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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Van Mieghem E, De Block C, De Herdt C. Idiopathic isolated adrenocorticotropic hormone deficiency: a systematic review of a heterogeneous and underreported disease. Pituitary 2024; 27:23-32. [PMID: 38151529 DOI: 10.1007/s11102-023-01366-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
Isolated adrenocorticotropic hormone deficiency (IAD) is considered to be a rare disease. Due to the nonspecific clinical presentation, precise data on the prevalence and incidence are lacking. In this systematic review, we aimed to analyse the clinical characteristics, association with autoimmune diseases, and management of acquired idiopathic IAD cases. A structured search was conducted after developing a search strategy combining terms for acquired (idiopathic) IAD. Articles describing an adult case with a diagnosis of ACTH deficiency using dynamic testing, no deficiency of other pituitary axes, and MRI of the brain/pituitary protocolled as normal, were included. Exclusion criteria were cases describing congenital IAD, cases with another aetiology for IAD, and articles where full text was not available. In total 42 articles were included, consisting of 85 cases of acquired idiopathic IAD. Distribution by sex was approximately equal (F:M; 47:38). Lethargy was the most common presenting symptom (38%), followed by weight loss (25%), anorexia (22%), and myalgia/arthralgia (12%). Eight cases (9.5%) presented with an Addison crisis. 31% of cases had an autoimmune disease at diagnosis of which Hashimoto hypothyroidism was the most frequent. Data about follow-up was scarce; dynamic testing was repeated in 4 cases of which 2 showed recovery of the adrenal axis. We report the largest case series of acquired idiopathic IAD to date. Our systematic review highlights the lack of a clear definition and diagnostic work-up. Based on the findings in this review a proposition is made for a flowchart to diagnose acquired idiopathic IAD.
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Affiliation(s)
- E Van Mieghem
- Department of Endocrinology, Diabetology and Metabolism, Faculty of Medicine, Antwerp University Hospital, Drie Eikenstraat 655, B-2650, Edegem, Belgium
| | - C De Block
- Department of Endocrinology, Diabetology and Metabolism, Faculty of Medicine, Antwerp University Hospital, Drie Eikenstraat 655, B-2650, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, B-2610, Belgium
| | - C De Herdt
- Department of Endocrinology, Diabetology and Metabolism, Faculty of Medicine, Antwerp University Hospital, Drie Eikenstraat 655, B-2650, Edegem, Belgium.
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Yang C, Li X, Ma X. Idiopathic Isolated Adrenocorticotropic Hormone Deficiency: A Single-Center Retrospective Study. Exp Clin Endocrinol Diabetes 2023; 131:523-531. [PMID: 37683667 DOI: 10.1055/a-2135-7708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Idiopathic isolated adrenocorticotrophic hormone deficiency (IIAD) is rare, with high clinical omission and misdiagnosis rates. This study retrospectively collected information on clinical presentation, laboratory findings, and treatment response of 17 patients with IIAD at Jining No. 1 People's Hospital from January 2014 to December 2022. The clinical characteristics were summarized, and the pertinent data were analyzed. As a result, most of the patients with IIAD were male (94.12%), with age at onset ranging from 13 to 80 years. The primary manifestations were anorexia (88.24%), nausea (70.59%), vomiting (47.06%), fatigue (64.71%), and neurological or psychiatric symptoms (88.24%). The median time to diagnosis was 2 months and the longest was 10 years. Laboratory tests mostly showed hyponatremia (88.24%) and hypoglycemia (70.59%). The symptoms and laboratory indicators returned to normal after supplementing patients with glucocorticoids. IIAD has an insidious onset and atypical symptoms; it was often misdiagnosed as gastrointestinal, neurological, or psychiatric disease. The aim of this study was to improve clinicians' understanding of IIAD, patients with unexplained gastrointestinal symptoms, neurological and psychiatric symptoms, hyponatremia, or hypoglycemia should be evaluated for IIAD and ensure early diagnosis and treatment.
