent pseudo-Cushing's state, suggesting the possible use of PSA as a marker of differentiation between these pathological conditions in women.

Desmopressin and hexarelin tests in alcohol-induced pseudo-Cushing's syndrome

BACKGROUND

A challenge in clinical endocrinology is the distinction between Cushing's disease (Cushing's syndrome dependent by adrenocorticotrophic hormone (ACTH)-secreting tumours of pituitary origin) and alcohol-dependent pseudo-Cushing's syndrome. Patients with Cushing's disease are known to have high ACTH/cortisol responses to desmopressin (DDAVP, a vasopressin analogue) and to hexarelin (HEX, a synthetic GH-releasing peptide).

OBJECTIVE

To compare the ACTH/cortisol responses to desmopressin and to hexarelin of subjects with alcohol pseudo-Cushing's syndrome with those obtained in patients with Cushing's disease and in normal controls.

DESIGN

Randomized, single-blind study.

SETTING

University medical centre.

SUBJECTS

Eight alcoholics with pseudo-Cushing's syndrome, six patients with Cushing's disease and nine age-matched normal controls.

INTERVENTION

Three tests at weekly intervals. The dexamethasone (1 mg) suppression test (DST) was carried out first. The desmopressin (10 microg intravenously at 09:00 h) test and hexarelin (2 microgram kg-1 intravenously at 09:00 h) test were carried out in random order.

MEASUREMENTS

Plasma ACTH and cortisol levels.

RESULTS

The basal plasma levels of ACTH and cortisol were significantly lower in normal subjects than in patients with Cushing's disease and in alcoholic subjects; these latter groups showed similar basal hormonal values. All normal controls, two patients with Cushing's disease and two alcoholics showed suppression of plasma cortisol levels (<5 microgram dL-1) after dexamethasone administration. Both desmopressin and hexarelin induced striking ACTH/cortisol responses in patients with Cushing's disease, whereas hexarelin, but not desmopressin, slightly increased ACTH/cortisol secretion in the normal controls. Neither desmopressin nor hexarelin administration induced any significant change in ACTH/cortisol secretion in alcoholics.

CONCLUSIONS

These data suggest that either the hexarelin or desmopressin test can be used to differentiate patients with Cushing's disease from subjects with alcohol-dependent pseudo-Cushing's syndrome.

The diagnosis and differential diagnosis of Cushing's syndrome

Cushing's syndrome is defined as the symptoms and signs of glucocorticoid excess, but the precise diagnosis may be difficult to establish and harder to localise. The clinicial, biochemical and imaging features of the syndrome are discussed in the light of our own extensive experience and the published literature. We describe the optimal diagnostic routines currently recommended in major centres, and analyse the sensitivities and specialities of the various tests employed. Only by means of establishing a precise diagnosis can the disorder be successfully treated.

Relative and combined effects of ethanol and protein deficiency on bone histology and mineral metabolism

This study was performed to analyze the relative and combined effects of ethanol and protein deficiency on bone histology and mineral metabolism in 4 groups of 7 animals each which were pair-fed during 8 weeks with 1) a nutritionally adequate diet; 2) a 36% (as energy) ethanol containing isocaloric diet; 3) a 2% protein, isocaloric diet; and 4) a 36% ethanol 2% protein isocaloric diet, respectively, following the Lieber-DeCarli model. Another group of five rats were fed ad libitum the control diet. The first and second lumbar vertebrae were removed after sacrifice, and processed for histomorphometrical analysis of undecalcified bone samples. Blood and 24-h urine were also collected. Protein malnutrition, but not ethanol, leads to osteoporosis and reduced osteoid synthesis, whereas ethanol and protein malnutrition both lead to impaired bone mineral apposition and increased urinary hydroxyproline excretion. These changes are accompanied by an increase in serum parathormone and serum 1,25 dihydroxy vitamin D3, a slight hypomagnesemia, hypercalciuria and hyperphosphaturia; protein deficiency plays an independent role in these alterations, whereas both ethanol and protein deficiency exert independent effects on decreasing serum testosterone levels; this last alteration may contribute to the bone changes mentioned before.

