Cushing's disease-induced remission of severe rheumatoid arthritis

Autoimmune Disorders Associated With Surgical Remission of Cushing's Disease : A Cohort Study

BACKGROUND

Glucocorticoids suppress inflammation. Autoimmune disease may occur after remission of Cushing's disease (CD). However, the development of autoimmune disease in this context is not well described.

OBJECTIVE

To determine 1) the incidence of autoimmune disease in patients with CD after surgical remission compared with patients with nonfunctioning pituitary adenomas (NFPAs) and 2) the clinical presentation of and risk factors for development of autoimmune disease in CD after remission.

DESIGN

Retrospective matched cohort analysis.

SETTING

Academic medical center/pituitary center.

PATIENTS

Patients with CD with surgical remission and surgically treated NFPA.

MEASUREMENTS

Cumulative incidence of new-onset autoimmune disease at 3 years after surgery. Assessment for hypercortisolemia included late-night salivary cortisol levels, 24-hour urine free cortisol (UFC) ratio (UFC value divided by the upper limit of the normal range for the assay), and dexamethasone suppression tests.

RESULTS

Cumulative incidence of new-onset autoimmune disease at 3 years after surgery was higher in patients with CD (10.4% [95% CI, 5.7% to 15.1%]) than in those with NFPAs (1.6% [CI, 0% to 4.6%]) (hazard ratio, 7.80 [CI, 2.88 to 21.10]). Patients with CD showed higher prevalence of postoperative adrenal insufficiency (93.8% vs. 16.5%) and lower postoperative nadir serum cortisol levels (63.8 vs. 282.3 nmol/L) than patients with NFPAs. Compared with patients with CD without autoimmune disease, those who developed autoimmune disease had a lower preoperative 24-hour UFC ratio (2.7 vs. 6.3) and a higher prevalence of family history of autoimmune disease (41.2% vs. 20.9%).

LIMITATION

The small sample of patients with autoimmune disease limited identification of independent risk factors.

CONCLUSION

Patients achieving surgical remission of CD have higher incidence of autoimmune disease than age- and sex-matched patients with NFPAs. Family history of autoimmune disease is a potential risk factor. Adrenal insufficiency may be a trigger.

PRIMARY FUNDING SOURCE

Recordati Rare Diseases Inc.

Etiology and Risk Factors for Rheumatoid Arthritis: A State-of-the-Art Review

Rheumatoid arthritis (RA) is the most common systemic inflammatory rheumatic disease. It is associated with significant burden at the patient and societal level. Extensive efforts have been devoted to identifying a potential cause for the development of RA. Epidemiological studies have thoroughly investigated the association of several factors with the risk and course of RA. Although a precise etiology remains elusive, the current understanding is that RA is a multifactorial disease, wherein complex interactions between host and environmental factors determine the overall risk of disease susceptibility, persistence and severity. Risk factors related to the host that have been associated with RA development may be divided into genetic; epigenetic; hormonal, reproductive and neuroendocrine; and comorbid host factors. In turn, environmental risk factors include smoking and other airborne exposures; microbiota and infectious agents; diet; and socioeconomic factors. In the present narrative review, aimed at clinicians and researchers in the field of RA, we provide a state-of-the-art overview of the current knowledge on this topic, focusing on recent progresses that have improved our comprehension of disease risk and development.

Clinical management of patients with Cushing syndrome treated with mifepristone: consensus recommendations

BACKGROUND

While surgery is the first-line treatment for patients with endogenous hypercortisolism (Cushing syndrome [CS]), mifepristone has been shown to be a beneficial medical treatment option, as demonstrated in the SEISMIC (Study of the Efficacy and Safety of Mifepristone in the Treatment of Endogenous Cushing Syndrome) trial. Mifepristone is a competitive glucocorticoid receptor antagonist and progesterone receptor antagonist that is associated with several treatment effects and adverse events that clinicians need to be aware of when considering its use. The objective of this review was to provide updated clinical management recommendations for patients with CS treated with mifepristone.

METHODS

A panel of endocrinologists from the US with extensive experience in treating patients with CS, including with mifepristone, convened as part of a clinical advisory board to develop a consensus on the practical, real-world clinical management of patients on mifepristone.

RESULTS

Comprehensive considerations and recommendations are provided for managing mifepristone-associated effects, including symptoms of cortisol withdrawal, hypokalemia, and change in thyroid function; effects related to its antiprogesterone activity; and rash. Additional management strategies to address concomitant medications and special clinical situations, such as surgery and use in specific populations, are also provided.

CONCLUSION

Safe and effective use of mifepristone requires clinical judgment and close patient monitoring to ensure optimal clinical outcomes. These consensus recommendations provide useful, practical guidance to clinicians using mifepristone.

