1
|
Inukai T, Harai N, Nakagawa Y, Hosokawa T, Antoku A, Muroi Y, Ogiwara M, Tsuchiya K. Subclinical Cushing's Disease with High-Molecular-Weight Forms of Adrenocorticotropic Hormone Production. Case Rep Endocrinol 2024; 2024:8721614. [PMID: 38566858 PMCID: PMC10985640 DOI: 10.1155/2024/8721614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/28/2023] [Accepted: 02/24/2024] [Indexed: 04/04/2024] Open
Abstract
Production of the high-molecular-weight forms of adrenocorticotropic hormone (big-ACTH) has been reported in a small number of ectopic ACTH syndrome and ACTH-producing pituitary macroadenoma. However, perioperative changes in big-ACTH in patients with subclinical Cushing's disease have not been reported. A 63-year-old woman presented 25 × 20 × 20-mm-sized macroadenoma in the pituitary gland. Her early morning plasma ACTH and cortisol levels were 111 pg/mL and 11.6 μg/dL, respectively. Cushingoid features and diurnal variation in plasma cortisol levels were not observed. The patient's urinary free cortisol (UFC) was 59.3 μg/day. The corticotropin-releasing hormone (CRH) test showed that plasma ACTH levels were 1.5 times higher than the preload value. The overnight dexamethasone suppression test (DST) showed that the plasma cortisol level was not suppressed by 0.5 mg of dexamethasone (DEX) but was suppressed by 8 mg of DEX. Inferior pyramidal sinus sampling was consistent with Cushing's disease. Taken together, the patient was clinically diagnosed with subclinical Cushing's disease caused by an ACTH-producing pituitary adenoma. Endoscopic transsphenoidal adenomectomy was performed. In the postoperative CRH test, plasma ACTH levels showed six-fold increase. The postoperative DST showed cortisol suppression at 0.5 mg of DEX. The UFC levels decreased to 35.1 μg/day. Pituitary contrast-enhanced MRI revealed no residual tumor, and plasma ACTH and cortisol levels remained within normal ranges. Gel filtration of preoperative and postoperative plasma ACTH was performed, and a high molecular weight fraction of ACTH was detected, which markedly decreased postoperatively. The absence of Cushingoid features and the lack of significant cortisol hypersecretion in this case were thought to be due in part to big-ACTH, which has low bioactivity. By careful evaluation of laboratory and clinical findings, we identified it as a big-ACTH-producing adenoma. This is the first report of a case in which the big-ACTH transition was observed perioperative and is a valuable case.
Collapse
Affiliation(s)
- Takahiko Inukai
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Nozomi Harai
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Yukie Nakagawa
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Tadatsugu Hosokawa
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Airi Antoku
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Yuko Muroi
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Masakazu Ogiwara
- Department of Neurosurgery, University of Yamanashi Hospital, Yamanashi, Japan
| | - Kyoichiro Tsuchiya
- Department of Diabetes and Endocrinology, University of Yamanashi Hospital, Yamanashi, Japan
| |
Collapse
|
2
|
Ozgen Saydam B, Adiyaman SC, Demir L, Yener S. ADRENOCORTICOTROPIC HORMONE IMMUNOASSAY INTERFERENCE IN A PATIENT WITH SUBCLINICAL HYPERCORTISOLISM. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 16:379-382. [PMID: 33363666 DOI: 10.4183/aeb.2020.379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Context Immunoassays are vulnerable to occasional analytical errors despite their sensitivity and specificity. Adrenocorticotropic hormone (ACTH) is among hormones which are vulnerable to assay interference. Objective In this case report, we aimed to present a case of ACTH interference in a patient with subclinical hypercortisolism. Case report We present a case of subclinical hypercortisolism with unexpectedly elevated levels of ACTH in whom interference was shown by different biochemical methods.It is important for the clinician to keep in mind the possibility of interference when clinical and laboratory results are discordant. The communication between the clinician and laboratory staff is important while interpreting results. This case report shows that ACTH interference should be considered in patients with subclinical hypercortisolism who have unexpectedly high levels of adrenocorticotropic hormone.
Collapse
Affiliation(s)
- B Ozgen Saydam
- Dokuz Eylul University Hospital, Division of Endocrinology and Metabolism, Izmir, Turkey
| | - S C Adiyaman
- Dokuz Eylul University Hospital, Division of Endocrinology and Metabolism, Izmir, Turkey
| | - L Demir
- Izmir Katip Celebi University, Ataturk Training and Research Hospital, Department of Biochemistry, Izmir, Turkey
| | - S Yener
- Dokuz Eylul University Hospital, Division of Endocrinology and Metabolism, Izmir, Turkey
| |
Collapse
|
3
|
Inder WJ. Towards a universally accepted definition of subclinical Cushing's syndrome - subclinical autonomous hypercortisolism. Clin Endocrinol (Oxf) 2017; 86:7-9. [PMID: 27662258 DOI: 10.1111/cen.13244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/21/2016] [Accepted: 09/21/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital and School of Medicine, the University of Queensland, Brisbane, Australia
| |
Collapse
|
4
|
Guttenberg KB, Mayson SE, Sawan C, Kharlip J, Lee JY, Martinez-Lage M, Loevner LA, Ewanichak J, Grady MS, Snyder PJ. Prevalence of clinically silent corticotroph macroadenomas. Clin Endocrinol (Oxf) 2016; 85:874-880. [PMID: 27346850 DOI: 10.1111/cen.13146] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/07/2016] [Accepted: 06/24/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The prevalence of clinically silent corticotroph macroadenomas is unknown. Our aim was to determine the prevalence of clinically silent corticotroph macroadenomas among all pituitary macroadenomas. DESIGN Patients scheduled to have transsphenoidal surgery for any sellar mass were prospectively evaluated clinically and biochemically. PATIENTS Adults who were scheduled for transsphenoidal surgery for a sellar mass at a single academic medical centre. MEASUREMENTS Patients were assessed clinically prior to surgery and graded as having typical, mild or no Cushingoid features. They were assessed biochemically by plasma ACTH and 24-h urine free cortisol (UFC). Excised tissue was examined histologically, and pituitary macroadenomas, examined by immunohistochemistry. Patients with corticotroph macroadenomas were classified as clinically silent if they exhibited no Cushingoid features but had elevated plasma ACTH and/or 24-h UFC. They were classified as totally silent if they exhibited neither Cushingoid features nor elevated plasma ACTH or 24-h UFC. RESULTS Of 124 patients who had pathologically confirmed pituitary macroadenomas, 20 (16%) had corticotroph macroadenomas. Eight (40%) of these were clinically silent, in that they had no Cushingoid features but could be identified biochemically by elevated plasma ACTH (seven) and/or 24-h UFC (three). Five (25%) were totally silent. CONCLUSIONS A substantial minority (16%) of pituitary macroadenomas treated surgically are corticotroph adenomas. Of these, 40% are clinically silent but can be recognized by elevated plasma ACTH and/or 24-h UFC. Recognizing these adenomas may influence the surgical approach and provide a marker by which to follow the response to treatment.
Collapse
Affiliation(s)
- Katie B Guttenberg
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah E Mayson
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carla Sawan
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Kharlip
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John Y Lee
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maria Martinez-Lage
- Departments of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laurie A Loevner
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jayme Ewanichak
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Sean Grady
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter J Snyder
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|