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Zhao P, Zhao T, Yu L, Ma W, Liu W, Zhang C. The risk of endocrine immune-related adverse events induced by PD-1 inhibitors in cancer patients: a systematic review and meta-analysis. Front Oncol 2024; 14:1381250. [PMID: 38756658 PMCID: PMC11096456 DOI: 10.3389/fonc.2024.1381250] [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: 02/03/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Objective Endocrinopathies are the most common immune-related adverse events (irAEs) observed during therapy with PD-1 inhibitors. In this study, we conducted a comprehensive systematic review and meta-analysis to evaluate the risk of immune-related endocrinopathies in patients treated with PD-1 inhibitors. Methods We performed a systematic search in the PubMed, Embase, and Cochrane Library databases to retrieve all randomized controlled trials (RCTs) involving PD-1 inhibitors, spanning from their inception to November 24, 2023. The comparative analysis encompassed patients undergoing chemotherapy, targeted therapy, or receiving placebo as control treatments. This study protocol has been registered with PROSPERO (CRD42023488303). Results A total of 48 clinical trials comprising 24,514 patients were included. Compared with control groups, patients treated with PD-1 inhibitors showed an increased risk of immune-related adverse events, including hypothyroidism, hyperthyroidism, hypophysitis, thyroiditis, diabetes mellitus, and adrenal insufficiency. Pembrolizumab was associated with an increased risk of all aforementioned endocrinopathies (hypothyroidism: RR=4.76, 95%CI: 3.55-6.39; hyperthyroidism: RR=9.69, 95%CI: 6.95-13.52; hypophysitis: RR=5.47, 95%CI: 2.73-10.97; thyroiditis: RR=5.95, 95%CI: 3.02-11.72; diabetes mellitus: RR=3.60, 95%CI: 1.65-7.88; adrenal insufficiency: RR=4.80, 95%CI: 2.60-8.88). Nivolumab was associated with an increased risk of hypothyroidism (RR=7.67, 95%CI: 5.00-11.75) and hyperthyroidism (RR=9.22, 95%CI: 4.71-18.04). Tislelizumab and sintilimab were associated with an increased risk of hypothyroidism (RR=19.07, 95%CI: 5.46-66.69 for tislelizumab and RR=18.36, 95%CI: 3.58-94.21 for sintilimab). For different tumor types, both hypothyroidism and hyperthyroidism were at high risks. Besides, patients with non-small cell lung cancer were at a higher risk of thyroiditis and adrenal insufficiency. Patients with melanoma were at a higher risk of hypophysitis and diabetes mellitus. Both low- and high-dose group increased risks of hypothyroidism and hyperthyroidism. Conclusion Risk of endocrine irAEs may vary in different PD-1 inhibitors and different tumor types. Increased awareness and understanding of the risk features of endocrine irAEs associated with PD-1 inhibitors is critical for clinicians. Systematic review registration crd.york.ac.uk/prospero, identifier PROSPERO (CRD42023488303).
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Affiliation(s)
- Pengfei Zhao
- Department of Clinical Pharmacy, Weifang People's Hospital, Weifang, China
| | - Ting Zhao
- Department of Clinical Pharmacy, Weifang People's Hospital, Weifang, China
| | - Lihong Yu
- Department of Clinical Pharmacy, Weifang People's Hospital, Weifang, China
| | - Wenming Ma
- Department of Clinical Pharmacy, Weifang People's Hospital, Weifang, China
| | - Wenyu Liu
- Department of Pharmacy, Weifang People's Hospital, Weifang, China
| | - Chenning Zhang
- Department of Rehabilitation Medicine & Department of Pharmacy, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, China
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Zhang TX, Xu HY, Ma W, Zheng JB. Addison's disease caused by adrenal tuberculosis may lead to misdiagnosis of major depressive disorder: A case report. World J Clin Cases 2024; 12:217-223. [PMID: 38292640 PMCID: PMC10824194 DOI: 10.12998/wjcc.v12.i1.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Addison's disease (AD) is a rare but potentially fatal disease in Western countries, which can easily be misdiagnosed at an early stage. Severe adrenal tuberculosis (TB) may lead to depression in patients. CASE SUMMARY We report a case of primary adrenal insufficiency secondary to adrenal TB with TB in the lungs and skin in a 48-year-old woman. The patient was misdiagnosed with depression because of her depressed mood. She had hyperpigmentation of the skin, nails, mouth, and lips. The final diagnosis was adrenal TB that resulted in the insufficient secretion of adrenocortical hormone. Adrenocortical hormone test, skin biopsy, T cell spot test of TB, and adrenal computed tomography scan were used to confirm the diagnosis. The patient's condition improved after hormone replacement therapy and TB treatment. CONCLUSION Given the current status of TB in high-burden countries, outpatient doctors should be aware of and pay attention to TB and understand the early symptoms of AD.
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Affiliation(s)
- Tian-Xiang Zhang
- Department of Tuberculosis, The Tuberculosis Hospital of Shaanxi Province, Xi’an 710100, Shaanxi Province, China
| | - Hong-Yan Xu
- Department of Tuberculosis, The Tuberculosis Hospital of Shaanxi Province, Xi’an 710100, Shaanxi Province, China
| | - Wei Ma
- Department of Tuberculosis, The Tuberculosis Hospital of Shaanxi Province, Xi’an 710100, Shaanxi Province, China
| | - Jian-Bao Zheng
- Department of Tuberculosis, The Tuberculosis Hospital of Shaanxi Province, Xi’an 710100, Shaanxi Province, China
- Department of General Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
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Gligorijevic N, Kaljevic M, Radovanovic N, Jovanovic F, Joksimovic B, Singh S, Dumic I. Adrenal Abscesses: A Systematic Review of the Literature. J Clin Med 2023; 12:4601. [PMID: 37510716 PMCID: PMC10380332 DOI: 10.3390/jcm12144601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Objective: To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and overall morbidity and mortality. Design: Systematic literature review. Methods: We performed a search in the PubMed database using search terms: 'abscess and adrenal glands', 'adrenalitis', 'infection and adrenal gland', 'adrenal abscess', 'adrenal infection' and 'infectious adrenalitis'. Articles from 2017 to 2022 were included. We found total of 116 articles, and after applying exclusion criteria, data from 73 articles was included in the final statistical analysis. Results: Of 84 patients included in this review, 68 were male (81%), with a mean age of 55 years (range: 29 to 85 years). Weight loss was the most frequent symptom reported in 58.3% patients, followed by fever in 49%. Mean duration of symptoms was 4.5 months. The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with Histoplasma capsulatum (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%. Multivariate analysis showed that the only independent risk factor for mortality was thrombocytopenia (p = 0.048). Conclusion: Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, Histoplasma capsulatum is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis. Further prospective studies are needed to better characterize optimal testing and treatment duration in patients with this relatively rare but challenging disorder.
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Affiliation(s)
- Nikola Gligorijevic
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Marija Kaljevic
- Department of Hospital Medicine, Saint Francis Hospital and Medical Center, Hartford, CT 06105, USA
- Division of Internal Medicine, University of Connecticut, Farmington, CT 06030, USA
| | - Natasa Radovanovic
- Department of Endocrinology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
| | - Filip Jovanovic
- Department of Internal Medicine, Merit Health Wesley, Hattiesburg, MS 39402, USA
| | - Bojan Joksimovic
- Department of Pathological Physiology, Faculty of Medicine Foca, University of East Sarajevo, 73300 Foca, Bosnia and Herzegovina
| | - Sandra Singh
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
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Van't Westeinde A, Padilla N, Siqueiros Sanchez M, Fletcher-Sandersjöö S, Kämpe O, Bensing S, Lajic S. Brain structure in autoimmune Addison's disease. Cereb Cortex 2022; 33:4915-4926. [PMID: 36227196 PMCID: PMC10110435 DOI: 10.1093/cercor/bhac389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/12/2022] Open
Abstract
Long-term disturbances in cortisol levels might affect brain structure in individuals with autoimmune Addison's disease (AAD). This study investigated gray and white matter brain structure in a cohort of young adults with AAD. T1- and diffusion-weighted images were acquired for 52 individuals with AAD and 70 healthy controls, aged 19-43 years, using magnetic resonance imaging. Groups were compared on cortical thickness, surface area, cortical gray matter volume, subcortical volume (FreeSurfer), and white matter microstructure (FSL tract-based spatial statistics). Individuals with AAD had 4.3% smaller total brain volume. Correcting for head size, we did not find any regional structural differences, apart from reduced volume of the right superior parietal cortex in males with AAD. Within the patient group, a higher glucocorticoid (GC) replacement dose was associated with smaller total brain volume and smaller volume of the left lingual gyrus, left rostral anterior cingulate cortex, and right supramarginal gyrus. With the exception of smaller total brain volume and potential sensitivity of the parietal cortex to GC disturbances in men, brain structure seems relatively unaffected in young adults with AAD. However, the association between GC replacement dose and reduced brain volume may be reason for concern and requires follow-up study.
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Affiliation(s)
- Annelies Van't Westeinde
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Karolinskavagen 37A, SE-171 76 Stockholm, Sweden
| | - Nelly Padilla
- Unit for Neonatology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Karolinskavagen 37A, SE-171 76 Stockholm, Sweden
| | - Monica Siqueiros Sanchez
- Brain Imaging, Development and Genetics (BRIDGE) Lab, Division of Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5101, United States
| | - Sara Fletcher-Sandersjöö
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Olle Kämpe
- Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.,Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Karolinskavagen 37A, SE-171 76 Stockholm, Sweden
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Van't Westeinde A, Ström S, Hirvikoski T, Dahlqvist P, Wahlberg J, Gezelius A, Kämpe O, Bensing S, Lajic S. Young adult Swedish patients with autoimmune Addison's disease report difficulties with executive functions in daily life despite overall good cognitive performance. Psychoneuroendocrinology 2022; 140:105714. [PMID: 35290880 DOI: 10.1016/j.psyneuen.2022.105714] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Sub-optimal replacement of glucocorticoids (GC) in autoimmune Addison's disease (AAD) may affect cognitive functioning. The present study therefore sought to investigate cognitive performance and self-reported problems with executive functions in a cohort of young adult patients with AAD. DESIGN AND METHODS 67 patients with AAD (39 females), mean age 32 yrs. (range 19-41), and 80 control participants (43 females), mean age 29 yrs. (range 19-43), completed neuropsychological tests estimating verbal and non-verbal intellectual ability, learning, memory and executive functioning, in addition to self-report scales assessing problems with executive functions, fatigue and symptoms of anxiety and depression. RESULTS Patients performed within the average range on all cognitive tests compared to population norms. However, female AAD patients reported more problems than controls with both hot (emotion regulation) and cold (cognitive regulation) executive functions in daily life. Moreover, experienced problems with executive functions in both male and female patients were associated with increased mental fatigue and lower GC replacement doses. CONCLUSIONS Despite average performance in neuropsychological tests by both sexes, young adult female patients with AAD experience problems with executive functions in daily life. Coping with mental fatigue and optimization of pharmacotherapy may be important factors to be addressed in order to provide timely support for patients. Future research is needed to further determine other risk factors for experiencing executive function impairments in AAD.