Lower activity of serum peptidases in abstinent alcohol-dependent patients

This study examines i) the activity of serum prolyl endopeptidase (PEP) and dipeptidlyl peptidase IV (DPP IV) in detoxified alcohol-dependent patients without liver disease versus normal controls, and ii) the relationships between serum DPP IV and PEP activity and the production of cytokines or cytokine receptors, such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), interferon-y (IFN-y), IL-1 receptor antagonist (IL-1RA), and IL-10, and granulocyte-macrophage colony stimulatory factor (GM-CSF). Alcohol-dependent patients had significantly lower serum PEP and DPP IV activity than normal controls. We found that 58.3% and 50.0% of the alcohol-dependent patients, respectively, had PEP and DPP IV activities, which were lower than the mean control values minus 2 SD. There were significant inverse correlations between lowered serum DPP IV and PEP activity and the increased production of IL-6, INF-gamma, IL-IRA, IL-10, and GM-CSF. These results show that lower serum DPP IV and PEP activity may be related to the pathophysiology of alcohol dependence.

Specific and nonspecific effects of ethanol vapor on plasma corticosterone in mice

The intent of this study was to determine whether chronic ethanol (EtOH) vapor inhalation, with or without adjunct pyrazole (PYR) administration, was stressful in mice, as defined by increases in plasma corticosterone (CORT) concentration. Mice were randomly assigned to groups differentiated both on the basis of EtOH vapor exposure and the presence or absence of PYR administration. Blood samples for blood EtOH concentration (BEC) and plasma CORT concentration were obtained from mice after 72-96 hours of treatment. Mice were sacrificed after 96 hours of treatment and body and adrenal weight determined. BEC was significantly higher in PYR-treated animals and animals treated with the higher EtOH vapor concentration. Plasma CORT was elevated in proportion to BEC; however, other nonspecific stresses, in particular that of PYR administration, also elevated plasma CORT. Nonspecific stresses associated with this protocol may reduce the generality of these observations. Nevertheless, the high correlation between BEC and plasma CORT concentration in the PYR groups indicates that, with suitable control groups, the PYR-EtOH vapor inhalation approach is viable for studies concerned with EtOH effects on hypothalamic-anterior pituitary-adrenocortical function.

Differential regulation of anterior pituitary corticotrope function is observed in vivo but not in vitro in two lines of ethanol-sensitive mice

Anterior pituitary corticotrope function was analyzed in the long sleep (LS) and short sleep (SS) lines of mice selectively bred for differences in sensitivity to ethanol. In vivo challenge with acute ethanol or CRH administration or the stress of novel handling resulted in a more pronounced increase in serum corticosterone levels in LS mice compared with SS mice. Likewise, in vivo administration of ethanol resulted in 3-fold higher levels of anterior pituitary pro-ACTH/endorphin mRNA in LS mice compared with SS mice. However, this differential regulation of the HPA axis during in vivo analysis was not observed during in vitro studies of anterior pituitary corticotrope function. Primary cultures of LS and SS anterior pituicytes responded appropriately but equivalently to a variety of secretagogues known to stimulate anterior pituitary ACTH secretion. These secretagogues included CRH (10 nM), dibutyryl-cAMP (1 mM), vasopressin (100 nM), and phorbol 12-myristate 13-acetate (10 nM). Ethanol had no direct stimulatory effect on pituitary ACTH secretion. Quantitation of anterior pituitary corticotrope peptide biosynthesis was determined by immunoprecipitation and sodium dodecyl sulfate-polyacrylamide gel electrophoresis of extracts from [35S]methionine-labeled anterior pituitary explants and from [35S]methionine-labeled primary cultures of anterior pituitary cells. LS mice pro-ACTH/endorphin biosynthesis in pituitary explants was 2-fold greater than pro-ACTH/endorphin biosynthesis in SS mice pituitary explants. However, in culture, isolated from hypothalamic and adrenal factors, the LS anterior pituitary pro-ACTH/endorphin biosynthetic rate became equivalent to the SS anterior pituitary pro-ACTH/endorphin biosynthetic rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Low basal levels of cortisol distinguish detoxified alcoholics with major depressive disorder from non-MDDs

Basal plasma levels of cortisol and its suppression by dexamethasone were measured in 60 inpatient alcoholics 12-13 days after detoxification. Both hypothalamic-pituitary adrenal system parameters were essentially within normal limits in most patients--those who did not meet criteria for major depressive disorder (n = 43) as well as those who met criteria for MDD per their episode (n-17). Basal levels of cortisol below 7 micrograms/dl distinguished alcoholics without MDD from those who met criteria for MDD per current episodes.

