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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] [What about the content of this article? (0)] [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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Percik R, Shlomai G, Tirosh A, Tirosh A, Leibowitz-Amit R, Eshet Y, Greenberg G, Merlinsky A, Barhod E, Steinberg-Silman Y, Sella T. Isolated autoimmune adrenocorticotropic hormone deficiency: From a rare disease to the dominant cause of adrenal insufficiency related to check point inhibitors. Autoimmun Rev 2019; 19:102454. [PMID: 31838158 DOI: 10.1016/j.autrev.2019.102454] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/03/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Immune checkpoint inhibitors have introduced a new and heterogeneous class of immune-related adverse effects, with the endocrine system being a predominant target for autoimmunity. Autoimmune hypothalamic-pituitary-adrenal axis (HPA) diseases induced by checkpoint inhibitors are being increasingly recognized. We aimed to characterize the spectrum of checkpoint associated hypothalamic-pituitary-adrenal axis endocrinopathies. DESIGN A retrospective cohort study of a tertiary cancer center. METHODS Patients were characterized for HPA axis abnormalities based on clinical and pituitary axes evaluation. The risk for developing HPA endocrinopathies was compared by log- rank test, by the time since checkpoint inhibitors initiation. Additionally, the risk for developing HPA endocrinopathies after adjusting for covariates was assessed using multivariable logistic regression analysis. RESULTS Among 1615 patients, fourteen (0.87%) patients developed isolated adrecocorticotrophic hormone deficiency (IAD), six (0.37%) - hypophysitis and no case of adrenalitis was identified. IAD presented with mild and non-specific symptoms, mainly asthenia. In multivariable analysis, exposure to both PD-1/PD-L1 and Ipilimumab and female gender were associated with an increased odds ratio (OR) for developing IAD (6.98 [95% CI 2.38-20.47, p < .001] and 3.67 [95% CI 1.13-11.84, p = .03]), respectively. CONCLUSIONS IAD, a rare disease before the immunotherapy era, has become a predominant checkpoint related HPA axis autoimmune injury. Despite its life threatening potential, IAD may be missed due to its subtle presentation. Patients exposed to Ipilimumab and PD-1/PD-L1 in combination or sequentially and women have an increased risk for developing IAD.
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Affiliation(s)
- Ruth Percik
- Institute of Endocrinology, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Institute of Oncology, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Gadi Shlomai
- Institute of Endocrinology, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel; Pinchas Burstein Talpiot Medical Leadership Program, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Amir Tirosh
- Institute of Endocrinology, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amit Tirosh
- Institute of Endocrinology, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raya Leibowitz-Amit
- Institute of Oncology, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Eshet
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Nuclear Medicine, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Gahl Greenberg
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Alex Merlinsky
- Institute of Clinical Pharmacology and Toxicology, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Ehud Barhod
- Institute of Endocrinology, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Yael Steinberg-Silman
- The Ella Lemelbaum Institute for Immuno-Oncology, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Tal Sella
- Institute of Oncology, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Pinchas Burstein Talpiot Medical Leadership Program, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Dana-Farber Cancer Institute, Boston, MA, USA
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Okahata S, Sakamoto K, Mitsumatsu T, Kondo Y, Noso S, Ikegami H, Shiba T. Fulminant type 1 diabetes associated with Isolated ACTH deficiency induced by anti-programmed cell death 1 antibody-insight into the pathogenesis of autoimmune endocrinopathy. Endocr J 2019; 66:295-300. [PMID: 30814440 DOI: 10.1507/endocrj.ej18-0328] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Therapeutic blocking antibodies against programmed death 1 (PD1) and cytotoxic T-lymphocyte antigen 4 (CTLA4) are applied for advanced cancer therapy, but induce a wide range of immune-related adverse events. In our recent case of a 52-year-old female doctor suffering from breast cancer having metastasized to the lung and liver, it was decided to use nivolumab to prevent the disease progressing after excisional surgeries and multiple chemotherapies. One month after completing the nivolumab course, fatigue, hypoglycemia and hypotension developed and isolated ACTH deficiency (IAD) was diagnosed. A further month later, under steroid supplementation, hyperglycemia emerged alongside thirst and polydipsia, prompting a diagnosis of fulminant type 1 diabetes (FT1D). Her susceptibility to type 1 diabetes was examined by HLA haplotype and CTLA4 gene polymorphism analyses. Polymorphisms CT60G>A and +49G>A in CTLA4 both generated a GG genotype. Our patient manifested one of the rarest combinations of autoimmune disease induced by nivolumab. Whereas the HLA haplotype was unsusceptible to autoimmune type 1 diabetes, polymorphisms of CTLA4, the antibody of which frequently causes hypophysitis, were susceptible to FT1D. Peripheral modulation of activated T cells, mainly by PD-1 antibodies, induced FT1D associated with IAD in patients with CTLA4 polymorphism. This case reveals hints of the T-cell etiology in T1D and evidence of CTLA4 involvement in IAD.
