Fine structure and morphogenesis of spironolactone bodies in the zona glomerulosa of the human adrenal cortex

Mineralocorticoid Receptor Antagonists Eplerenone and Spironolactone Modify Adrenal Cortex Morphology and Physiology

Mineralocorticoid receptor antagonists (MRAs) are a class of anti-hypertensive drugs that act by blocking aldosterone action. The aim of this study was to evaluate whether the MRAs spironolactone and eplerenone influence adrenal cortical physiology and morphology. Spontaneous hypertensive rats (SHR, n = 18) and normotensive rats (WKY, n = 18) were randomly exposed to a daily dose of spironolactone (n = 6), eplerenone (n = 6), or no drug (n = 6) over 28 days. After that, aldosterone, corticosterone, and 11-deoxycorticosterone plasma concentrations were quantified. Adrenal glands were subjected to morphological analysis to assess lipid droplets content, capsular width, cell proliferation, and steroidogenic proteins expression. The adrenal cortex in untreated SHR showed higher lipid droplet content as than in WKY. In SHR, MRA treatment was associated with higher circulating aldosterone levels and Ki-67 expression in aldosterone-secreting cells. In WKY, the only difference observed after MRA spironolactone treatment was a narrower capsule. There was no difference in abundance of steroidogenic enzyme between groups. In conclusion, MRAs modify adrenal gland function and morphology in SHR. The effects observed within the adrenal glomerulosa with aldosterone-secreting cell proliferation and higher circulating aldosterone levels suggests that MRA treatment provokes activation of the renin angiotensin system. The prognostic value of hyperaldosteronism secondary to MRAs blockade requires further investigation.

Progress in primary aldosteronism. Mineralocorticoid antagonist treatment for aldosterone-producing adenoma

Mineralocorticoid receptor antagonists have been used in patients with aldosterone-producing adenomas (APAs) as a test designed to predict the blood pressure (BP) outcome of surgery. They are commonly used in patients undergoing adrenalectomy to reduce BP and increase plasma potassium levels during the preoperative period. A small number of studies have compared the effects of surgery and mineralocorticoid antagonists either on BP, on serum potassium levels, or on the incidence of cardiovascular and renal outcomes in patients with primary aldosteronism with or without an APA; these studies found no difference between the two therapeutic options. Mineralocorticoid receptor antagonists can be used as a maintenance treatment for patients with APAs, who are judged to be poor operative risks or who do not want to undergo surgery.

Adrenal gland inclusions in patients treated with aldosterone antagonists (Spironolactone/Eplerenone): incidence, morphology, and ultrastructural findings

Abstract

Background

Spironolactone is often used to treat hypertension caused by hyperaldosteronism, and as a result, can form concentrically laminated electron dense spironolactone body inclusions within the adrenal gland. Spironolactone bodies have not been investigated in a contemporary cohort or in patients treated with the more recently approved aldosterone antagonist, eplerenone.

Methods

Spironolactone bodies were retrospectively investigated in patients treated for hyperaldosteronism (n = 15) from 2012-2013 that underwent a subsequent adrenalectomy.

Results

Inclusions were identified in 33% of patients treated with aldosterone antagonists, far less than previously reported. Remarkably, 50% of patients treated with spironolactone had inclusions while no patients using eplerenone alone had inclusions. Two patients treated with spironolactone had bodies present longer than the duration described in prior studies. Inclusions unexpectedly persisted in 1 patient despite increased duration of discontinued pharmacological treatment. A spectrum of histologic and ultrastructural findings were encountered within an adrenal cortical adenoma from a patient treated with both spironolactone and eplerenone. Ultrastructural examination revealed laminated electron dense bodies with the appearance of classic spironolactone inclusions as well as electron dense bodies without laminations and laminated bodies without electron dense cores.

Conclusions

Our incidence rate of spironolactone bodies was much lower than previously reported, with no inclusions seen in patients treated solely with the newer aldosterone antagonist, eplerenone. Pathologists should be aware of these infrequently encountered inclusions, particularly as the clinical history of hyperaldosteronism and pharmacologic treatment may not be provided.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/4597918761268031

Hypokalemia and Uncontrolled Hypertension

In a 45-year-old female with chronic uncontrolled hy-pertension complicated by hypokalemia, laboratory and radiological findings were consistent with an aldosterone producing adenoma (APA). Diagnosis of Conn's syndrome was confirmed by histopathology. The hypokalemia re-solved and her hypertension improved after laparoscopic adrenalectomy. Discussion of the case, diagnosis and treat-ment are presented.