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Affiliation(s)
- Annelies Van't Westeinde
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sara Ström
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Tatja Hirvikoski
- Department of Women's and Children's Health, Pediatric Neuropsychiatry Unit, Center for Neurodevelopmental Disorders at Karolinska Institutet (KIND), Karolinska Institutet, SE-17177 Stockholm Sweden; Unit for Habilitation & Health, Stockholm County Council, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, SE-901 87 Umeå, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology and Department of Medical and Health Sciences, Linköpings University, SE-581 83 Linköping, Sweden; Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, SE-702 81 Örebro, Sweden
| | - Anton Gezelius
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Olle Kämpe
- Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
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Winter WE, Pittman DL, Jialal I. Practical Clinical Applications of Islet Autoantibody Testing in Type 1 Diabetes. J Appl Lab Med 2022; 7:197-205. [PMID: 34996067 DOI: 10.1093/jalm/jfab113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/09/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The distinction between type 1 diabetes (T1D) and type 2 diabetes (T2D) is extremely important for the choice of therapy, body weight and dietary management, screening for coexistent autoimmune diseases and comorbidities, anticipated prognosis, and risk assessment in relatives. Not uncommonly, the presentation of the patient may not allow an unambiguous discrimination between T1D and T2D. To help resolve this challenge, the detection of islet autoantibodies can support the diagnosis of T1D. CONTENT The presence of islet autoantibodies in a person with diabetes indicates an autoimmune etiology therefore establishing the diagnosis of T1D. Presently 5 islet autoantibodies are available for routine clinical use: islet cell cytoplasmic autoantibodies (ICA), insulin autoantibodies (IAA), glutamic acid decarboxylase autoantibodies (GADA), insulinoma associated-2 autoantibodies (IA-2A), and zinc transporter-8 autoantibodies (ZnT8A). There are caveats to the selection of which islet autoantibodies should be measured. Islet autoantibodies can also predict the development of T1D. Therefore, once safe and effective therapies are available to prevent T1D, islet autoantibody testing is expected to become a routine part of medical practice. A very rare cause of autoimmune diabetes is the type B insulin resistance syndrome resulting from antagonistic autoantibodies to the insulin receptor. Rarely hypoglycemia can result from agonistic insulin receptor autoantibodies, or high-titer IAA causing the autoimmune insulin syndrome (i.e., Hirata disease). SUMMARY In summary, autoimmune causes of dysglycemia are increasing in clinical importance requiring the scrutiny of laboratorians. The determination of islet autoantibodies can greatly aid in the diagnosis and the prediction of T1D.
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Affiliation(s)
- William E Winter
- Departments of Pathology and Pediatrics, University of Florida, Gainesville, FL, USA
| | - David L Pittman
- Department of Pathology, University of Florida, Gainesville, FL, USA
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Mofokeng TRP, Beshyah SA, Ross IL. Characteristics and Challenges of Primary Adrenal Insufficiency in Africa: A Review of the Literature. Int J Endocrinol 2022; 2022:8907864. [PMID: 36060294 PMCID: PMC9433274 DOI: 10.1155/2022/8907864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/28/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUNDS Africa comprises 54 countries with varying degrees of economic development. As with other healthcare systems, rare diseases such as adrenal insufficiency are neglected and poorly documented. OBJECTIVES We wished to explore primary adrenal insufficiency (PAI) in Africa, its prevalence, aetiology, genetics, presentation, diagnosis, and treatment and to determine the unmet needs in clinical care, education, and research. MATERIALS AND METHODS A narrative nonsystematic review of the literature was undertaken. We searched two online databases (PubMed and Google scholar) using the search terms "Addison's disease/PAI, primary adrenal insufficiency coupled with "Africa," "country names," and "genetic disorders." A total of 184 PAI records were reviewed. The exclusion of abstracts, conference proceedings, single case reports, and duplicate studies covering the same subject matter yielded 124 articles, of which 97 informed the final manuscript. RESULTS A wide range of aetiology of PAI was encountered, but their true prevalence is unknown. Aetiology varied with region and age of presentation as reflected by predominantly TB, HIV, and infective causes occurring in sub-Saharan Africa and more congenital forms described in North Africa associated with consanguinity. In Africa, the diagnostic criteria for PAI do not universally accord with conventional criteria, and there is a heavy reliance on clinical suspicion and biochemistry, including random cortisol of <400 nmol/L, rather than the tetracosactide test where stimulated cortisol <500-550 nmol/L confirms the diagnosis. CONCLUSIONS A high index of suspicion is warranted to diagnose PAI in resource-limited settings, especially where tetracosactide tests are not universally available.
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Affiliation(s)
- Thabiso R. P. Mofokeng
- Division of Endocrinology, Department of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Salem A. Beshyah
- Dubai Medical College for Girls, Dubai, UAE
- Yas Clinic Group Hospital, Khalifa City, Abu Dhabi, UAE
| | - Ian L. Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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[New aspects of glucocorticoid substitution in adrenal insufficiency]. Internist (Berl) 2021; 63:12-17. [PMID: 34860258 PMCID: PMC8640964 DOI: 10.1007/s00108-021-01209-4] [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] [Accepted: 10/27/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Appropriate glucocorticoid dose adjustment in specific situations significantly impacts quality of life and performance of patients with adrenal insufficiency. It is also pivotal for the prevention of adrenal crisis. OBJECTIVES Improving medical care for patients with adrenal insufficiency. MATERIALS AND METHODS Selective literature research focussing on the most recent studies. RESULTS Optimal glucocorticoid substitution aims at closely mimicking physiological fluctuations of cortisol levels. In recent years glucocorticoid preparations with modified pharmacokinetics have expanded the therapeutic arsenal. Adrenal crises occur with an incidence of 4.8-9.3 crises per 100 patient years. With a mortality of 0.5 per 100 patient years adrenal crisis is a life-threatening event. Therefore, it is of the utmost importance to adjust glucocorticoid dose in situations with increased cortisol demand in order to prevent as well as appropriately treat adrenal crisis. CONCLUSIONS To prevent life-threatening adrenal crisis, patients, their families and medical staff require training.
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Van den Berghe G. Adrenal function/dysfunction in critically ill patients: a concise narrative review of recent novel insights. J Anesth 2021; 35:903-910. [PMID: 34302540 DOI: 10.1007/s00540-021-02977-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 12/23/2022]
Abstract
The "fight or flight" response to critical illness relies on increased cortisol availability, traditionally attributed to several-fold-increased cortisol production via hypothalamus-pituitary-adrenal-axis activation. Recent studies provided evidence against this concept with clinical implications. First, high cortisol availability during critical illness is driven by suppressed cortisol binding and reduced cortisol breakdown rather than increased cortisol production. This implies reduction of hydrocortisone doses when prescribed in ICU. Second, plasma ACTH is low, explained by feedback inhibition by peripherally driven high free cortisol and/or other central glucocorticoid-receptor ligands. Third, ICU patients have elevated plasma concentrations of the ACTH-precursor hormone, pro-opiomelanocortin, because of impaired pituitary processing into ACTH, and pro-opiomelanocortin could drive some adrenocortical cortisol production in face of low ACTH. Fourth, in prolonged critically ill patients, endogenously suppressed ACTH, aggravated by exogenous corticosteroids, associates with poor outcome. In long-stay ICU patients, central adrenal insufficiency may occur due to lack of trophic ACTH signaling. Finally, the Cosyntropin test is not suitable to assess adrenocortical reserve in ICU patients as the test is confounded by increased cortisol distribution volume. These insights necessitate further research focusing on the need, if any, of treating ICU patients with corticosteroids, and timing thereof, outside indications for pharmacological anti-inflammatory drugs.
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Affiliation(s)
- Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, 3000, Leuven, Belgium.
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Histoplasmosis: An Unusual Cause of Adrenal Insufficiency. AACE Clin Case Rep 2021; 7:29-31. [PMID: 33851016 PMCID: PMC7924147 DOI: 10.1016/j.aace.2020.11.005] [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] [Indexed: 11/23/2022] Open
Abstract
Objective Adrenal insufficiency (AI), if not diagnosed in a timely manner, can lead to fatal outcomes. Here we describe an unusual case of AI secondary to disseminated histoplasmosis (DH) and the importance of being aware of the association of infections and AI. Methods A 56-year-old Hispanic man with untreated HIV infection presented for the evaluation of left upper jaw swelling and pain. A brain magnetic resonance imaging scan revealed a 4-cm soft-tissue mass in the left maxilla. Biopsy of the mass was consistent with histoplasmosis. He was also noted to have hyponatremia and hyperkalemia, which raised the suspicion of AI. Laboratory investigation showed a baseline cortisol level of 7 μg/dL (normal, 7-23 μg/dL) and adrenocorticotropic hormone level of 86 pg/mL (normal, 7-69 pg/mL). His 60-minute cortisol level after a 250-μg cosyntropin stimulation test was 9 μg/dL (normal, 7-23 μg/dL). Computed tomography of the chest incidentally noted bilateral adrenal enlargement. An adrenal biopsy was not pursued due to the high index of clinical suspicion of DH as the etiology of AI. Results He was diagnosed with adrenal histoplasmosis because of the evidence of AI and bilateral adrenal enlargement in the setting of DH. He was started on glucocorticoid replacement for primary AI and continues to be on glucocorticoids even after 5 years of diagnosis. DH frequently involves the adrenal gland (80%) and can present as adrenal enlargement but does not always cause primary AI. Conclusion Our case demonstrates the importance of being vigilant about infections like histoplasmosis as a potential cause of AI. Delay in treatment in such cases could result in life-threatening consequences.