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Affiliation(s)
| | - Xinpei Li
- Jining Medical University, Jining, China
| | - Xiaoqing Ma
- Jining No 1 People's Hospital, Jining, China
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Azam H, Tuch B. A rare case of isolated ACTH deficiency associated with a Rathke's Cleft Cyst and a review of the literature. Clin Case Rep 2023; 11:e8026. [PMID: 37822479 PMCID: PMC10562649 DOI: 10.1002/ccr3.8026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/13/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023] Open
Abstract
A 78-year-old man was referred to clinic due to a 5-year history of weight loss, lethargy, and pathology showing hyponatremia. In the year prior, he had a hospital admission for symptomatic hyponatremia. MRI brain during that admission showed a 1-2 mm pituitary lesion of unknown significance. Testing during this presentation revealed hypocortisolism with ACTH deficiency. Progress MRI brain revealed the presence of a Rathke's Cleft Cyst (RC). Medical management with glucocorticoids resulted in symptomatic and biochemical parameter improvement. To our knowledge this is the first reported case of isolated ACTH deficiency in the setting of a RC.
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Affiliation(s)
- Hamza Azam
- Liverpool HospitalLiverpoolNew South WalesAustralia
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Giannakopoulos A, Efthymiadou A, Chrysis D. Acquired idiopathic isolated ACTH deficiency with associated autoimmune thyroiditis in pediatrics: case report and review of the literature. J Pediatr Endocrinol Metab 2023:jpem-2023-0080. [PMID: 37222702 DOI: 10.1515/jpem-2023-0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/14/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVES Isolated ACTH deficiency (IAD) is defined as an impaired secretion of ACTH from the pituitary gland without any other anterior pituitary hormonal deficits. The idiopathic form of IAD has been described mainly in adults and is thought to be caused by an autoimmune mechanism. CASE PRESENTATION Herein, we present an 11-year-old _prepubertal previously healthy boy, who suffered a severe hypoglycemic episode short after the initiation of thyroxine for autoimmune thyroiditis and was finally diagnosed with secondary adrenal failure due to idiopathic IAD, after all other etiologies were excluded, thought an extensive diagnostic work-up. CONCLUSIONS Idiopathic IAD is a rare entity of adrenal insufficiency in pediatrics that should be considered as an etiology of secondary adrenal failure in children, when clinical signs of glucocorticoid deficiency are present and other causes are excluded.
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Affiliation(s)
- Aristeidis Giannakopoulos
- Division of Pediatric Endocrinology, Department of Pediatrics, Medical School of Patras, University Hospital, Rio, Patras, Greece
| | - Alexandra Efthymiadou
- Division of Pediatric Endocrinology, Department of Pediatrics, Medical School of Patras, University Hospital, Rio, Patras, Greece
| | - Dionisios Chrysis
- Division of Pediatric Endocrinology, Department of Pediatrics, Medical School of Patras, University Hospital, Rio, Patras, Greece
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Hataya Y, Okubo M, Hakata T, Fujimoto K, Iwakura T, Matsuoka N. Clinical characteristics of patients with unexplainable hypothalamic disorder diagnosed by the corticotropin-releasing hormone challenge test: a retrospective study. BMC Endocr Disord 2022; 22:312. [PMID: 36494805 PMCID: PMC9733005 DOI: 10.1186/s12902-022-01237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The corticotropin-releasing hormone (CRH) challenge test can distinguish the disorders of the hypothalamus from those of the pituitary. However, the pathophysiology of hypothalamic disorder (HD) has not been fully understood. This study aimed to elucidate the clinical characteristics of patients with unexplainable HD, diagnosed by the CRH challenge test. METHODS We retrospectively reviewed patients who underwent the CRH challenge test. Patients were categorized into four groups as follows: patients with peak serum cortisol ≥18 μg/dL were assigned to the normal response (NR) group (n = 18), among patients with peak serum cortisol < 18 μg/dL and peak adrenocorticotropic hormone (ACTH) increase ≥two-fold, patients without obvious background pathology were assigned to the unexplainable-HD group (n = 18), whereas patients with obvious background pathology were assigned to the explainable-HD group (n = 38), and patients with peak serum cortisol < 18 μg/dL and peak ACTH increase <two-fold were assigned to the pituitary disorder (PD) group (n = 15). Inter-group comparisons were performed based on clinical characteristics. RESULTS In the CRH challenge test, the peak plasma ACTH levels were significantly lower in the unexplainable-HD group than in the NR group, despite more than two-fold increase compared to basal levels. The increase in serum cortisol was significantly higher in the unexplainable-HD group than in the explainable-HD and PD groups. Although patients in the unexplainable-HD group showed a clear ACTH response in the insulin tolerance test, some patients had peak serum cortisol levels of < 18 μg/dL. Furthermore, attenuated diurnal variations and low normal levels of urinary free cortisol were observed. Most patients in the unexplainable-HD group were young women with chronic fatigue. However, supplementation with oral hydrocortisone at physiological doses reduced fatigue only in some patients. CONCLUSIONS Patients with unexplainable HD diagnosed by the CRH challenge test had hypothalamic-pituitary-adrenal (HPA) axis dysfunction and some patients had mild central adrenal insufficiency. Hydrocortisone supplementation reduced fatigue only in some patients, suggesting that HPA axis dysfunction may be a physiological adaptation. Further investigation of these patients may help elucidate the pathophysiology of myalgic encephalitis/chronic fatigue syndrome.