[Effects of drugs on the adrenal cortex and its tumors]

The structure of the normal adrenal cortex is changed by stimulating hormones (ACTH) and inhibiting hormonal drugs (especially glucocorticoids). ACTH induces hyperplasia and lipid depletion in the fascicular and reticular zones, whereas glucocorticoids lead to atrophy and lipid accumulation in both zones. In animal experiments, the adrenostatic drug mitotane causes shrinkage of the cells of the fascicular and reticular zones, whereas metyrapone induces a decrease in the steroid producing organelle system and aminoglutethimide leads to an increase in lipids. In the therapy of patients with adrenocortical cancer, mitotane can cause an increase in of necrosis and fibrosis, but also in intracellular lipid. The ultrastructure shows increased liposomes, more pigment-rich lysosomes and laminated bodies.

Effects of humoral hypercalcemia of malignancy on the parathyroid gland in nude mice

The ultrastructure of parathyroid chief cells was examined from four groups of nude mice (NIH:Swiss) with different serum calcium concentrations. The groups consisted of eight male mice with hypercalcemia induced by transplantable canine adenocarcinoma (CAC-8), eight female mice with hypercalcemia induced by infusion of parathyroid hormone-related protein, ten male control mice, and six male mice fed a low calcium (0.01%) diet. Hypercalcemia induced by malignancy or parathyroid hormone-related protein infusion was associated with low serum phosphorus concentration, a decrease in the number of secretory and prosecretory granules in the parathyroid chief cells, and an increase in the cytoplasmic area of chief cells. Prominent myelinlike membranous whorls were present in the cytoplasm of chief cells of tumor-bearing and parathyroid hormone-related protein-infused hypercalcemic mice. Mice fed a low calcium diet had decreases in the number of secretory granules and cell area but increases in the number of prosecretory granules compared with control mice. The number of mitochondria and the nuclear area of chief cells were similar in all four groups. The prominent membranous whorls and increased cytoplasmic area of chief cells from these hypercalcemic mice mark these cells as distinctly different from the parathyroid chief cells of other species with hypercalcemia.

B-cell lymphoma with vimentin-positive cytoplasmic inclusions

A 60-year-old woman complaining of cervical lymphadenopathy was admitted to Keiyu General Hospital, Yokohama. Malignant lymphoma involving systemic lymph nodes and the bilateral tonsils was suspected by computed tomography. The biopsy diagnosis of the cervical lymph nodes was B-cell lymphoma, diffuse medium-sized cell type. The cleaved centrocytic lymphoma cells were immunoreactive for CD20 and CD22 but negative for immunoglobulins. Characteristically, a considerable number of neoplastic lymphocytes possessed eosinophilic round inclusions in the cytoplasm. The inclusions were green in color by Papanicolaou staining, whereas they appeared vacuole-like in Giemsa-stained preparations. Ultrastructural study confirmed the presence of aggregates of intermediate-sized filamentous structures mainly in the perinuclear area. The rough endoplasmic reticulum and Golgi apparatus were poorly developed. Immunocytochemical staining using cytologic specimens and fresh-frozen sections disclosed that the inclusions were composed of vimentin filaments. Morphologic similarities to signet ring cell lymphoma are discussed.

Ultrastructure of parathyroid autografts in chronic renal failure including the occurrence of concentric membranous bodies and intermediate filaments

The ultrastructure of long-term parathyroid autografts and their donor glands has been studied in nine patients with chronic renal failure. Autografts showed ultrastructural features of functional activity. Unusual findings included the presence of 'spironolactone-like' concentric membranous bodies derived from the endoplasmic reticulum in one hyperplastic autograft and prominent intracellular intermediate filaments (tonofilaments) in the donor parathyroid gland and recurrent autograft growths in another patient.

Adrenocortical adenoma with primary aldosteronism in culture

Four adrenocortical adenomata with primary aldosteronism (Conn's adenomata) were examined by light and electron microscopy employing cell culture methods. Unstimulated cells existed as a unit of the clusters, but Conn's adenoma cells reacted to ACTH. The cultured cells produced mostly cortisol under ACTH-stimulation as time passed. Lipid droplets in their cytoplasm decreased in number and the smooth endoplasmic reticulum (sER) was well-developed with dilated, anastomosing tubule. Moreover, mitochondria sometimes had tubulovesicular cristae. It is assumed that Conn's adenoma cells are hybrid type cells, which are intrinsically capable of producing cortisol as well as aldosterone.