A case of systemic lupus erythematosus in which Cushing's syndrome caused by adrenal adenoma accidentally occurred during long-term maintenance therapy with corticosteroids

A 30-year-old female patient had been administered 5-mg/day prednisolone for systemic lupus erythematosus. She developed hypertension, dyslipidemia, moon face, central obesity, hypertrichosis, and impaired glucose tolerance. Although iatrogenic Cushing syndrome was initially suspected, we made a diagnosis of Cushing syndrome caused by a right adrenal adenoma, on the basis of the endocrine function test result and imaging findings. After surgery, the Cushingoid signs disappeared. Autoimmune diseases are often treated with corticosteroids; therefore, a differential diagnosis of primary Cushing syndrome should be made adequately.

Combination therapy with azathioprine, cyclosporine and ketoconazole in a dog with concurrent pemphigus foliaceus and hyperadrenocorticism - Case report

A 10-year-old, spayed female Shih Tzu dog presented with a history of progressive erythema and multiple crusts developing 85 days previously. The dog had been diagnosed with hyperadrenocorticism (HAC) 55 days prior to presentation and was treated with oral trilostane (2.86 mg/kg, once daily) that was discontinued due to a poor response. In addition to generalised alopecia, erythematous plaques and crusts were noted on the trunk, head and footpads. Lesional impression smears revealed numerous acantholytic cells and non-degenerated neutrophils. Histopathological findings demonstrated subcorneal pustules with acantholytic cells and intact neutrophils. On the basis of these findings, we diagnosed pemphigus foliaceus (PF) with concurrent HAC. We wished to avoid glucocorticoids and, therefore, prescribed oral, once-daily azathioprine (2 mg/kg), modified cyclosporine (7 mg/kg) and ketoconazole (5 mg/kg). By day 71 post-treatment, the erythematous crusts had almost disappeared and the alopecia had improved considerably. However, by the subsequent follow-up examination on day 99, the clinical signs had reappeared due to the tapering of cyclosporine. To the best of our knowledge, this is the first case report describing concurrent PF and HAC in a dog. Combination therapy with azathioprine, modified cyclosporine and ketoconazole was effective, and should be considered for dogs diagnosed with concurrent autoimmune diseases and HAC.

A case of systemic lupus erythematosus complicated by subclinical Cushing's syndrome: case report

An 18-year-old female was diagnosed with subclinical Cushing's syndrome (CS) due to a left adrenal adenoma. When she was 20 years old, she developed lupus nephritis. She was treated with high-dose prednisolone (PSL) and soon developed the symptoms of CS. When she was 25 years old, we evaluated her serum glucocorticoid level while she continued to take oral PSL. The result suggested her CS was affected by both the oral PSL and the endogenous cortisol secreted by the adrenocortical adenoma, which was therefore resected. Seven months after the operation, the patient's body weight was decreasing, and her SLE remained in clinical remission. CS complicated by SLE is rare, and the decision to surgically remove an adrenal tumor in such a case is even more rare.

Autoimmune Diseases in Patients with Cushing's Syndrome after Resolution of Hypercortisolism: Case Reports and Literature Review

INTRODUCTION

Cushing's syndrome (CS) is a clinical condition characterized by excessive cortisol production, associated with metabolic complications, such as diabetes mellitus, dyslipidemia, metabolic syndrome, hypertension, and cardiovascular diseases. Nowadays, the occurrence of autoimmune diseases in CS have not been completely evaluated in the previous studies.

OBJECTIVE

The aim of this study was to evaluate the occurrence of autoimmune diseases in CS patients after successfully treated.

MATERIALS AND METHODS

From January 2001 to December 2017, in our Secondary Hypertension Unit, we evaluated 147 CS patients (91 with ACTH-independent disease, 54 with ACTH-dependent disease, and 2 patients with ectopic ACTH production.

RESULTS

109 CS patients (74.1%) were surgically treated (67 ACTH-independent CS patients (61.5%) undergone adrenalectomy and 42 ACTH-dependent CS (38.5%) undergone transsphenoidal surgery) and evaluated after 6, 12, and 24 months after clinical and biochemical remission of disease. In 9 (8.3%) of overall treated CS patients (8.3%), during follow-up, we observed the onset of some manifestations of autoimmune diseases. In particular, one patient had a systemic lupus erythematosus, one patient had rheumatoid arthritis, 4 patients reported autoimmune thyroiditis (Basedow-Graves' disease and Hashimoto's thyroiditis), one patient had clinical features of psoriasis, one patient showed myasthenia gravis, and one patient had giant cell arteritis.

CONCLUSIONS

Our results demonstrate that patients successfully treated for CS could develop autoimmune diseases. Therefore, after treatment, CS patients need to be strictly monitored in order to evaluate the possible onset of autoimmune diseases.

Common ground: the overlap between Endocrinology and Rheumatology

A number of medical specialities have witnessed a dramatic change in the provision of in patient care over the last decade. Work has moved into outpatient and Day Unit settings and, more recently, into the community. This has led to the amalgamation of speciality based beds with the perceived threat of loss of independence and potential reduction in training opportunities. In reality, our experience of a combined inpatient ward for Rheumatology and Endocrinology patients has been positive, with increased awareness of the coexistence of certain disorders and a resulting enhanced approach to the delivery of patient care, junior doctor education and clinical research. We would like to share our experience by describing some of the overlapping clinical conditions between these specialities that physicians might wish to consider.