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Gershony LC, Belanger JM, Hytönen MK, Lohi H, Famula TR, Oberbauer AM. Genetic characterization of Addison's disease in Bearded Collies. BMC Genomics 2020; 21:833. [PMID: 33243158 PMCID: PMC7690126 DOI: 10.1186/s12864-020-07243-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/18/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Primary hypoadrenocorticism (or Addison's disease, AD) is an autoimmune disease that results in destruction of the adrenal cortex and consequent adrenal insufficiency. The disease has been described in purebred and mixed breed dogs, although some breeds, including the Bearded Collie, are at increased risk for AD. Candidate gene approaches have yielded few associations that appear to be breed-specific. A single other genome-wide association study reported no significant regions of association for AD in Standard Poodles. The present study aimed to identify genomic regions of association for canine AD in Bearded Collies. RESULTS Our study consists of the first genome-wide association analysis to identify a genome-wide significant region of association with canine AD (CFA18). Peaks of suggestive association were also noted on chromosomes 11, 16 and 29. Logistic regression analysis supported an additive effect of risk genotypes at these smaller effect loci on the probability of disease associated with carrying a risk genotype on CFA18. Potential candidate genes involved in adrenal steroidogenesis, regulation of immune responses and/or inflammation were identified within the associated regions of chromosomes 11 and 16. The gene-poor regions of chromosomes 18 and 29 may, however, harbor regulatory sequences that can modulate gene expression and contribute to disease susceptibility. CONCLUSION Our findings support the polygenic and complex nature of canine AD and identified a strongly associated locus on CFA18 that, when combined with three other smaller effect loci, was predictive of disease. The results offer progress in the identification of susceptibility loci for canine AD in the Bearded Collie. Further studies are needed to confirm association with the suggested candidate genes and identify actual causative mutations involved with AD susceptibility in this breed.
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Affiliation(s)
- Liza C Gershony
- Department of Animal Science, University of California-Davis, Davis, CA, 95616, USA
- Brazilian National Council for Scientific and Technological Development (CNPq) fellow, Brasilia, DF, 71605, Brazil
| | - Janelle M Belanger
- Department of Animal Science, University of California-Davis, Davis, CA, 95616, USA
| | - Marjo K Hytönen
- Department of Medical and Clinical Genetics, and Department of Veterinary Biosciences, University of Helsinki, 00014 Helsinki, Finland; Folkhälsan Research Center, Helsinki, 00290, Finland
| | - Hannes Lohi
- Department of Medical and Clinical Genetics, and Department of Veterinary Biosciences, University of Helsinki, 00014 Helsinki, Finland; Folkhälsan Research Center, Helsinki, 00290, Finland
| | - Thomas R Famula
- Department of Animal Science, University of California-Davis, Davis, CA, 95616, USA
| | - Anita M Oberbauer
- Department of Animal Science, University of California-Davis, Davis, CA, 95616, USA.
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Mofokeng TRP, Ndlovu KCZ, Beshyah SA, Ross IL. Tiered healthcare in South Africa exposes deficiencies in management and more patients with infectious etiology of primary adrenal insufficiency. PLoS One 2020; 15:e0241845. [PMID: 33152017 PMCID: PMC7644036 DOI: 10.1371/journal.pone.0241845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/21/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE We wished to determine the prevalence, etiology, presentation, and available management strategies for primary adrenal insufficiency (PAI) in South Africa (SA), hypothesizing a prevalence greater than the described 3.1 per million. There is great inequity in healthcare allocation, as two parallel healthcare systems exist, potentially modifying PAI patients' clinical profiles, private being better resourced than public healthcare. METHODS An online survey of physicians' experience relating to PAI. RESULTS The physicians were managing 811 patients, equal to a prevalence of 14.2 per million. Likely causes of PAI in public/ academic vs private settings included: AIDS-related [304 (44.8%) vs 5 (3.8%); p<0.001], tuberculosis [288 (42.5%) vs 8 (6.0%); p<0.001], autoimmune disease [50 (7.4%) vs 88 (66.2%); p<0.001], malignancy [27 (4.0%) vs 7 (5.3%); p = 0.500], genetic including adrenoleukodystrophy (ALD) [5 (0.7%) vs 16 (12.0%); p<0.001], respectively. Overall, more patients presented with nausea [101 (74.3%) and vomiting 89 (65.9%), than diarrhoea 76 (58.9%); p = 0.008 and 126 (15.5%) in adrenal crisis. Features suggestive of a crisis were hypoglycaemia [40 (78.4%) vs 42 (48.8%); p = 0.001], shock [36 (67.9%) vs 31(36.9%); p<0.001], and loss of consciousness [25 (52.1%) vs 27 (32.9%); p = 0.031]. Greater unavailability of antibody testing in the public vs. the private sector [32 (66.7%) vs 30 (32.1%); p = 0.001], [serum-ACTH 25 (52.1%) vs 16 (19.5%); p<0.001] and glucocorticoids were [26 (54.2%) vs 33 (40.2%); p = 0.015]. Many patients, 389(66.7%) were not using identification, indicating that they need steroids in an emergency. CONCLUSION A survey of South African physicians suggests a higher prevalence than previously reported. Patients presented with typical symptoms, and 15.5% presented in adrenal crisis. Significant disparities in the availability of physicians' expertise, diagnostic resources, and management options were noted in the public versus private settings. Greater awareness among health practitioners to timeously diagnose PAI is required to prevent a life-threatening outcome.
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Affiliation(s)
| | - Kwazi Celani Zwakele Ndlovu
- Division of Nephrology and Hypertension, Department of Medicine (University of Cape Town), Cape Town, South Africa
| | - Salem A. Beshyah
- Dubai Medical College, Dubai, United Arab Emirates
- Department of Endocrinology, Mediclinic Airport Road Hospital, Abu Dhabi, United Arab Emirates
| | - Ian L. Ross
- Division of Endocrinology, Department of Medicine (University of Cape Town), Cape Town, South Africa
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Bost C, Jordan T, Magali D, Françoise F, Nicole F. Anti-ZnT8 autoantibodies: A new marker to be screened in patients with anti-adrenal antibodies. Clin Chim Acta 2020; 511:1-6. [PMID: 32946793 DOI: 10.1016/j.cca.2020.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/04/2020] [Accepted: 09/13/2020] [Indexed: 01/21/2023]
Abstract
Patients with autoimmune Addison's disease (AAD) can develop other autoimmune diseases. They often display autoantibodies other than anti-adrenal cortex autoantibodies (ACA) which could be of interest in predicting the development of other diseases such as type 1 diabetes (T1D). Among the well-established autoantibodies associated with T1D, anti-ZnT8 autoantibodies (ZnT8A) could be found in absence of anti-GADA and anti-IA2A. Thus, the aim of our study was to evaluate the prevalence of ZnT8A in a cohort of AAD patients. The presence of ZnT8A was studied in 36 patients (19 children and 17 adults) displaying ACA. ZnT8A were detected in both children and adults with an overall prevalence of 19%. The results also indicated that ZnT8A were associated with coexisting T1D in more than 70% of this population regardless of age. Even if the titer of ZnT8A for the one third of patients without T1D was low, they have to be followed due to the potential risk of developing T1D. ZnT8A in those cases could also be a marker of autoimmunity associated to the adrenal gland destruction in AAD. As ZnT8A screening has been included in the diagnostic investigation of T1D, it should also be incorporated in the autoantibodies screening panel of the AAD population.
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Affiliation(s)
- Chloé Bost
- Immunology Laboratory, IFB, Toulouse University Hospital, 31000 Toulouse, France.
| | - Teoli Jordan
- Immunology Laboratory, Hospices Civils of Lyon, 69495 Pierre-Bénite, France.
| | - Dechomet Magali
- Immunology Laboratory, Hospices Civils of Lyon, 69495 Pierre-Bénite, France.
| | - Fortenfant Françoise
- Immunology Laboratory, IFB, Toulouse University Hospital, 31000 Toulouse, France.
| | - Fabien Nicole
- Immunology Laboratory, Hospices Civils of Lyon, 69495 Pierre-Bénite, France.
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Sozaeva LS, Makazan NV, Nikankina LV, Malysheva NM, Kuvaldina EV, Kareva MA, Orlova EM, Peterkova VA. [Assessment of autoantibodies against 21-hydroxylase in the diagnosis of primary autoimmune adrenal insufficiency]. ACTA ACUST UNITED AC 2020; 65:466-473. [PMID: 33351330 DOI: 10.14341/probl12106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 02/07/2020] [Indexed: 11/06/2022]
Abstract
Primary adrenal insufficiency is manifested by a deficiency of adrenal cortex hormones and can lead to a life-threatening condition. Early diagnosis is key to patient survival. Auto-antibodies to one of the adrenal steroidogenesis enzymes, 21-hydroxylase, are an immunological marker of autoimmune adrenal insufficiency. On the one hand, the study of antibodies to 21-hydroxylase is a method that helps establish the etiology of the disease – the autoimmune genesis of adrenal gland damage. On the other hand, the determination of autoantibodies to 21-hydroxylase is the only prognostic factor of the risk of adrenal insufficiency, which makes it possible to prevent the development of acute adrenal crisis. The article provides a brief literature review on autoantibodies to 21-hydroxylase and the pathogenesis of autoimmune adrenal insufficiency, and a series of clinical cases that illustrates the significant role of autoantibodies to 21-hydroxylase in diagnosis of adrenal insufficiency.
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Isidori AM, Arnaldi G, Boscaro M, Falorni A, Giordano C, Giordano R, Pivonello R, Pozza C, Sbardella E, Simeoli C, Scaroni C, Lenzi A. Towards the tailoring of glucocorticoid replacement in adrenal insufficiency: the Italian Society of Endocrinology Expert Opinion. J Endocrinol Invest 2020; 43:683-696. [PMID: 31773582 DOI: 10.1007/s40618-019-01146-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/11/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Glucocorticoid (GC) replacement therapy in patients with adrenal insufficiency (AI) is life saving. After over 50 years of conventional GC treatment, novel formulations are now entering routine clinical practice. METHODS Given the spectrum of medications currently available and new insights into the understanding of AI, the authors reviewed relevant medical literature with emphasis on original studies, prospective observational data and randomized controlled trials performed in the past 35 years. The Expert Opinion of a panel of selected endocrinologists was sought to answer specific clinical questions. The objective was to provide an evidence-supported guide, for the use of GC in various settings from university hospitals to outpatient clinics, that offers specific advice tailored to the individual patient. RESULTS The Panel reviewed available GC replacement therapies, comprising short-acting, intermediate and long-acting oral formulations, subcutaneous formulations and the novel modified-release hydrocortisone. Advantages and disadvantages of these formulations were reviewed. CONCLUSIONS In the Panel's opinion, achieving the optimal GC timing and dosing is needed to improve the outcome of AI. No-single formulation offers the best option for every patients. Recent data suggest that more emphasis should be given to the timing of intake. Tailoring of GS should be attempted in all patients-by experts-on a case-by-case basis. The Panel identified specific subgroups of AI patients that could be help by this process. Long-term studies are needed to confirm the short-term benefits associated with the modified-release GCs. The impact of GC tailoring has yet to be proven in terms of hospitalization rate, morbidity and mortality.