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Affiliation(s)
- Yuji Hataya
- Department of Diabetes and Endocrinology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Marie Okubo
- Department of Diabetes and Endocrinology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Takuro Hakata
- Department of Diabetes and Endocrinology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kanta Fujimoto
- Department of Diabetes and Endocrinology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Toshio Iwakura
- Department of Diabetes and Endocrinology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Naoki Matsuoka
- Department of Diabetes and Endocrinology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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Ono M, Fukuda I, Nagao M, Tomiyama K, Okazaki-Hada M, Shuto Y, Kobayashi S, Yamaguchi Y, Nagamine T, Nakajima Y, Inagaki-Tanimura K, Sugihara H. HLA analysis of immune checkpoint inhibitor-induced and idiopathic isolated ACTH deficiency. Pituitary 2022; 25:615-621. [PMID: 35653047 DOI: 10.1007/s11102-022-01231-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Isolated adrenocorticotropic hormone deficiency is a rare disease; however, since immune check point inhibitors (ICIs) have become widely used, many more cases have been reported. In this study, we compared the human leukocyte antigen (HLA) signatures between ICI-induced isolated adrenocorticotropic hormone deficiency (IAD) and idiopathic IAD (IIAD). DESIGN AND METHODS Clinical features and HLA frequencies were compared among 13 patients with ICI-induced IAD, 8 patients with IIAD, and healthy controls. HLA frequencies of healthy controls were adopted from a HLA database of Japanese population. RESULTS Age and body mass index were higher, while the rate of weight loss was lower, in patients with ICI-induced IAD than in those with IIAD. No HLA alleles had a significantly higher frequency in patients with ICI-induced IAD than in healthy controls, whereas the frequencies of HLA-DRB1*09:01, HLA-DQA1*03:02, and DQB1*03:03 were significantly higher in patients with IIAD than in healthy controls. CONCLUSIONS ICI-induced IAD and IIAD were different in terms of HLA frequencies. There were no specific HLAs related to ICI-induced IAD, whereas several HLAs in strong linkage disequilibrium were associated with IIAD. This might suggest that the two diseases have different pathological mechanisms. HLAs unique to IIAD may be helpful in predicting its pathophysiology.
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Affiliation(s)
- Mayo Ono
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Izumi Fukuda
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan.