Circadian Rhythms: Glucocorticoids and Arthritis

Circadian rhythms are driven by biological clocks and are endogenous in origin. Therefore, circadian changes in the metabolism or secretion of endogenous glucocorticoids are certainly responsible in part for the time-dependent changes observed in the inflammatory response and arthritis. More recently, melatonin (MLT), another circadian hormone that is the secretory product of the pineal gland, has been found implicated in the time-dependent inflammatory reaction with effects opposite those of cortisol. Interestingly, cortisol and MLT show an opposite response to the light. The light conditions in the early morning have a strong impact on the morning cortisol peak, whereas MLT is synthesized in a strictly nocturnal pattern. Recently, a diurnal rhythmicity in healthy humans between cellular (Th1 type) or humoral (Th2 type) immune responses has been found and related to immunomodulatory actions of cortisol and MLT. The interferon (IFN)-gamma/interleukin (IL)-10 ratio peaked during the early morning and correlated negatively with plasma cortisol and positively with plasma MLT. Accordingly, the intensity of the arthritic pain varies consistently as a function of the hour of the day: pain is greater after waking up in the morning than in the afternoon or evening. The reduced cortisol and adrenal androgen secretion, observed during testing in rheumatoid arthritis (RA) patients not treated with glucocoticoids, should be clearly considered as a "relative adrenal insufficiency" in the presence of a sustained inflammatory process, and allows Th1 type cytokines to be produced in higher amounts during the late night. In conclusion, the right timing (early morning) for the glucocorticoid therapy in arthritis is fundamental and well justified by the circadian rhythms of the inflammatory mechanisms.

Circadian Rhythms and Arthritis

The clinical symptoms of rheumatoid arthritis (RA) show a circadian variation; joint stiffness and pain are more prominent in the early morning. An altered functioning of the hypothalamic-pituitary-adrenal axis (cortisol) and of the pineal gland (melatonin) seems to be important factors in the perpetuation and clinical circadian symptoms of RA. Consistently, human proinflammatory cytokine production exhibits a diurnal rhythmicity with peak levels during the night and early morning, at a time when plasma cortisol (anti-inflammatory) is lowest and melatonin (proinflammatory) is highest. Sex hormones also seem to be involved in circadian rhythms of RA symptoms. Increased pain intensity and sleep disturbances are observed during the luteal phase in patients who have RA, when estrogen (and progesterone) levels would be higher than in the follicular phase. The occurrence of circadian rhythms of the inflammatory reaction suggest important implications for scheduling activities of daily living, for measurements in clinical trials, and possibly for the time at which antirheumatic drugs--including corticosteroids and nonsteroidal anti-inflammatory drugs--are administered.

Analysis of adrenocortical secretory responses during acute an prolonged immune stimulation in inflammation-susceptible and -resistant rat strains

Endogenous corticosterone secreted during immune challenge restricts the inflammatory process and genetic variations in this neuroendocrine-immune dialogue have been suggested to influence an individuals sensitivity to develop chronic inflammatory disorders. We have tested inflammation-susceptible Dark Agouti (DA) rats and resistant, MHC-identical, PVG.1AV1 rats for their abilities to secrete corticosterone in response to acute challenge with bacterial lipopolysaccharide (LPS) or a prolonged activation of the nonspecific immune system with arthritogenic yeast beta-glucan. Intravenous injection of LPS triggered equipotent secretion of corticosterone in both rat strains. Interestingly, peak concentrations of corticosterone did not differ significantly between the strains. Intradermal injection of beta-glucan caused severe, monophasic, polyarthritis in DA rats while PVG.1AV1 responded with significantly milder joint inflammation. Importantly, serial sampling of plasma from glucan-injected DA and PVG.1AV1 rats did not reveal elevated concentrations of plasma corticosterone at any time from days 1-30 postinjection compared to preinjection values, in spite of the ongoing inflammatory process. Interestingly, adrenalectomized, beta-glucan-challenged DA rats responded with an aggravated arthritic process, indicating an anti-inflammatory role for the basal levels of corticosterone that were detected in intact DA rats challenged with beta-glucan. Moreover, substitution with subcutaneous corticosterone-secreting pellets, yielding moderate stress-levels, significantly attenuated the arthritic response. In contrast, adrenalectomized and glucan-challenged PVG.1AV1 rats did not respond with an elevated arthritic response, suggesting that these rats contain the arthritic process via corticosterone-independent mechanisms. In conclusion, the hypothalamic-pituitary-adrenal axis in both rat strains exhibited strong activation after challenge with LPS. This contrasted to the basal corticosterone levels observed strains during a prolonged arthritic process. No correlation between ability to secrete corticosterone and susceptibility to inflammation could be demonstrated. Basal levels of endogenous corticosterone appeared to restrain inflammation in beta-glucan-challenged DA rats whereas resistance to inflammation in PVG.1AV1 rats may be mediated via corticosterone-independent mechanisms.