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Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - G Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Azienda Ospedaliero-Universitaria, Università Politecnica delle Marche, Ancona, Italy
| | - M Boscaro
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - A Falorni
- Dipartimento di Medicina, Università di Perugia, Perugia, Italy
| | - C Giordano
- Section of Diabetology, Endocrinology and Metabolism, PROMISE, University of Palermo, Palermo, Italy
| | - R Giordano
- Department of Clinical and Biological Sciences, Division of Endocrinology, Diabetes and Metabolism-Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - C Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C Scaroni
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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Mofokeng TRP, Beshyah SA, Mahomed F, Ndlovu KCZ, Ross IL. Significant barriers to diagnosis and management of adrenal insufficiency in Africa. Endocr Connect 2020; 9:445-456. [PMID: 32348958 PMCID: PMC7274557 DOI: 10.1530/ec-20-0129] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/28/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND The burden and management of primary adrenal insufficiency (PAI) in Africa have not been well documented. We aimed to identify specific disease characteristics, patient demographics, and patterns of clinical management in established PAI in Africa. METHODS An online survey of physicians' experience relating to PAI. RESULTS There were 1334 responses received, 589 were complete, and 332 respondents reported managing patients with hypoadrenalism. The described responses were related to a calculated pool of 5787 patients with hypoadrenalism (2746 females, 3041 males), of whom 2302 had PAI. The likely causes of PAI in Sub-Saharan Africa (SSA) vs the Middle East and North Africa (MENA) regions included autoimmune disease (20% vs 60.3%; P < 0.001), tuberculosis (34% vs 4.1%; P < 0.001), AIDS (29.8% vs 1%; P < 0.001), malignancy, and genetic conditions. Sixteen percent of AD patients (376/2302) presented in an adrenal crisis. Medical emergency identification was not used by 1233 (83.6%) SSA vs 330 (40.4%) MENA patients (P < 0.001), respectively. Relative non-availability of diagnostic tests across both regions included adrenal antibodies 63% vs 69.6% (P = 0.328), s-cortisol 49.4 % vs 26.7% (P = 0.004), s-ACTH 55.7% vs 53.3% (P = 0.217), and adrenal CT scans 52.4% vs 31.8% (P = 0.017) in the SSA and MENA region, respectively. Across the entire cohort, the overall hydrocortisone use and extrapolated proportion of synacthen use were 59.4% and 50.7%, respectively. CONCLUSIONS Through the perception and practice of healthcare professionals, we identified significant challenges in the diagnosis and management of PAI which may herald high mortality. Differences between regions may reflect the allocation of healthcare resources.
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Affiliation(s)
- Thabiso R P Mofokeng
- Department of Medicine, University of the Free State, Bloemfontein, South Africa
- Correspondence should be addressed to T R P Mofokeng:
| | - Salem A Beshyah
- Department of Medicine, Dubai Medical College, Duabi, United Arab Emirates
- Department of Endocrinology, Mediclinic Airport Road Hospital, Abu Dhabi, United Arab Emirates
| | - Fazleh Mahomed
- Department of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Kwazi C Z Ndlovu
- Department of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Ian L Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Fasano A, Leonard MM, Mitchell DM, Eng G. Case 1-2020: An 11-Year-Old Boy with Vomiting and Weight Loss. N Engl J Med 2020; 382:180-189. [PMID: 31914246 PMCID: PMC8176458 DOI: 10.1056/nejmcpc1913469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Alessio Fasano
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Maureen M Leonard
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Deborah M Mitchell
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
| | - George Eng
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
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18
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Botelho ECM, Botelho ERS, Rodrigues LCDS, Wanderley TP, Queiroz FN, Borges PCG, Cruz SARAX, Silva JPD, Sá LBCD, Arbex AK. Adrenal Insufficiency by Adrenoleukodystrophy. Health (London) 2020. [DOI: 10.4236/health.2020.121001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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19
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Téblick A, Peeters B, Langouche L, Van den Berghe G. Adrenal function and dysfunction in critically ill patients. Nat Rev Endocrinol 2019; 15:417-427. [PMID: 30850749 DOI: 10.1038/s41574-019-0185-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Critical illnesses are characterized by increased systemic cortisol availability, which is a vital part of the stress response. Relative adrenal failure (later termed critical-illness-related corticosteroid insufficiency (CIRCI)) is a condition in which the systemic availability of cortisol is assumed to be insufficiently high to face the stress of the illness and is most typically thought to occur in the acute phase of septic shock. Researchers suggested that CIRCI could be diagnosed by a suppressed incremental cortisol response to an injection of adrenocorticotropic hormone, irrespective of the baseline plasma cortisol. This concept triggered several randomized clinical trials on the impact of large stress doses of hydrocortisone to treat CIRCI, which gave conflicting results. Recent novel insights into the response of the hypothalamic-pituitary-adrenal axis to acute and prolonged critical illnesses challenge the concept of CIRCI, as currently defined, as well as the current practice guidelines for diagnosis and treatment. In this Review, these novel insights are integrated within a novel conceptual framework that can be used to re-appreciate adrenocortical function and dysfunction in the context of critical illness. This framework opens new avenues for further research and for preventive and/or therapeutic innovations.
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Affiliation(s)
- Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Bram Peeters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium.
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20
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Li XX, Liu J, Chen YL, Chen GJ, Wang ZY, Zhu JJ, Guo YW, Wei XQ. Atypical Presentation of Adrenocortical Insufficiency with Anorexia and Jaundice. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:705-709. [PMID: 29910458 PMCID: PMC6042472 DOI: 10.12659/ajcr.909190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patient: Female, 65 Final Diagnosis: Adrenocortical insufficiency Symptoms: Anorexia and jaundice Medication: Glucocorticoid replacement Clinical Procedure: — Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Xiang-Xing Li
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Jie Liu
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - You-Lian Chen
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Guang-Jian Chen
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Zhen-Yu Wang
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Jun-Jun Zhu
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Yun-Wei Guo
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Xiu-Qing Wei
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland).,Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
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21
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Kraus AU, Penna-Martinez M, Meyer G, Badenhoop K. Vitamin D effects on monocytes' CCL-2, IL6 and CD14 transcription in Addison's disease and HLA susceptibility. J Steroid Biochem Mol Biol 2018; 177:53-58. [PMID: 28765037 DOI: 10.1016/j.jsbmb.2017.07.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 12/31/2022]
Abstract
Addison's disease is a rare autoimmune disorder leading to adrenal insufficiency and life-long glucocorticoid dependency. Vitamin D receptor (VDR) polymorphisms and vitamin D deficiency predispose to Addison's disease. Aim of the current study was, to investigate potential anti-inflammatory vitamin D effects on monocytes in Addison's disease, focusing on inflammatory CCL-2 and IL6, as well on monocyte CD14 markers. Addison's disease is genetically linked to distinct HLA susceptibility alleles. Therefore we analyzed, whether HLA genotypes differed for vitamin D effects on monocyte markers. CD14+ monocytes were isolated from Addison's disease patients (AD, n=13) and healthy controls (HC, n=15) and stimulated with 1,25-dihydroxyvitamin D3 and IL1β as an inflammatory stimulant. Cells were processed for mRNA expression of CCL-2, IL6 and CD14 and DNA samples were genotyped for major histocompatibility class (MHC) class II-encoded HLA- DQA1-DQB1 haplotypes. We found a downregulation of CCL-2 after vitamin D treatment in IL1β-stimulated monocytes both from AD patients and HC (AD p<0.001; HC p<0.0001). CD14 expression however, was upregulated in both HC and AD patients after vitamin D treatment (p<0.001, respectively). HC showed higher CD14 transcription level than AD patients after vitamin D treatment (p=0.04). Compared to IL1β-induced inflammation, HC have increased CD14 levels after vitamin D treatment (p<0.001), whereas the IL1β-induced CD14 expression of AD patients' monocytes did not change after vitamin D treatment (p=0.8). AD patients carrying HLA high-risk haplotypes showed an increased CCL-2 expression after IL1β-induced inflammation compared to intermediate-risk HLA carriers (p=0.05). Also HC monocytes' CD14 transcription after IL1β and vitamin D co-stimulation differed according to HLA risk profile. We show that vitamin D can exert anti-inflammatory effects on AD patients' monocytes which may be modulated by HLA risk genotypes.
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Affiliation(s)
- A U Kraus
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital Frankfurt, Germany.
| | - M Penna-Martinez
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital Frankfurt, Germany
| | - G Meyer
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital Frankfurt, Germany
| | - K Badenhoop
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital Frankfurt, Germany
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Schwindel, Übelkeit und Hyperpigmentierung. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0445-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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del Pilar Larosa M, Chen S, Steinmaus N, Macrae H, Guo L, Masiero S, Garelli S, Costa MD, Bossowski A, Furmaniak J, Betterle C, Smith BR. A new ELISA for autoantibodies to steroid 21-hydroxylase. ACTA ACUST UNITED AC 2017; 56:933-938. [DOI: 10.1515/cclm-2017-0456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 11/06/2017] [Indexed: 01/21/2023]
Abstract
Abstract
Background:
A new ELISA for autoantibodies to steroid 21-hydroxylase (21-OH Ab) is described.
Methods:
In the assay test sample autoantibodies form a bridge between 21-OH coated onto the plate well and liquid phase 21-OH-biotin. Bound 21-OH-biotin is detected by the addition of streptavidin peroxidase and colorogenic peroxidase substrate.