Glucocorticoid-suppressible hyperaldosteronism. Ultrastructural observation of a case

A 56-year-old woman presented with intracranial hemorrhage. Laboratory examinations revealed severe hypertension, hypokalemia, elevated aldosterone excretion, and suppressed plasma renin activity. Left adrenocortical tumor was suspected and adrenalectomy was performed. The laboratory data after operation, however, showed no significant difference from the preoperative data. On the basis of further examinations, dexamethasone was administered and returned blood pressure to normal, and also normalized serum potassium, plasma aldosterone, and renin activity. The patient's illness was diagnosed as glucocorticoid-suppressible hyperaldosteronism. Light microscopically, the zona glomerulosa was hypertrophic and the outer zona fasciculata decreased in lipid droplets and was centrifugally arranged in small alveoli. Electronmicroscopically, the cells of the outer zona fasciculata had several lipid droplets and well-developed sER. Mitochondria were round to oval with lamellar or lamellovesicular cristae. These findings were evidence of hyperfunction. The cytoplasm of the cells also contained spironolactone bodies. Therefore, it is assumed that the aldosterone, which induced the disorder, was produced mainly in the outer zona fasciculata.

Adrenal changes in Niemann-Pick disease: differences between sphingomyelinase deficiency and type C

Structural, chemical, and histochemical analyses of adrenal tissue performed in 8 cases of Niemann-Pick disease (NPD) revealed stark differences of storage between spingomyelinase (SMase) deficiency (6 cases) and type C (2 cases). In all the full-blown cases of the SMase deficiency group, pronounced sphingomyelin (SM) storage was found in all the zones of the cortical epithelium with slightly increasing centripetal gradient. The storage resulted in the reduction or even disappearance of lipofuscinogenesis in the reticular zone, in the reduction of the physiological fat content, in the generalized foamy transformation of the epithelium, and in moderate organomegaly. The storage was expressed in both A and B types and was roughly proportional to the storage in other viscera. The stromal storage was confined to the vascular endothelium, and in particular, to the macrophages. One of the cases showed the presence of typical spirolactone bodies unmodified in fine structure by the lysosomal storage. Their most conspicuous enzymatic activity was that of non-specific esterase and NADH tetrazolium reductase. The adrenals in type C were macroscopically and histologically normal except for a variable population of stromal foam cells. Chemically, there was slight increase in all phospholipids with borderline or moderate percentual increase of SM. There was also slight increase in some of the lower neutral glycosphingolipids. Electron microscopy dislosed rudimentar storage in lower cortical layer epithelium which by its fine structure and according to results of lipid histochemistry was qualitatively different from that in SMase deficiency. The stromal storage was expressed mainly in macrophages in which there was histochemically detectable amount of SM. There was no storage detectable in medullary cells in neither group of NPD complex. The results point not only to striking quantitative differences in storage intensity between the 2 basic groups of NPD showing the cortical epithelium in type C as being remarkably resistant to the metabolic disorder, but also to difference in quality of the storage very much like that found in other tissues, too.

Ultrastructural studies of adrenal adenoma causing primary aldosteronism

Adrenal adenoma tissue was obtained from 7 patients with the diagnosis of primary aldosteronism and was studied electron microscopically. Spironolactone was administered in 6 of these patients, but not in the remaining patient. Most of the mitochondria of the tumour cells possessed tubular cristae, giving an appearance similar to the mitochondria in the cells of the zona glomerulosa. Spironolactone bodies were seen in the tumour cells of 6 patients who were given spironolactone preoperatively, but were not observed in these cells in the patient not given spironolactone. The literature on the developmental mechanism of this spironolactone body was reviewed.

Factors affecting the frequency of occurrence of spironolactone bodies in aldosteronomas and non-tumorous cortex

Histological sections taken from aldosterone-producing-adenomas and from non-tumorous adrenal cortex of 18 patients treated for primary aldosteronism by unilateral adrenalectomy were examined for spironolactone inclusion bodies. Typical inclusions were found in 10 of the 13 patients who received spironolactone up to within 24 h of surgery. They were present in the tumours of 7 patients, and their frequency correlated positively with the percentage of glomerulosa type cells in the tumours. In tumours containing 50% or more glomerulosa-type cells, their frequency correlated negatively with duration of treatment. They were present in the non-tumorous cortex of 4 of these 7 patients, and in the cortex of 3 others whose tumours did not contain them. In the cortex, they were found only in glomerulosa cells, and their presence appeared unrelated to dosage or duration of treatment. No spironolactone inclusion bodies were seen in either the tumour of the non-tumorous cortex of 3 patients who had discontinued spironolactone 19 to 97 d before surgery, or of 2 patients who had never received spironolactone.