| | - Mototsugu Nagao
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Keiko Tomiyama
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Mikiko Okazaki-Hada
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Yuki Shuto
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Shunsuke Kobayashi
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Yuji Yamaguchi
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Tomoko Nagamine
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Yasushi Nakajima
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Kyoko Inagaki-Tanimura
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Hitoshi Sugihara
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
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Martin-Grace J, Tomkins M, O’Reilly MW, Thompson CJ, Sherlock M. Approach to the Patient: Hyponatremia and the Syndrome of Inappropriate Antidiuresis (SIAD). J Clin Endocrinol Metab 2022; 107:2362-2376. [PMID: 35511757 PMCID: PMC9282351 DOI: 10.1210/clinem/dgac245] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Indexed: 12/31/2022]
Abstract
Hyponatremia is the most common electrolyte disturbance seen in clinical practice, affecting up to 30% of acute hospital admissions, and is associated with significant adverse clinical outcomes. Acute or severe symptomatic hyponatremia carries a high risk of neurological morbidity and mortality. In contrast, chronic hyponatremia is associated with significant morbidity including increased risk of falls, osteoporosis, fractures, gait instability, and cognitive decline; prolonged hospital admissions; and etiology-specific increase in mortality. In this Approach to the Patient, we review and compare the current recommendations, guidelines, and literature for diagnosis and treatment options for both acute and chronic hyponatremia, illustrated by 2 case studies. Particular focus is concentrated on the diagnosis and management of the syndrome of inappropriate antidiuresis. An understanding of the pathophysiology of hyponatremia, along with a synthesis of the duration of hyponatremia, biochemical severity, symptomatology, and blood volume status, forms the structure to guide the appropriate and timely management of hyponatremia. We present 2 illustrative cases that represent common presentations with hyponatremia and discuss the approach to management of these and other causes of hyponatremia.
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Affiliation(s)
- Julie Martin-Grace
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maria Tomkins
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Michael W O’Reilly
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chris J Thompson
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark Sherlock
- Correspondence: Mark Sherlock, MD, PhD, Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin 9, Ireland. E-mail:
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Husebye ES, Pearce SH, Krone NP, Kämpe O. Adrenal insufficiency. Lancet 2021; 397:613-629. [PMID: 33484633 DOI: 10.1016/s0140-6736(21)00136-7] [Citation(s) in RCA: 140] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/12/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022]
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.
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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
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10
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Alabdrabalnabi FM, Saeed ZAA, Elamin YA. Hypoglycemia As Initial Presentation In Patient With Isolated Acth Deficiency. AACE Clin Case Rep 2020; 6:e338-e341. [DOI: 10.4158/accr-2020-0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/26/2020] [Indexed: 11/15/2022] Open
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Adrenal insufficiency: Physiology, clinical presentation and diagnostic challenges. Clin Chim Acta 2020; 505:78-91. [PMID: 32035851 DOI: 10.1016/j.cca.2020.01.029] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/21/2022]
Abstract
Adrenal insufficiency (AI) is a serious condition, which can arise from pathology affecting the adrenal gland itself (primary adrenal insufficiency, PAI), hypothalamic or pituitary pathology (secondary adrenal insufficiency, SAI), or as a result of suppression of the hypothalamic-pituitaryadrenal (HPA) axis by exogenous glucocorticoid therapy (tertiary adrenal insufficiency, TAI). AI is associated with an increase in morbidity and mortality and a reduction in quality of life. In addition, the most common cause of PAI, autoimmune adrenalitis, may be associated with a variety of other autoimmune disorders. Untreated AI can present with chronic fatigue, weight loss and vulnerability to infection. The inability to cope with acute illness or infection can precipitate life-threatening adrenal crisis. It is therefore a critical diagnosis to make in a timely fashion, in order to institute appropriate management, aimed at reversing chronic ill health, preventing acute crises, and restoring quality of life. In this review, we will describe the normal physiology of the HPA axis and explain how knowledge of the physiology of this axis helps us understand the clinical presentation of AI, and forms the basis for the biochemical investigations which lead to the diagnosis of AI.