Results:
Of 100 samples from patients with autoimmune Addison’s disease, 86 (86%) were positive for 21-OH Ab ELISA whereas 84 (84%) were positive in an immunoprecipitation assay based on 125I-labeled 21-OH. Six (0.6%) of 928 healthy adult blood donors and 1 (2.0%) of 49 adult patients with type 1 diabetes mellitus (T1DM) were positive by ELISA. No samples from adult patients with Graves’ disease (GD; n=50), celiac disease (n=29), systemic lupus erythematosis (n=9) or rheumatoid arthritis (n=20) were positive by ELISA. However, 2/51 (3.9%) children with GD, 3/69 (4.3%) children with Hashimoto’s thyroiditis (HT) and 3/119 (2.5%) children with T1DM alone or associated with autoimmune thyroid disorders were ELISA positive.
Conclusions:
The new assay should be useful for screening patients known to be at increased risk of developing clinical autoimmune Addison’s disease, in particular children with HT, GD and/or T1DM.
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Affiliation(s)
| | - Shu Chen
- FIRS Laboratories, RSR Ltd., Parc Ty Glas, Llanishen , Cardiff , UK
| | - Nora Steinmaus
- FIRS Laboratories, RSR Ltd., Parc Ty Glas, Llanishen , Cardiff , UK
| | - Hannah Macrae
- FIRS Laboratories, RSR Ltd., Parc Ty Glas, Llanishen , Cardiff , UK
| | - Liang Guo
- FIRS Laboratories, RSR Ltd., Parc Ty Glas, Llanishen , Cardiff , UK
| | - Stefano Masiero
- Unit of Endocrinology, Department of Medical and Surgical Sciences , University of Padua , Padua , Italy
| | - Silvia Garelli
- Unit of Endocrinology, Department of Medical and Surgical Sciences , University of Padua , Padua , Italy
| | - Miriam Dalla Costa
- Unit of Endocrinology, Department of Medical and Surgical Sciences , University of Padua , Padua , Italy
| | - Artur Bossowski
- Department of Pediatrics, Endocrinology and Diabetes with a Cardiology Unit , Medical University in Bialystok , Bialystok , Poland
| | | | - Corrado Betterle
- Unit of Endocrinology, Department of Medical and Surgical Sciences , University of Padua , Padua , Italy
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Ferreira L, Silva J, Garrido S, Bello C, Oliveira D, Simões H, Paiva I, Guimarães J, Ferreira M, Pereira T, Bettencourt-Silva R, Martins AF, Silva T, Fernandes V, Pereira ML. Primary adrenal insufficiency in adult population: a Portuguese Multicentre Study by the Adrenal Tumours Study Group. Endocr Connect 2017; 6:935-942. [PMID: 29089364 PMCID: PMC5712836 DOI: 10.1530/ec-17-0295] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 10/31/2017] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Primary adrenal insufficiency (PAI) is a rare but severe and potentially life-threatening condition. No previous studies have characterized Portuguese patients with PAI. AIMS To characterize the clinical presentation, diagnostic workup, treatment and follow-up of Portuguese patients with confirmed PAI. METHODS This multicentre retrospective study examined PAI patients in 12 Portuguese hospitals. RESULTS We investigated 278 patients with PAI (55.8% were females), with a mean age of 33.6 ± 19.3 years at diagnosis. The most frequent presenting clinical features were asthenia (60.1%), mucocutaneous hyperpigmentation (55.0%) and weight loss (43.2%); 29.1% of the patients presented with adrenal crisis. Diagnosis was established by high plasma ACTH and low serum cortisol in most patients (43.9%). The most common aetiology of PAI was autoimmune adrenalitis (61.0%). There were 38 idiopathic cases. Autoimmune comorbidities were found in 70% of the patients, the most frequent being autoimmune thyroiditis (60.7%) and type 1 diabetes mellitus (17.3%). Seventy-nine percent were treated with hydrocortisone (mean dose 26.3 ± 8.3 mg/day) mostly in three (57.5%) or two (37.4%) daily doses. The remaining patients were treated with prednisolone (10.1%), dexamethasone (6.2%) and methylprednisolone (0.7%); 66.2% were also on fludrocortisone (median dose of 100 µg/day). Since diagnosis, 33.5% of patients were hospitalized for disease decompensation. In the last appointment, 17.2% of patients had complaints (7.6% asthenia and 6.5% depression) and 9.7% had electrolyte disturbances. CONCLUSION This is the first multicentre Portuguese study regarding PAI. The results emphasize the need for standardization in diagnostic tests and etiological investigation and provide a framework for improving treatment.
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Affiliation(s)
- Lia Ferreira
- Department of EndocrinologyCentro Hospitalar do Porto, Porto, Portugal
| | - João Silva
- Department of EndocrinologyHospital das Forças Armadas, Lisboa, Portugal
| | - Susana Garrido
- Department of EndocrinologyCentro Hospitalar Tâmega e Sousa, Porto, Portugal
| | - Carlos Bello
- Department of EndocrinologyCentro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Diana Oliveira
- Department of EndocrinologyCentro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Hélder Simões
- Department of EndocrinologyInstituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
| | - Isabel Paiva
- Department of EndocrinologyCentro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Guimarães
- Department of EndocrinologyCentro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Marta Ferreira
- Department of EndocrinologyCentro Hospitalar de Leiria, Leiria, Portugal
| | - Teresa Pereira
- Department of EndocrinologyCentro Hospitalar de Leiria, Leiria, Portugal
| | | | - Ana Filipa Martins
- Department of EndocrinologyCentro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Tiago Silva
- Department of EndocrinologyHospital Garcia da Orta, Lisboa, Portugal
| | - Vera Fernandes
- Department of EndocrinologyHospital de Braga, Braga, Portugal
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Krywanczyk A, Bundock EA. Fatal Rotavirus Infection in a 4-Year-Old with Unsuspected Autoimmune Adrenal Insufficiency. Acad Forensic Pathol 2017; 7:130-135. [PMID: 31239965 PMCID: PMC6474472 DOI: 10.23907/2017.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 12/19/2016] [Indexed: 11/12/2022]
Abstract
The diagnosis of adrenal insufficiency is often delayed, as the presenting symptoms of fatigue, abdominal pain, and anorexia are vague and nonspecific. However, timely diagnosis and treatment with replacement steroids are needed to prevent fatal adrenal crisis. While the most common cause of primary adrenal insufficiency in childhood is congenital adrenal hyperplasia, a significant minority (13-23%) is caused by autoimmune destruction of the gland. We present a case of a 4-year-old, previously healthy child who had a one-day history of nausea and vomiting, and was found unresponsive by her caretaker. Despite emergency rescue and transport to the hospital, she was pronounced dead. At autopsy, the adrenal glands were atrophied. Histologic examination revealed lymphocytic infiltration of the adrenal glands consistent with autoimmune adrenal insufficiency. Fecal viral antigen testing was positive for rotavirus. The cause of death was determined to be adrenal crisis in the setting of rotavirus gastroenteritis due to adrenal insufficiency (Addison disease).
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Vinnard C, Blumberg EA. Endocrine and Metabolic Aspects of Tuberculosis. Microbiol Spectr 2017; 5:10.1128/microbiolspec.TNMI7-0035-2016. [PMID: 28233510 PMCID: PMC5785104 DOI: 10.1128/microbiolspec.tnmi7-0035-2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Indexed: 12/26/2022] Open
Abstract
Endocrine and metabolic derangements are infrequent in patients with tuberculosis, but they are important when they occur. The basis for these abnormalities is complex. While Mycobacterium tuberculosis has been described to infect virtually every endocrine gland, the incidence of gland involvement is low, especially in the era of effective antituberculosis therapy. Furthermore, endocrine and metabolic abnormalities do not always reflect direct infection of the gland but may result from physiological response or as a consequence of therapy. Metabolic disease may also predispose patients to the development of active tuberculosis, particularly in the case of diabetes mellitus. While hormonal therapy may be necessary in some instances, frequently these endocrine complications do not require specific interventions other than antituberculous therapy itself. With the exception of diabetes mellitus, which will be covered elsewhere, this chapter reviews the endocrinologic and metabolic issues related to tuberculosis.
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Affiliation(s)
- Christopher Vinnard
- The Public Health Research Institute Center and Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103
| | - Emily A. Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104
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Fares AB, Santos RAD. Conduct protocol in emergency: Acute adrenal insufficiency. Rev Assoc Med Bras (1992) 2016; 62:728-734. [PMID: 27992012 DOI: 10.1590/1806-9282.62.08.728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/28/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction: Acute adrenal insufficiency or addisonian crisis is a rare comorbidity in emergency; however, if not properly diagnosed and treated, it may progress unfavorably. Objective: To alert all health professionals about the diagnosis and correct treatment of this complication. Method: We performed an extensive search of the medical literature using specific search tools, retrieving 20 articles on the topic. Results: Addisonian crisis is a difficult diagnosis due to the unspecificity of its signs and symptoms. Nevertheless, it can be suspected in patients who enter the emergency room with complaints of abdominal pain, hypotension unresponsive to volume or vasopressor agents, clouding, and torpor. This situation may be associated with symptoms suggestive of chronic adrenal insufficiency such as hyperpigmentation, salt craving, and association with autoimmune diseases such as vitiligo and Hashimoto's thyroiditis. Hemodynamically stable patients may undergo more accurate diagnostic methods to confirm or rule out addisonian crisis. Delay to perform diagnostic tests should be avoided, in any circumstances, and unstable patients should be immediately medicated with intravenous glucocorticoid, even before confirmatory tests. Conclusion: Acute adrenal insufficiency is a severe disease that is difficult to diagnose. It should be part of the differential diagnosis in cases of hypotensive patient who is unresponsive to vasoactive agents. Therefore, whenever this complication is considered, health professionals should aim specifically at this pathology.