Adrenal scintigraphy in primary aldosteronism. Spironolactone as a cause of incorrect classification between adenoma and hyperplasia

In primary aldosteronism the type of adrenal lesion was correctly identified in 28 of 40 patients (70%) by standard adrenal scintigraphy. Suppression scintigraphy did not improve the validity of the method. In all patients the diagnosis was confirmed by surgery (unilateral adenoma n = 32; bilateral adrenal hyperplasia n = 11). False classification of the adrenal lesion(s) by standard scintigraphy was mostly due to a bilateral adrenal isotopic uptake in patients with an unilateral aldosteronoma. However, a substantial number of these patients (6 of 11 patients) received long-term spironolactone treatment prior to the examination. Thus, in primary aldosteronism adrenal changes induced by chronic spironolactone administration are probably a major cause for incorrect differentiation between adenoma and hyperplasia by adrenal scintigraphy.

Spironolactone bodies in aldosteronomas and in the attached adrenals. Enzyme histochemical study of 19 cases of primary aldosteronism and a case of aldosteronism due to bilateral diffuse hyperplasia of the zona glomerulosa

The formation of spironolactone (S) bodies, eosinophilic laminated cytoplasmic inclusions, is induced in the aldosterone-producing cells of the human adrenal cortex after the administration of spironolactone. The aim of this study was to define the enzyme histochemical characteristics of S bodies, S-body-containing cells, and the apparently hyperplastic zona glomerulosa (zG) of adrenal tissues attached to aldosteronomas. S bodies were found in 14 of 19 aldosteronomas, in 10 of 19 adrenal tissues attached to aldosteronomas, and in the adrenal tissues in a patient with aldosteronism due to bilateral diffuse zG hyperplasia. The S bodies themselves exhibited most intense 3 beta-hydroxysteroid dehydrogenase (3 beta HSD) activity but did not exhibit glucose-6-phosphate dehydrogenase (G6PD), NADP-dependent isocitrate dehydrogenase (NADP-ICDH), or succinate dehydrogenase (SDH) activity, confirming histochemically the origin of S bodies in the smooth endoplasmic reticulum. In two adenomas, S bodies were found to be surrounded by reaction products of acid hydrolase but were not found in the other adenomas and the remaining adrenal tissues. S-body-containing cells, irrespective of being neoplastic or not, showed enhanced 3 beta HSD, G6PD, and NADP-ICDH activity and weak SDH activity (Type I pattern of enzyme activity). Though zG was hyperplastic in most of the adrenal tissues attached to the adenomas, zG cells that did not contain S bodies showed the opposite pattern (Type II pattern) of enzyme activity (ie, weak 3 beta HSD, G6PD, and NADP-ICDH activity and intense SDH activity), in contrast to those in the adrenal tissues in a patient with aldosteronism due to bilateral diffuse zG hyperplasia (which showed the Type I pattern). The results are consistent with the view that hyperplastic zG cells, except S-body-containing cells, in the case of aldosteronoma are not hyperfunctioning. The latter cells may have enhanced but possibly abortive steroidogenic activity.

Functional pathology of aldosterone-producing adenoma

In addition to the morphological examination, the measurement of the content of corticosteroids was done in aldosterone-producing adenoma. Histologically, the adenoma consists of four types of cells. The major component of the adenoma was clear-type cells. In this type of cells, the activities of 3 beta-hydroxysteroid dehydrogenase and glucose-6-phosphate dehydrogenase showed weakly positive. The fine structure was characterized by numerous lipid vacuoles and poor organellae. On the contrary, intermediate- and compact-type cells revealed higher than moderate activities of these enzymes. Moreover, marked development of smooth endoplasmic reticulum and mitochondria was noted. Zona glomerulosa-type cells were observed only in a small part. The content of aldosterone and corticosterone in aldosterone-producing adenoma was significantly larger than those of the other type of adenoma. A tendency of positive correlation between the increase of compact-type cells and content of aldosterone was found. The cell origin of this aldosterone-producing adenoma and functional role of clear- and compact-type cells were also discussed.

Adrenal adenomata causing primary aldosteronism. An ultrastructural study of twenty five cases

Adenomata taken from 25 patients with primary aldosteronism were observed by electron microscopy. The cells in the adenoma had a well developed agranular endoplasmic reticulum but granular endoplasmic reticulum was not prominent. Most of the mitochondria resembled those in the cells of the zona glomerulosa, suggesting that the adenomata which caused primary aldosteronism are derived from this zone. Spironolactone bodies were found in the cells of the adenoma from a patient who received spironolactone. Their appearance was identical to that described in previous reports.