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Okauchi S, Tatsumi F, Kan Y, Horiya M, Mizoguchi A, Fushimi Y, Sanada J, Nishioka M, Shimoda M, Kohara K, Nakanishi S, Kaku K, Mune T, Kaneto H. Idiopathic and isolated adrenocorticotropic hormone deficiency presenting as continuous epigastric discomfort without symptoms of hypoglycemia: a case report. J Med Case Rep 2019; 13:113. [PMID: 31036085 PMCID: PMC6489309 DOI: 10.1186/s13256-019-2050-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 03/13/2019] [Indexed: 11/20/2022] Open
Abstract
Background Isolated adrenocorticotropic hormone deficiency is one kind of hypopituitarism and is triggered by various diseases including autoimmune disorder and/or autoimmune hypophysitis. Adrenocorticotropic hormone deficiency brings out various serious symptoms such as severe hypoglycemia, hypotensive shock, and disturbance of consciousness. Case presentation Here we report a case of 65-year-old Japanese man who developed idiopathic and isolated adrenocorticotropic hormone deficiency. He had continued epigastric comfort without any symptom of hypoglycemia or any autoimmune abnormality. Since he continued to complain of mild epigastric discomfort and general malaise, he was misdiagnosed as having functional dyspepsia and a depression state and took medicine for them for several months. Infection markers and several antibodies which we examined were all negative. An abdominal computed tomography scan showed no mass in adrenal tissue; contrast magnetic resonance imaging of his brain showed that pituitary size was within normal range, and pituitary gland deep dyeing delay and/or deeply stained deficit were not observed. However, in a corticotropin-releasing hormone load test, response of adrenocorticotropic hormone and cortisol was poor after corticotropin-releasing hormone loading, and in growth hormone-releasing peptide 2 load test, adrenocorticotropic hormone response was poor, suggesting the presence of adrenocorticotropic hormone deficiency. Therefore, we started treatment with hydrocortisone, and his various symptoms were soon mitigated. Conclusions We should bear in mind the possibility of adrenocorticotropic hormone deficiency even when patients complain of epigastric discomfort or general malaise alone.
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Affiliation(s)
- Seizo Okauchi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Fuminori Tatsumi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Yuki Kan
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Megumi Horiya
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Akiko Mizoguchi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Yoshiro Fushimi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Junpei Sanada
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Momoyo Nishioka
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Masashi Shimoda
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Kenji Kohara
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Shuhei Nakanishi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Kohei Kaku
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Tomoatsu Mune
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan.
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Manthri S, Bandaru S, Ibrahim A, Mamillapalli CK. Acute Pericarditis as a Presentation of Adrenal Insufficiency. Cureus 2018; 10:e2474. [PMID: 29904615 PMCID: PMC5999392 DOI: 10.7759/cureus.2474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acute pericarditis as a presenting sign of adrenal insufficiency is rarely reported. We present a rare case that highlights pericarditis as a clinical presentation of secondary adrenal insufficiency later complicated by cardiac tamponade. A 44-year-old lady who presented to the hospital with a one-day history of pleuritic chest pain and shortness of breath. In the emergency room, she had a blood pressure of 70/35 mmHg. Laboratory evaluation revealed white blood cell count of 16.08 k/cumm with neutrophilia, normal renal function and elevated troponin (0.321 ng/mL, normal 0.000-0.028). An electrocardiogram (EKG) showed sinus tachycardia, low voltage, PR suppression and ST changes consistent with acute pericarditis. Echocardiogram showed small pericardial effusion without tamponade physiology. Infectious workup was negative; she was thought to have acute adrenal insufficiency likely secondary to viral pericarditis. We treated the patient with high dose nonsteroidal anti-inflammatory drugs (NSAIDS) and hydrocortisone. Three weeks later, she presented to emergency room with complaints of persistent nausea, vomiting, chills, weakness. Her blood pressure was 49/23 mmHg. Random serum cortisol level was <1.2 mcg/dl (normal A.M. specimens 3.7-19.4 mcg/dl). Echocardiogram showed loculated pericardial fluid adjacent to the right ventricle with echocardiographic evidence of tamponade. Emergent pericardiocentesis yielded 250 ml of straw color fluid. Blood pressure improved after the procedure. The patient was initially started on IV stress dose steroids, but following clinical stabilization, hydrocortisone was switched to a physiological dose of 15 mg in am and 10 mg in pm. Although the mechanism of pericarditis in adrenal failure is unknown, this clinical presentation may help early diagnosis of adrenal failure and pericarditis. Early recognition and prompt treatment of this rare presentation are critical to prevent morbidity and mortality.
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Affiliation(s)
- Sukesh Manthri
- Department of Geriatrics, Saint Louis University School of Medicine
| | - Sindhura Bandaru
- Department of Internal Medicine, Southern Illinois University School of Medicine
| | - Abdisamad Ibrahim
- Department of Internal Medicine, Southern Illinois University School of Medicine
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