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Affiliation(s)
- Adil Bachir Fares
- Medical Student, 6th year, Faculdade de Medicina de São José do Rio Preto (Famerp), São José do Rio Preto, SP, Brazil
| | - Rômulo Augusto Dos Santos
- Degree in Endocrinology and Metabology from Sociedade Brasileira de Endocrinologia e Metabologia (SBEM). Assistant Physician at the Internal Medicine Service of Hospital de Base. Researcher at Centro Integrado de Pesquisa (CIP), Hospital de Base, São José do Rio Preto. Endocrinology Coordinator of the Specialties Outpatient Clinic (AME), São José do Rio Preto, SP, Brazil
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Bansal S, Castells S, Umpaichitra V, Perez-Colon S. Presence of 21-Hydroxylase Antibodies in a Boy with X-Linked Adrenal Hypoplasia Congenita. Horm Res Paediatr 2016; 84:408-13. [PMID: 26448365 DOI: 10.1159/000440803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/31/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND X-linked adrenal hypoplasia congenita is a rare cause of primary adrenal insufficiency (PAI) in children due to mutations in NR0B1/DAX1 (nuclear receptor subfamily 0, group B, member 1/dosage-sensitive sex reversal-adrenal hypoplasia congenita at the critical region of the X chromosome, gene 1). Another rare cause of PAI in children is autoimmune adrenal disease (AAD) which could be either isolated or as part of autoimmune polyglandular syndrome. Antibody to major auto-antigen, 21-hydroxylase, is highly specific for AAD. METHODS We report a now 19-month-old male with PAI due to NR0B1 gene mutation and positive adrenal antibodies. Initially, he presented at 15 days of life with isolated hypoaldosteronism which later unfolded into complete PAI. Data analysis was done via retrospective chart review. RESULTS Genetic analysis of the NR0B1 gene revealed a known hemizygous mutation in c.1069C>T; p.Gln357X. Simultaneously, he was noted to have positive 21-hydroxylase antibodies. CONCLUSION According to our knowledge, this is the first case in the literature with NR0B1 mutation causing adrenal insufficiency with coexistent positive adrenal antibodies. In addition to his already compromised adrenal function due to NR0B1 mutation, he is now at risk for the development of associated autoimmune conditions requiring close follow-up.
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Affiliation(s)
- Shipra Bansal
- Division of Pediatric Endocrinology, Department of Pediatrics, Kings County Hospital Center, Brooklyn, N.Y., USA
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Kemp S, Huffnagel IC, Linthorst GE, Wanders RJ, Engelen M. Adrenoleukodystrophy - neuroendocrine pathogenesis and redefinition of natural history. Nat Rev Endocrinol 2016; 12:606-15. [PMID: 27312864 DOI: 10.1038/nrendo.2016.90] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
X-Linked adrenoleukodystrophy (ALD) is a peroxisomal metabolic disorder with a highly complex clinical presentation. ALD is caused by mutations in the ABCD1 gene, which leads to the accumulation of very long-chain fatty acids in plasma and tissues. Virtually all men with ALD develop adrenal insufficiency and myelopathy. Approximately 60% of men develop progressive cerebral white matter lesions (known as cerebral ALD). However, one cannot identify these individuals until the early changes are seen using brain imaging. Women with ALD also develop myelopathy, but generally at a later age than men and adrenal insufficiency or cerebral ALD are very rare. Owing to the multisystem symptomatology of the disease, patients can be assessed by the paediatrician, general practitioner, endocrinologist or a neurologist. This Review describes current knowledge on the clinical presentation, diagnosis and treatment of ALD, and highlights gaps in our knowledge of the natural history of the disease owing to an absence of large-scale prospective cohort studies. Such studies are necessary for the identification of new prognostic biomarkers to improve care for patients with ALD, which is particularly relevant now that newborn screening for ALD is being introduced.
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Affiliation(s)
- Stephan Kemp
- Department of Pediatrics, Academisch Medisch Centrum, University of Amsterdam Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Genetic Metabolic Diseases, Academisch Medisch Centrum, University of Amsterdam Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Irene C Huffnagel
- Department of Pediatrics, Academisch Medisch Centrum, University of Amsterdam Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Pediatric Neurology, Academisch Medisch Centrum, University of Amsterdam Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Gabor E Linthorst
- Endocrinology and Metabolism, Academisch Medisch Centrum, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ronald J Wanders
- Department of Pediatrics, Academisch Medisch Centrum, University of Amsterdam Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Genetic Metabolic Diseases, Academisch Medisch Centrum, University of Amsterdam Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marc Engelen
- Department of Pediatrics, Academisch Medisch Centrum, University of Amsterdam Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Pediatric Neurology, Academisch Medisch Centrum, University of Amsterdam Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Bensing S, Hulting AL, Husebye ES, Kämpe O, Løvås K. MANAGEMENT OF ENDOCRINE DISEASE: Epidemiology, quality of life and complications of primary adrenal insufficiency: a review. Eur J Endocrinol 2016; 175:R107-16. [PMID: 27068688 DOI: 10.1530/eje-15-1242] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/06/2016] [Indexed: 12/13/2022]
Abstract
In this article, we review published studies covering epidemiology, natural course and mortality in primary adrenal insufficiency (PAI) or Addison's disease. Autoimmune PAI is a rare disease with a prevalence of 100-220 per million inhabitants. It occurs as part of an autoimmune polyendocrine syndrome in more than half of the cases. The patients experience impaired quality of life, reduced parity and increased risk of preterm delivery. Following a conventional glucocorticoid replacement regimen leads to a reduction in bone mineral density and an increase in the prevalence of fractures. Registry studies indicate increased mortality, especially evident in patients diagnosed with PAI at a young age and in patients with the rare disease autoimmune polyendocrine syndrome type-1. Most notably, unnecessary deaths still occur because of adrenal crises. All these data imply the need to improve the therapy and care of patients with PAI.
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Affiliation(s)
- Sophie Bensing
- Department of Molecular Medicine and SurgeryKarolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Anna-Lena Hulting
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - Eystein S Husebye
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
| | - Olle Kämpe
- Department of Medicine (Solna)Centre for Molecular Medicine, Karolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Kristian Løvås
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
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31
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Meyer G, Badenhoop K, Linder R. Addison's disease with polyglandular autoimmunity carries a more than 2·5-fold risk for adrenal crises: German Health insurance data 2010-2013. Clin Endocrinol (Oxf) 2016; 85:347-53. [PMID: 26896640 DOI: 10.1111/cen.13043] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/23/2016] [Accepted: 02/16/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Adrenal crises are potentially life-threatening complications in patients with adrenal insufficiency (AI). Our objective was to investigate the frequency of adrenal crises in different forms of AI. DESIGN/PATIENTS The Statutory Health Insurance (SHI) database of the Techniker Krankenkasse - covering more than 12% of the German population - was analysed for diagnostic codes from 1 January 2010 to 31 December 2013. MEASUREMENTS By analysis of routine data from a large healthcare provider. Diagnoses of AI were recorded and classified in primary AI, secondary AI and autoimmune polyglandular syndrome (APS). The ICD-code E27·2 (AC) was retrieved in all cohorts. RESULTS We found a prevalence of 222/million for secondary and 126/million for primary AI. AC was documented with a frequency of 4·8/100 patient years. Crises were significantly more frequent in patients with primary (7·6/100 patient years) compared to those with secondary AI (3·2/100 patient years; P < 0·0001). Prevalence of crises was higher in individuals with APS (10·9/100 patient years) and highest in patients with primary AI and type 1 diabetes (12·5/100 patient years). CONCLUSIONS Applying a SHI database comprising more than 9 million individuals, we identified robust data about the risk of AC in different groups of patients with AI. Our data confirm and extend the clinical observation that patients with APS are at highest risk for AC. Approximately 1 of 8 patients with primary AI and type 1 diabetes suffers from an AC each year. Specific targeting of efforts aiming at the prevention of AC is necessary.
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Affiliation(s)
- Gesine Meyer
- Department of Medicine 1 - Endocrinology, Goethe-University Hospital, Frankfurt, Germany
| | - Klaus Badenhoop
- Department of Medicine 1 - Endocrinology, Goethe-University Hospital, Frankfurt, Germany
| | - Roland Linder
- WINEG, Scientific Institute of the TK for Benefit and Efficiency in Health Care, Hamburg, Germany
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Gómez Rodríguez S, Pavón de Paz I, Torán Ranero C, Modroño Móstoles N, Pérez Blanco C. Afecciones de ayer y hoy. Enfermedad de Addison de causa tuberculosa. Semergen 2016; 42:416-8. [DOI: 10.1016/j.semerg.2015.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/03/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
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Uçar A, Baş F, Saka N. Diagnosis and management of pediatric adrenal insufficiency. World J Pediatr 2016; 12:261-274. [PMID: 27059746 DOI: 10.1007/s12519-016-0018-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 02/24/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Adrenal insufficiency (AI) is a wellknown cause of potentially life-threatening disorders. Defects at each level of the hypothalamic-pituitary-adrenal axis can impair adrenal function, leading to varying degrees of glucocorticoid (GC) deficiency. Iatrogenic AI induced by exogenous GCs is the most common cause of AI. The criteria for the diagnosis and management of iatrogenic AI, neonatal AI, and critical illness-related corticosteroid insufficiency (CIRCI) are not clear. DATA SOURCES We reviewed the recent original publications and classical data from the literature, as well as the clinical, diagnostic and management strategies of pediatric AI. RESULTS Practical points in the diagnosis and management of AI with an emphasis on iatrogenic AI, neonatal AI, and CIRCI are provided. Given the lack of sensitive and practical biochemical tests for diagnosis of subtle AI, GC treatment has to be tailored to highly suggestive clinical symptoms and signs. Treatment of adrenal crisis is well standardized and patients almost invariably respond well to therapy. It is mainly the delay in treatment that is responsible for mortality in adrenal crisis. CONCLUSIONS Education of patients and health care professionals is mandatory for timely interventions for patients with adrenal crisis.
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Affiliation(s)
- Ahmet Uçar
- Growth-Development and Pediatric Endocrine Unit, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey.
| | - Firdevs Baş
- Growth-Development and Pediatric Endocrine Unit, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Nurçin Saka
- Growth-Development and Pediatric Endocrine Unit, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
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Effect of Associated Autoimmune Diseases on Type 1 Diabetes Mellitus Incidence and Metabolic Control in Children and Adolescents. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6219730. [PMID: 27525273 PMCID: PMC4971288 DOI: 10.1155/2016/6219730] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 04/06/2016] [Accepted: 04/19/2016] [Indexed: 02/06/2023]
Abstract
Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases developing in childhood. The incidence of the disease in children increases for unknown reasons at a rate from 3 to 5% every year worldwide. The background of T1DM is associated with the autoimmune process of pancreatic beta cell destruction, which leads to absolute insulin deficiency and organ damage. Complex interactions between environmental and genetic factors contribute to the development of T1DM in genetically predisposed patients. The T1DM-inducing autoimmune process can also affect other organs, resulting in development of additional autoimmune diseases in the patient, thereby impeding diabetes control. The most common T1DM comorbidities include autoimmune thyroid diseases, celiac disease, and autoimmune gastritis; additionally, diabetes can be a component of PAS (Polyglandular Autoimmune Syndrome). The aim of this review is to assess the prevalence of T1DM-associated autoimmune diseases in children and adolescents and their impact on the course of T1DM. We also present suggestions concerning screening tests.