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Affiliation(s)
- Sumie Okahata
- Division of Diabetes and Metabolism, Toho University Ohashi Medical Center, Tokyo 153-8515, Japan
| | - Kentaro Sakamoto
- Division of Diabetes and Metabolism, Toho University Ohashi Medical Center, Tokyo 153-8515, Japan
| | - Takako Mitsumatsu
- Division of Diabetes and Metabolism, Toho University Ohashi Medical Center, Tokyo 153-8515, Japan
| | - Yuko Kondo
- Division of Diabetes and Metabolism, Toho University Ohashi Medical Center, Tokyo 153-8515, Japan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Teruo Shiba
- Division of Diabetes and Metabolism, Toho University Ohashi Medical Center, Tokyo 153-8515, Japan
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Abstract
A 37-year-old female patient was hospitalized because of general fatigue and loss of axillary and pubic hair after massive bleeding at delivery of her third child. The basal levels of both plasma adrenocorticotropin hormone (ACTH) and serum cortisol were very low, 5.2 pg/mL and 1.9 μg/dL, respectively. Based on the fact that ACTH showed a low response to insulin tolerance test and a normal response to corticotropin-releasing hormone (CRH), she was diagnosed with hypothalamic adrenal insufficiency. No organic lesions were found in the hypothalamic-pituitary region by pituitary MRI and hydrocortisone therapy was instituted. Basedow's disease was also discovered and treated with methimazole, and thyroid function returned to normal. Surprisingly, adrenal insufficiency gradually resolved, making it possible to stop hydrocortisone therapy 2 years from the onset of disease. To our knowledge, there are no previous case reports discussing the remission of hypothalamic adrenal insufficiency. The etiology of the unusual clinical course of this case remains unclear and we discussed several possibilities of the pathogenesis.
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Affiliation(s)
- Yuko Akehi
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
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Kacem FH, Charfi N, Mnif MF, Kamoun M, Akid F, Mnif F, Naceur BB, Rekik N, Mnif Z, Abid M. Isolated adrenocorticotropic hormone deficiency due to probable lymphocytic hypophysitis in a woman. Indian J Endocrinol Metab 2013; 17:S107-S110. [PMID: 24251125 PMCID: PMC3830271 DOI: 10.4103/2230-8210.119521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We report a 22-year-old woman who presented with asthenia, weight loss and hypotension in which extensive pituitary and adrenal investigations were diagnostic of isolated adrenocorticotropic hormone deficiency (IAD) of pituitary origin. Magnetic resonance imaging of the hypothalamus and pituitary showed a normal-sized pituitary, with no mass lesion. The diagnosis of IAD probably secondary to lymphocytic hypophysitis (LYH) was made. IAD is able to be the way of presentation of LYH, although the disease could or could not turn into a panhypopituitarism. Prompt recognition of this potentially fatal condition is important because of the availability of effective treatment. Indeed, regular endocrine and imaging follow up is important for patients with IAD and normal initial pituitary imaging results to detect early new-onset pituitary hormones deficiencies or imaging abnormalities.