Alcohol-induced pseudo-Cushing's disease: a study of prevalence with review of the literature

Alcohol-induced pseudo-Cushing's syndrome has been described in numerous case reports, yet the patients have been thoroughly evaluated in only a few cases and the prevalence of hypercortisolism in the alcoholic population is not known. We studied a group of 56 alcoholic men on admission to a detoxification ward using the overnight 1 mg dexamethasone suppression test as a screening test. Most (82%) had normal cortisol suppression, and of those who did not (18%), three of four who could be retested became normal within four days. A smaller group of 14 patients was evaluated with measurement of 24-hour urinary free cortisol, baseline plasma ACTH and serum cortisol measurements, and measurement of ACTH and cortisol after dexamethasone. One patient with sustained abnormal suppression of serum cortisol by dexamethasone (up to 18 days) also demonstrated a striking lack of suppression of plasma ACTH by dexamethasone, compared to the other alcoholics studied. The data obtained on this patient, as well as information obtained from published case reports, are consistent with the concept that alcohol-induced pseudo-Cushing's syndrome is a centrally mediated defect that occurs uncommonly in alcoholics.

Chronic ethanol exposure potentiates the locomotor-activating effects of corticotropin-releasing factor (CRF) in rats

The effects of chronic exposure (21 days) to ethanol vapors on locomotor response to intracerebroventricular (i.c.v.) administration of corticotropin releasing factor (CRF) was investigated in male Wistar rats. Responses to CRF were tested during chronic exposure, 1 1/2 hours following removal of ethanol vapors, and two weeks after withdrawal of ethanol. A greater sensitivity to the locomotor-activating effects of CRF was found in ethanol-treated rats as compared to their controls during ethanol exposure (P less than 0.001) and 90 min following removal of ethanol vapors (P less than 0.001) but not two weeks following withdrawal. These results support clinical findings of a reversible activation in the hypothalamic-pituitary-adrenal (HPA) axis in alcoholism. In addition, it appears that chronic exposure to ethanol can also modify central neuronal systems specifically responsive to the locomotor activating effects of CRF.

Ethanol-glucocorticoid regulation of hepatic glucose-6-phosphate dehydrogenase

The effect of ethanol, alone and in combination with glucocorticoid and insulin, on glucose-6-phosphate dehydrogenase (G6PDH; EC 1.1.1.49) was studied in primary cultures of rat hepatocytes maintained in a chemically defined medium. Maintenance of hepatocytes from fasted animals in a culture medium devoid of hormones and ethanol resulted in a 2.5-fold increase in G6PDH activity in 48 hr. Parallel cultures treated with glucocorticoid and insulin or glucocorticoid, insulin and ethanol stimulated enzyme activity 6- and 9-fold, respectively in 48 hr. Treatment with ethanol for 48 hr potentiated basal and glucocorticoid plus insulin-induced enzyme activity 1.4-fold. The activity of G6PDH mRNA, estimated by cell-free translation of hepatic mRNA in a mRNA-dependent reticulocyte lysate and by RNA dot-blot hybridization, was compared with enzyme activity and relative rate of G6PDH synthesis. The increases in enzyme activity observed in response to glucocorticoid and insulin or ethanol, alone or in combination with glucocorticoid and insulin, were paralleled by comparable increases in the rate of synthesis and mRNA levels of G6PDH. The results of this study show that the glucocorticoids, insulin and ethanol interact to stimulate the synthesis of G6PDH primarily by increasing the concentration of G6PDH mRNA.

Dysregulation of hypothalamic-pituitary-adrenal axis function in depressed alcoholic patients

Hypothalamic-pituitary-adrenal (HPA) axis function was examined in 28 hospitalized, withdrawing alcoholic patients. Fourteen patients met DSM-III criteria for Major Depressive Disorder. Elevated 8 a.m. basal cortisols were noted in 7 depressed alcoholic patients (50%) and no non-depressed alcoholics (P less than 0.01). Escape from dexamethasone suppression was noted in 9 depressed alcoholics (64%) and no non-depressed alcoholics (P less than 0.005). The measurement of HPA axis function may be a useful marker for endogenous depression in an alcoholic population.

Hypothalamic-pituitary-adrenocortical function in chronic alcoholism

Hypothalamic-pituitary-adrenocortical (HPA) function was assessed during normal daily work and family life in fifteen male brewery workers with a daily alcohol intake of 100 g or more for at least 10 years. Free urinary cortisol was determined during three baseline days and for 3 days during administration of dexamethasone 0.5 mg 6-hourly. All subjects had normal basal urinary cortisol excretion and all except one suppressed normally upon dexamethasone. Four subjects had Cushingoid-like moon face and two of these also had buffalo hump. There was no correlation between free urinary cortisol excretion or dexamethasone suppression and the Cushingoid stigmata. These results suggest that chronic alcohol intake per se does not influence HPA-function.