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Abstract
Adrenal insufficiency, a rare disorder which is characterized by the inadequate production or absence of adrenal hormones, may be classified as primary adrenal insufficiency in case of direct affection of the adrenal glands or secondary adrenal insufficiency, which is mostly due to pituitary or hypothalamic disease. Primary adrenal insufficiency affects 11 of 100,000 individuals. Clinical symptoms are mainly nonspecific and include fatigue, weight loss, and hypotension. The diagnostic test of choice is dynamic testing with synthetic ACTH. Patients suffering from chronic adrenal insufficiency require lifelong hormone supplementation. Education in dose adaption during physical and mental stress or emergency situations is essential to prevent life-threatening adrenal crises. Patients with adrenal insufficiency should carry an emergency card and emergency kit with them.
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Affiliation(s)
- A Pulzer
- Medizinische Klinik und Poliklinik I, Schwerpunkt Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - S Burger-Stritt
- Medizinische Klinik und Poliklinik I, Schwerpunkt Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - S Hahner
- Medizinische Klinik und Poliklinik I, Schwerpunkt Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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Tsai SL, Green J, Metherell LA, Curtis F, Fernandez B, Healey A, Curtis J. Primary Adrenocortical Insufficiency Case Series: Genetic Etiologies More Common than Expected. Horm Res Paediatr 2015; 85:35-42. [PMID: 26650942 DOI: 10.1159/000441843] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/19/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Primary adrenal insufficiency (AI) is an important cause of morbidity in children. Our objectives were: (1) to describe the clinical presentation of children with new-onset primary AI, and (2) to identify monogenic causes of primary AI in children. METHODS Chart review and mutation detection in candidate genes were conducted for 11 patients with primary AI. RESULTS The likely cause of AI was determined in 9 patients. One had a homozygous MC2R mutation associated with familial glucocorticoid deficiency. Two had the same homozygous mutation in the AIRE gene which is associated with type 1 autoimmune polyglandular syndrome. One patient had a heterozygous change in this gene of undetermined significance. Five were homozygous for the previously reported p.R188C STAR mutation causing nonclassic lipoid congenital adrenal hyperplasia, representing the largest cohort of such patients from a single geographic area. In the remaining 2 patients, no clear etiology was identified. CONCLUSIONS We recommend genetic testing for patients who have negative anti-adrenal antibodies or suggestive family history. Diagnosing a genetic etiology can provide information about prognosis and treatment, and is therefore beneficial for patients. Our high proportion of patients with nonclassic lipoid congenital adrenal hyperplasia likely represents a founder effect.
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Affiliation(s)
- Sarah L Tsai
- Discipline of Pediatrics (Division of Endocrinology), Memorial University of Newfoundland, St. John's, Nfld., Canada
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Quinkler M, Beuschlein F, Hahner S, Meyer G, Schöfl C, Stalla GK. Adrenal cortical insufficiency--a life threatening illness with multiple etiologies. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 110:882-8. [PMID: 24529304 DOI: 10.3238/arztebl.2013.0882] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 08/06/2013] [Accepted: 08/06/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND The clinical signs of adrenal cortical insufficiency (incidence, ca. 25 per million per year; prevalence, ca. 400 per million) are nonspecific, and misdiagnoses are therefore common. Glucocorticoid substitution therapy has been in use for 50 years but is not a wholly adequate treatment. Our understanding of this disease remains incomplete in many ways. METHOD We selectively searched the Medline database for publications on adrenal cortical insufficiency, with particular attention to studies from the year 2000 onward (search terms: "adrenal insufficiency" or "Addison's disease" or "hypopituitarism"). RESULTS Hydrocortisone substitution therapy is often given in doses of 10-25 mg/day, timed according to the circadian rhythm. Gastrointestinal and other, febrile infections account for 30-50% of life-threatening adrenocortical crises. Such crises affect 8 of 100 persons with adrenal cortical insufficiency per year and must be treated by the immediate administration of glucocorticoids and fluids. When persons with adrenal cortical insufficiency are acutely ill or are otherwise under unusual stress, they may need additional amounts of hydrocortisone, often in the range of 5-10 mg but occasionally as high as 200 mg. The sustained administration of excessive amounts of steroid can shorten patients lives by several years. Inappropriate substitution therapy can cause other major medical conditions, such as metabolic syndrome and osteoporosis. CONCLUSION Important measures for the prevention of adrenocortical crises include improved care by treating physicians, education of patients and their families, the provision of emergency identifying documents, and the prescription of glucocorticoid emergency kits.
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Affiliation(s)
- Marcus Quinkler
- Department of Endocrinology and Metabolic Diseases, Charité Campus Mitte, Charité Universitätsmedizin Berlin
| | - Felix Beuschlein
- Endocrine Research Unit, Medizinische Klinik - Campus Innenstadt, Klinikum der Ludwig-Maximilian-Universität München
| | - Stefanie Hahner
- Department of Internal Medicine I, Universitätsklinikum Würzburg, Department of Endocrinology
| | - Gesine Meyer
- Department of Internal Medicine, Division of Endocrinology, Johann Wolfgang Goethe-University, Frankfurt am Main/Germany
| | - Christof Schöfl
- Department of Medicine 1 - Gastroenterology, Pneumology and Endocrinology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg
| | - Günter K Stalla
- Department of Clinical Neuroendocrinology, Max Planck Institute of Psychiatry, Munich
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Hansen MP, Matheis N, Kahaly GJ. Type 1 diabetes and polyglandular autoimmune syndrome: A review. World J Diabetes 2015; 6:67-79. [PMID: 25685279 PMCID: PMC4317318 DOI: 10.4239/wjd.v6.i1.67] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 11/11/2014] [Accepted: 12/01/2014] [Indexed: 02/05/2023] Open
Abstract
Type 1 diabetes (T1D) is an autoimmune disorder caused by inflammatory destruction of the pancreatic tissue. The etiopathogenesis and characteristics of the pathologic process of pancreatic destruction are well described. In addition, the putative susceptibility genes for T1D as a monoglandular disease and the relation to polyglandular autoimmune syndrome (PAS) have also been well explored. The incidence of T1D has steadily increased in most parts of the world, especially in industrialized nations. T1D is frequently associated with autoimmune endocrine and non-endocrine diseases and patients with T1D are at a higher risk for developing several glandular autoimmune diseases. Familial clustering is observed, which suggests that there is a genetic predisposition. Various hypotheses pertaining to viral- and bacterial-induced pancreatic autoimmunity have been proposed, however a definitive delineation of the autoimmune pathomechanism is still lacking. In patients with PAS, pancreatic and endocrine autoantigens either colocalize on one antigen-presenting cell or are expressed on two/various target cells sharing a common amino acid, which facilitates binding to and activation of T cells. The most prevalent PAS phenotype is the adult type 3 variant or PAS type III, which encompasses T1D and autoimmune thyroid disease. This review discusses the findings of recent studies showing noticeable differences in the genetic background and clinical phenotype of T1D either as an isolated autoimmune endocrinopathy or within the scope of polyglandular autoimmune syndrome.
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Marković VM, Čupić Ž, Maćešić S, Stanojević A, Vukojević V, Kolar-Anić L. Modelling cholesterol effects on the dynamics of the hypothalamic–pituitary–adrenal (HPA) axis. MATHEMATICAL MEDICINE AND BIOLOGY-A JOURNAL OF THE IMA 2014; 33:1-28. [DOI: 10.1093/imammb/dqu020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 09/09/2014] [Indexed: 02/04/2023]
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Passanisi S, Timpanaro T, Lo Presti D, Caruso-Nicoletti M. Recurrent hypoglycaemia in type-1 diabetes mellitus may unravel the association with Addison's disease: a case report. BMC Res Notes 2014; 7:634. [PMID: 25214204 PMCID: PMC4169830 DOI: 10.1186/1756-0500-7-634] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 09/08/2014] [Indexed: 12/04/2022] Open
Abstract
Background Primary adrenocortical insufficiency or Addison’s disease is caused by a progressive destruction of the adrenal cortex, resulting into a reduction of glucocorticoids, mineralocorticoids, and androgens. Autoimmune Addison’s disease is the most common etiological form, accounting for about 80% of all cases. Case presentation We describe the case of a 16-year-old Caucasian boy affected by type-1 diabetes mellitus and autoimmune thyroiditis, who experienced recurrent hypoglycaemia as presenting symptom of Addison’s disease. Conclusions Hypoglycaemia is not a common presenting feature of Addison’s disease, both in patients with type-1 diabetes mellitus and in non-diabetic patients. However, hypoglycaemia may occur in association with primary and secondary glucocorticoid deficiency as a result of an enhanced insulin sensitivity. Hypoglycaemia is the most common acute complication of insulin therapy in patients with type-1 diabetes mellitus. Addison’s disease has been described in approximately 0.5% of patients with type-1 diabetes mellitus, being more frequent in females and occurring in middle-aged patients. An association among type-1 diabetes mellitus, autoimmune thyroiditis, and Addison’s disease is found in the “Schmidt’s syndrome”, a rare disorder that may occur in the paediatric age. Our case suggests that the presence of Addison’s disease should be taken into consideration in patients with type-1 diabetes mellitus and frequent episodes of hypoglycaemia. We wish to highlight that there are no specific indications to screen for the association between Addison’s disease and type-1 diabetes mellitus, although an early diagnosis of Addison’s disease in diabetic patients would prevent the morbidity and potential mortality of this association.
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Affiliation(s)
| | | | | | - Manuela Caruso-Nicoletti
- Department of Medical and Pediatric Sciences, University of Catania; Azienda Ospedaliero Universitaria Policlinico-Vittorio Emanuele, Via Santa Sofia, n,78, 95123 Catania, Italy.
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Baselga Torres E, Torres-Pradilla M. Cutaneous Manifestations in Children with Diabetes Mellitus and Obesity. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.adengl.2014.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Adrenal insufficiency is the clinical manifestation of deficient production or action of glucocorticoids, with or without deficiency also in mineralocorticoids and adrenal androgens. It is a life-threatening disorder that can result from primary adrenal failure or secondary adrenal disease due to impairment of the hypothalamic-pituitary axis. Prompt diagnosis and management are essential. The clinical manifestations of primary adrenal insufficiency result from deficiency of all adrenocortical hormones, but they can also include signs of other concurrent autoimmune conditions. In secondary or tertiary adrenal insufficiency, the clinical picture results from glucocorticoid deficiency only, but manifestations of the primary pathological disorder can also be present. The diagnostic investigation, although well established, can be challenging, especially in patients with secondary or tertiary adrenal insufficiency. We summarise knowledge at this time on the epidemiology, causal mechanisms, pathophysiology, clinical manifestations, diagnosis, and management of this disorder.