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Affiliation(s)
- Faten Hadj Kacem
- Department of Endocrinology, HediChaker Hospital, 3029 Sfax, Tunisia
| | - Nadia Charfi
- Department of Endocrinology, HediChaker Hospital, 3029 Sfax, Tunisia
| | - Mouna Feki Mnif
- Department of Endocrinology, HediChaker Hospital, 3029 Sfax, Tunisia
| | - Mahdi Kamoun
- Department of Endocrinology, HediChaker Hospital, 3029 Sfax, Tunisia
| | - Faouzi Akid
- Department of Radiology, HediChaker Hospital, 3029 Sfax, Tunisia
| | - Fatma Mnif
- Department of Endocrinology, HediChaker Hospital, 3029 Sfax, Tunisia
| | - Basma Ben Naceur
- Department of Endocrinology, HediChaker Hospital, 3029 Sfax, Tunisia
| | - Nabila Rekik
- Department of Endocrinology, HediChaker Hospital, 3029 Sfax, Tunisia
| | - Zainab Mnif
- Department of Radiology, HediChaker Hospital, 3029 Sfax, Tunisia
| | - Mohamed Abid
- Department of Endocrinology, HediChaker Hospital, 3029 Sfax, Tunisia
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Baumann CR. Traumatic Brain Injury and Disturbed Sleep and Wakefulness. Neuromolecular Med 2012; 14:205-12. [DOI: 10.1007/s12017-012-8178-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 03/03/2012] [Indexed: 11/26/2022]
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Baumann CR, Bassetti CL, Valko PO, Haybaeck J, Keller M, Clark E, Stocker R, Tolnay M, Scammell TE. Loss of hypocretin (orexin) neurons with traumatic brain injury. Ann Neurol 2009; 66:555-9. [PMID: 19847903 DOI: 10.1002/ana.21836] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Chronic, daytime sleepiness is a major, disabling symptom for many patients with traumatic brain injury (TBI), but thus far, its etiology is not well understood. Extensive loss of the hypothalamic neurons that produce the wake-promoting neuropeptide hypocretin (orexin) causes the severe sleepiness of narcolepsy, and partial loss of these cells may contribute to the sleepiness of Parkinson disease and other disorders. We have found that the number of hypocretin neurons is significantly reduced in patients with severe TBI. This observation highlights the often overlooked hypothalamic injury in TBI and provides new insights into the causes of chronic sleepiness in patients with TBI.
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Bremer AA, Ranadive S, Conrad SC, Vallette-Kasic S, Rosenthal SM. Isolated adrenocorticotropic hormone deficiency presenting as an acute neurologic emergency in a peripubertal girl. J Pediatr Endocrinol Metab 2008; 21:799-803. [PMID: 18825881 DOI: 10.1515/jpem.2008.21.8.799] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Isolated adrenocorticotropic hormone (ACTH) deficiency (IAD) is extraordinarily rare, and the clinical manifestations of its accompanying adrenal insufficiency are diverse. Early-onset forms of IAD have been linked to mutations in the Tpit transcription factor gene TPIT; however, the genetic basis of juvenile- or late-onset IAD is unknown. Herein, we describe a case of a peripubertal girl with IAD and a normal TPIT gene who presented with an acute neurologic emergency, demonstrating both the variable clinical presentation of IAD and the need for continued investigation into the molecular mechanisms underlying juvenile- and late-onset IAD.
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Affiliation(s)
- Andrew A Bremer
- Department of Pediatrics, Division of Endocrinology, University of California Davis Medical Center, Sacramento, CA 95817-2208, USA.
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Moro N, Katayama Y, Igarashi T, Mori T, Kawamata T, Kojima J. Hyponatremia in patients with traumatic brain injury: incidence, mechanism, and response to sodium supplementation or retention therapy with hydrocortisone. ACTA ACUST UNITED AC 2007; 68:387-93. [PMID: 17905062 DOI: 10.1016/j.surneu.2006.11.052] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2006] [Accepted: 11/21/2006] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hyponatremia is a frequently observed electrolyte abnormality in patients with central nervous system disease. Several mechanisms, such as SIADH, hypopituitarism, and CSWS, have been proposed with varied incidences among several studies. We attempted to clarify the incidence and mechanism of hyponatremia for each type of TBI. We also assessed the efficacy of sodium supplementation and retention therapy. For sodium retention therapy, hydrocortisone was administered, expecting its mineralocorticoid effect, when the hyponatremia was associated with excess natriuresis. METHODS Retrospective analysis of 298 patients with TBI between January 2003 and December 2004 was performed. The incidence, background, clinical data, and outcome were evaluated. RESULTS Of the 298 patients, 50 (16.8%) presented hyponatremia during the time course. Hyponatremia was associated with longer hospital stay (P < .001) and bad outcome (P = .02). Among these 50 patients, 37 recovered from the hyponatremia with simple sodium supplementation. The remaining 13 patients presented massive natriuresis and required additional sodium retention therapy. Hydrocortisone statistically reduced the amount of sodium excretion (P = .002) and returned the serum sodium level to a normal value. CONCLUSIONS A high rate of hyponatremia after TBI was observed. Further studies are required to establish the precise mechanism of hyponatremia after TBI. Clear definition of CSWS is required to avoid confusion of the pathophysiology that causes hyponatremia. Hydrocortisone was useful to prevent excess natriuresis.
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Affiliation(s)
- Nobuhiro Moro
- Department of Neurological Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo 173-8610, Japan.