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Affiliation(s)
- Evangelia Charmandari
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.
| | - Nicolas C Nicolaides
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - George P Chrousos
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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Cutaneous manifestations in children with diabetes mellitus and obesity. ACTAS DERMO-SIFILIOGRAFICAS 2014; 105:546-57. [PMID: 24698434 DOI: 10.1016/j.ad.2013.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 11/03/2013] [Accepted: 11/06/2013] [Indexed: 01/21/2023] Open
Abstract
Obesity and diabetes are chronic diseases that affect people all over the world, and their incidence is increasing in both children and adults. Clinically, they affect a number of organs, including the skin. The cutaneous manifestations caused or aggravated by obesity and diabetes are varied and usually bear some relation to the time that has elapsed since the onset of the disease. They include soft fibromas, acanthosis nigricans, striae, xerosis, keratosis pilaris, plantar hyperkeratosis, fungal and bacterial skin infections, granuloma annulare, necrobiosis lipoidica, psoriasis, and atopic dermatitis. In this review article we present the skin changes found in children with diabetes mellitus and obesity and related syndromes and highlight the importance of the skin as a tool for establishing clinical suspicion and early diagnosis of systemic disease.
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Meyer G, Neumann K, Badenhoop K, Linder R. Increasing prevalence of Addison's disease in German females: health insurance data 2008-2012. Eur J Endocrinol 2014; 170:367-73. [PMID: 24322183 DOI: 10.1530/eje-13-0756] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Our objective was to investigate the epidemiology of autoimmune Addison's disease (AD) in Germany. DESIGN Routine data were analyzed from the Statutory Health Insurance (SHI) database of the Techniker Krankenkasse (TK) for an observation period from 01/01/2008 to 31/12/2012. The TK is one of the largest German health care insurance providers covering more than 10% of the German population. SUBJECTS AND METHODS Between 2008 and 2012, a total of 2477 diagnoses of primary adrenal failure were recorded in the SHI database. After exclusion of secondary, iatrogenic or other non-idiopathic forms and after adjustment for incomplete data sets, 1364 diagnoses of autoimmune-mediated AD remained. RESULTS The prevalence of AD in our cohort showed a steady increase from 82 per million in 2008 to 87 per million in 2012. On average, the prevalence rose about 1.8% per year, and due to a pronounced increase (2.7%) in females. The prevalence was lower in men (63-68 per million) than in women (96-108 per million). Autoimmune comorbidities were found in 46.5% of AD patients. Adrenal crises were documented with a frequency of 14-17/100 patient years. CONCLUSIONS These data provide a first epidemiological profile of this rare and perilous endocrine disease in Germany. Although the prevalence of AD appears lower than in the Scandinavian countries, the increasing figures in females over the last 5 years warrant further investigations. Furthermore, adrenal crises pose a considerable burden. Hereby, we can show that health insurance data provide a valuable tool for epidemiological studies in the absence of national registries.
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Affiliation(s)
- Gesine Meyer
- Division of Endocrinology, Department of Medicine 1, University Hospital, Goethe-University Frankfurt, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
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Abstract
An increasing body of evidence suggests that immune-mediated processes affect female reproductive success at multiple levels. Crosstalk between endocrine and immune systems regulates a large number of biological processes that affect target tissues, and this crosstalk involves gene expression, cytokine and/or lymphokine release and hormone action. In addition, endocrine-immune interactions have a major role in the implantation process of the fetal (paternally derived) semi-allograft, which requires a reprogramming process of the maternal immune system from rejection to temporary tolerance for the length of gestation. Usually, the female immune system is supportive of all of these processes and, therefore, facilitates reproductive success. Abnormalities of the female immune system, including autoimmunity, potentially interfere at multiple levels. The relevance of the immune system to female infertility is increasingly recognized by investigators, but clinically is often not adequately considered and is, therefore, underestimated. This Review summarizes the effect of individual autoimmune endocrine diseases on female fertility, and points towards selected developments expected in the near future.
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Affiliation(s)
- Aritro Sen
- The Center for Human Reproduction (CHR), 21 East 69th Street, New York, NY 10021, USA
| | - Vitaly A Kushnir
- The Center for Human Reproduction (CHR), 21 East 69th Street, New York, NY 10021, USA
| | - David H Barad
- The Center for Human Reproduction (CHR), 21 East 69th Street, New York, NY 10021, USA
| | - Norbert Gleicher
- The Center for Human Reproduction (CHR), 21 East 69th Street, New York, NY 10021, USA
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Iqbal MS, Hardman J. Addisonian crisis secondary to bilateral adrenal metastases in rectal carcinoma: report of a rare case and literature review. J Gastrointest Cancer 2013; 44:225-7. [PMID: 22890387 DOI: 10.1007/s12029-012-9426-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zhernakova A, Withoff S, Wijmenga C. Clinical implications of shared genetics and pathogenesis in autoimmune diseases. Nat Rev Endocrinol 2013; 9:646-59. [PMID: 23959365 DOI: 10.1038/nrendo.2013.161] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Many endocrine diseases, including type 1 diabetes mellitus, Graves disease, Addison disease and Hashimoto disease, originate as an autoimmune reaction that affects disease-specific target organs. These autoimmune diseases are characterized by the development of specific autoantibodies and by the presence of autoreactive T cells. They are caused by a complex genetic predisposition that is attributable to multiple genetic variants, each with a moderate-to-low effect size. Most of the genetic variants associated with a particular autoimmune endocrine disease are shared between other systemic and organ-specific autoimmune and inflammatory diseases, such as rheumatoid arthritis, coeliac disease, systemic lupus erythematosus and psoriasis. Here, we review the shared and specific genetic background of autoimmune diseases, summarize their treatment options and discuss how identifying the genetic and environmental factors that predispose patients to an autoimmune disease can help in the diagnosis and monitoring of patients, as well as the design of new treatments.
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Affiliation(s)
- Alexandra Zhernakova
- University of Groningen, University Medical Centre Groningen, Department of Genetics, PO Box 30001, 9700 RB Groningen, Netherlands
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Yuen KCJ, Chong LE, Koch CA. Adrenal insufficiency in pregnancy: challenging issues in diagnosis and management. Endocrine 2013; 44:283-92. [PMID: 23377701 DOI: 10.1007/s12020-013-9893-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 01/21/2013] [Indexed: 10/27/2022]
Abstract
Adrenal insufficiency (AI) in pregnancy is relatively rare, but it is associated with significant maternal and fetal morbidity and mortality if untreated during gestation or in the puerperium. Hence, timely diagnosis and decisive treatment by the clinician are critical. However, due to pregnancy-induced metabolic and endocrine changes and the resemblance of symptomatology of AI to those of pregnancy, the diagnosis is often difficult to recognize and challenging to confirm. Normal pregnancy is a state of glucocorticoid excess particularly in the latter stages, and normative values for serum cortisol levels are not well-established. Furthermore, testing the hypothalamic-pituitary-adrenal axis using validated stimulation tests during pregnancy are lacking. Therefore, it is the aim of the present review to discuss and to summarize the current knowledge, focussing on the challenges in recognizing AI in pregnancy and interpreting the diagnostic tests, and to propose a clinical approach for optimizing the management of AI in women diagnosed before or during pregnancy.
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Affiliation(s)
- Kevin C J Yuen
- Division of Endocrinology, Diabetes and Clinical Nutrition, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mailcode L607, Portland, OR, 97239-3098, USA,
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Lebovitz HE. Autoimmune polyglandular syndromes: interplay between the immune and the endocrine systems leading to a diverse set of clinical diseases and new insights into immune regulation. Diabetes Technol Ther 2013; 15 Suppl 2:S2-21-S2-28. [PMID: 23786295 DOI: 10.1089/dia.2013.0130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
During the last 50 years, three major classes of autoimmune polyglandular syndromes (APSs) have been defined, and their characteristics and heritability have been delineated. Simultaneously, studies of the immunologic bases of these syndromes provided fundamental information in understanding immune regulation. Genetic analyses of patients and their families with APS type 1 (autoimmune polyendocrinopathy candidiasis, ectodermal dystrophy) identified the autoimmune regulator (AIRE) gene, which drives the expression of peripheral tissue-specific antigens in thymic cells and is critical in the development of self-tolerance. Mutations in this gene cause APS type 1. In contrast, studies in APS type 2 have been instrumental in understanding the role of human leukocyte antigen type II and related molecules in the pathogenesis of polygenetic autoimmune diseases such as type 1A diabetes. Immune dysfunction polyendocrinopathy, enteropathy, X-linked syndrome, which is caused by mutations in the forkhead box P3 gene, has been a model for studying regulatory T cell biology. The APSs epitomize the synergies that the merger of clinical and basic science can achieve. This is the environment that George Eisenbarth was able to create at the Barbara Davis Center for Diabetes.
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Affiliation(s)
- Harold E Lebovitz
- Department of Medicine, State University of New York Health Science Center at Brooklyn, Brooklyn, New York 11203, USA.
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Royo Gómez M, Olmos Jiménez MJ, Rodríguez Arnao MD, Roldán Martín MB. [Addison's disease: forms of presentation in paediatrics]. An Pediatr (Barc) 2013; 78:405-8. [PMID: 23428759 DOI: 10.1016/j.anpedi.2012.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/25/2012] [Accepted: 10/18/2012] [Indexed: 01/21/2023] Open
Abstract
Addison's disease or primary adrenal insufficiency is a rare disease in children. The signs and symptoms at diagnosis are frequently non-specific and insidious. Since adrenal crisis represents an emergency, it is important to be aware and to have a high degree of suspicion of the disorder in order to achieve an early diagnosis and treatment. We present a retrospective study describing the epidemiological, clinical and etiological data at diagnosis of five patients with Addison's disease followed up in our hospital. Dehydration, hyponatremia and skin hyperpigmentation were the most prevalent signs and symptoms at onset of the disease. The patients had low serum cortisol levels and positive adrenal antibodies. One patient with negative antibodies presented with a polyglandular syndrome.
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Affiliation(s)
- M Royo Gómez
- Unidad de Metabolismo y Endocrinología Infantil, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, España.
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