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Abstract
OBJECTIVE To estimate the prevalence and predictive factors of hypopituitarism following traumatic brain injury (TBI). DESIGN A cross-sectional cohort study. PATIENTS One hundred and four hospitalized TBI patients (26F/78M), median age 41 (range 18-64) years, body mass index (BMI) 25 (17-39) kg/m(2); severity: mild [Glasgow Coma Scale (GCS) score 13-15) n = 44, moderate (GCS 9-12) n = 20, severe (GCS < 9) n = 40]. MEASUREMENTS Patients were evaluated 13 (10-27) months post-injury, with measurement of baseline (0800-1000 h) and post-stimulatory hormonal levels during an insulin tolerance test (ITT) (86%) or, if contraindicated, an arginine(arg)-GHRH test + Synacthen test (14%). Insufficiencies were confirmed by retesting. RESULTS Hypopituitarism was found in 16 (15%) patients, affecting one axis in 10, two axes in four and more than two axes in two patients. The GH axis was most frequently affected (15%), followed by secondary hypoadrenalism (5%), hypogonadism (2%), hypothyroidism (2%) and diabetes insipidus (2%). The risk of pituitary insufficiency was increased in patients with severe TBI as opposed to mild TBI [odds ratio (OR) 10.1, 95% confidence interval (CI) 2.1-48.4, P = 0.004], and in those patients with increased intracerebral pressure [OR 6.5, 95% CI 1.0-42.2, P = 0.03]. Patients with only one affected axis were all GH deficient; 60% (n = 6) of these were overweight or obese. CONCLUSION The prevalence of hypopituitarism was estimated at 16%. Although high, this value was lower than previously reported, and may still be overestimated because of well-known confounding factors, such as obesity. Indicators of increased TBI severity were predictive of hypopituitarism, with a high negative predictive value. Neuroendocrine evaluation should therefore be considered in patients with severe TBI, and in particular in those with increased intracerebral pressure (ICP).
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Affiliation(s)
- M Klose
- Department of Medical Endocrinology, the University Hospital of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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Abstract
Traumatic brain injury (TBI) is a frequent health problem and increased prevalence of neurendocrine dysfunction in patients with TBI has been reported. Sports injuries and particularly boxing may result in pituitary dysfunction. However, transient hypogonadotropic hypogonadism after an acute head trauma due to boxing and/or kickboxing has not been defined yet. We describe the case of a 20-yr-old male amateur kickboxer who was admitted to hospital complaining of decreased libido and impotence 2 weeks after an intensive bout. Basal hormone levels were compatible with mild hyperprolactinemia and hypogonadotpopic hypogonadism. GH axis was evaluated by GHRH+GHRP-6 test and peak GH level was within normal reference range. Three months later his complaints improved and abnormalities in basal hormone levels normalized. He was also re-evaluated 9 months after the first evaluation; basal hormone levels were within normal ranges and he had no complaints. In conclusion acute head trauma due to kickboxing may cause transient gonadotropin deficiency. Therefore, screening the pituitary functions of sportsmen dealing with combative sports is crucial.
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Affiliation(s)
- F Tanriverdi
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
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Abstract
Isolated ACTH deficiency (IAD) is a rare disorder, characterized by secondary adrenal insufficiency (AI) with low or absent cortisol production, normal secretion of pituitary hormones other than ACTH and the absence of structural pituitary defects. In adults, IAD may appear after a traumatic injury or a lymphocytic hypophysitis, the latter possibly due to autoimmune etiology. Conversely, a genetic origin may come into play in neonatal or childhood IAD. Patients with IAD usually fare relatively well during unstressed periods until intervening events spark off an acute adrenal crisis presenting with non specific symptoms, such as asthenia, anorexia, unintentional weight loss and tendency towards hypoglycemia. Blood chemistry may reveal mild hypoglycemia, hyponatremia and normal-high potassium levels, mild anemia, lymphocytosis and eosinophilia. Morning serum cortisol below 3 microg/dl are virtually diagnostic for adrenal insufficiency. whereas cortisol values comprised between 5-18 microg/dl require additional investigations: insulin tolerance test (ITT) is considered the gold standard but-when contraindicated-high or low dose-ACTH stimulation test with serum cortisol determination provides a viable alternative. Plasma ACTH concentration and prolonged ACTH infusion test are useful in differential diagnosis between primary and secondary adrenal insufficiency. For some patients with mild, near-to-asymptomatic disease, glucocorticoid replacement therapy may not be required except during stressful events; for symptomatic patients, replacement doses i.e., mean daily dose 20 mg (0.30 mg/kg) hydrocortisone or 25 mg (0.35 mg/kg) cortisone acetate, are usually sufficient. Administration of mineralocorticoids is generally not necessary as their production is maintained.
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