Adrenal insufficiency

Multimodality imaging of adrenal gland pathologies: A comprehensive pictorial review

The assessment of acute abdominal and pelvic emergencies typically involves a multimodal approach consisting of plain radiographs, ultrasound, computed tomography (CT), and rarely magnetic resonance imaging (MRI). Although MRI is not traditionally employed in acute care settings, there are several instances in which MRI provides superior functional and prognostic information. In this manuscript, we highlight multimodal findings of adrenal gland emergencies: Hemorrhage, infarction, and infection. The purpose of our study is to highlight significant findings in various modalities, including CT, MRI, ultrasound, and PET/CT. Due to the scarcity of published data and limited clinical use, primary ultrasound findings are limited in our multimodal review. In conclusion, we find that synergistic use of CT, MRI, and functional imaging provides an effective tool for evaluation and management of adrenal pathology.

Effect of hydrocortisone on hypocorticolism caused by pituitary adenoma

OBJECTIVES

Pituitary adenoma is a tumor that can cause hormonal secretion problems, including hypocortisolism. Hypocortisolism may result in negative impacts such as an increase in proinflammatory cytokine and immune system activation. Hypocortisolism therapy is performed by giving high-dose hydrocortisone. This case report presented a hypocortisolism therapy using hydrocortisone in a patient with pituitary adenoma.

CASE PRESENTATION

A 17-year-old boy was admitted to a hospital due to right-eye vision loss, headache, and swallowing difficulty. During the treatment at the hospital, the patient had light depression. The brain Magnetic Resonance Imaging (MRI) scanning with contrast showed there was a supratentorial axial lesion enlarged from the intrasellar to the suprasellar. The anamnesis and physical examination, as well as laboratory and supporting examinations, showed that the patient was diagnosed to suffer from pituitary macroadenoma. The laboratory examination showed that the size of hypocortisolism was at <0.5 μg/dL (reference value ranges from 4.30-22.40 μg/dL). The patient was treated with hydrocortisone IV therapy at 100 mg/dose administered in the morning and evening for 4 days. Then, the dose tapering off of 100 mg/dose was administered in the morning for 4 days. After that, the patient received hydrocortisone of 20 mg/dose peroral administration in the morning and evening until the patient was discharged from the hospital. Tapering off was performed to prevent the side effects of high-dose hydrocortisone. Besides, the patient was alsounder the Endoscopic Endonasal Transsphenoidal Hypophysectomy (EETH). The cortisol level in the pretreatment was at <0.5 and 5.3 μg/dL during the treatment. There were no side effects of the treatment when the patients were hospitalized.

CONCLUSIONS

The hydrocortisone IV therapy with 100 mg/do was administered in the morning and evening for 4 days, and then the dose tapering off of 100 mg/dose was done in the morning for 4 days. Then, the hydrocortisone therapy of 20 mg/dose peroral administration to the patient with pituitary macroadenoma in the morning and evening to improve the cortisol level. The cortisol level in the pretreatment was at 0.5 and 5.3 μg/dL in the post-treatment.

Knowledge and attitude of patients with adrenal insufficiency

Background

Adrenal insufficiency (AI) is a rare and a dangerous disease requiring a life-long glucocorticoid replacement therapy with dose adjustment in stressful situations which is linked to patient's knowledge and understanding. The aim of this study was to explore AI patients understanding regarding their disease, risk factors of adrenal crisis, as well as their attitude in stressful situations.

Materials and Methods

We prospectively enrolled from October to January 2017, all patients with adrenal insufficiency (primary or secondary) treated and followed up in the Department of Endocrinology at University Hospital Center Hassan II of Fez. Patients were asked to fill out a questionnaire to assess their self-perceived subjective understanding to objectively evaluate their knowledge.

Results

A total of 55 AI patients participated in this study. Overall, 74% of patients had no sufficient understanding of their disease; more participants gave incorrect answers to how to act in different stressful situations. Eleven patients (20%) did not possess a "steroid warning card," twenty-five patients (45%) had the injectable hydrocortisone (HC) set at home; 40% carried the HC required for the day with them. Globally, the patients self-perceived, subjective knowledge level was not good, a severe lack of knowledge had been identified concerning the knowledge of risk factors of AI.

Conclusion

The present study shows the urgent need to develop a structured and continuous education of patients with adrenal insufficiency to improve their self-management of the disease.

The contribution of serum cortisone and glucocorticoid metabolites to detrimental bone health in patients receiving hydrocortisone therapy

BACKGROUND

Glucocorticoid therapy is the most common cause of iatrogenic osteoporosis. Less is known regarding the effect of glucocorticoids when used as replacement therapy on bone remodelling in patients with adrenal insufficiency. Enhanced intracellular conversion of inactive cortisone to active cortisol, by 11 beta-hydroxysteroid dehydrogenase type 1(11β-HSD1) and other enzymes leading to alterations in glucocorticoid metabolism, may contribute to a deleterious effect on bone health in this patient group.

METHODS

Study design: An open crossover prospective study randomizing ten hypopituitary men, with severe ACTH deficiency, to three commonly used hydrocortisone dose regimens.

MEASUREMENTS

Following 6 weeks of each regimen, patients underwent 24-h serum cortisol/cortisone sampling, measurement of bone turnover markers, and a 24-h urine collection for measurement of urinary steroid metabolites by gas chromatography-mass spectrometry (GC-MS). Serum cortisone and cortisol were analysed by liquid chromatography-mass spectrometry (LC-MS).

RESULTS

Dose-related and circadian variations in serum cortisone were seen to parallel those for cortisol, indicating conversion of ingested hydrocortisone to cortisone. The median area under the curve (AUC) of serum cortisone was significantly higher in patients on dose A (20 mg/10 mg) [670.5 (IQR 621-809.2)] compared to those on dose C (10 mg/5 mg) [562.8 (IQR 520.1-619.6), p = 0.01]. A negative correlation was observed between serum cortisone and bone formation markers, OC [1-49] (r = - 0.42, p = 0.03), and PINP (r = - 0.49, p = 0.01). There was a negative correlation between the AUC of night-time serum cortisone levels with the bone formation marker, OC [1-49] (r = - 0.41, p = 0.03) but there were no significant correlations between day-time serum cortisone or cortisol with bone turnover markers. There was a negative correlation between total urinary cortisol metabolites and the bone formation markers, PINP (r = - 0.39, p = 0.04), and OC [1-49] (r = - 0.35, p = 0.06).

CONCLUSION

Serum cortisol and cortisone and total urinary corticosteroid metabolites are negatively associated with bone turnover markers in patients receiving replacement doses of hydrocortisone, with nocturnal glucocorticoid exposure having a potentially greater influence on bone turnover.

TRIAL REGISTRATION

Irish Medicines Board Clinical Trial Number - CT900/459/1 and EudraCT Number - 2007-005018-37 . Registration date: 07-09-2007.

Adrenal crisis in a 14-year-old boy 12 years after hematopoietic stem cell transplantation

We report on a boy of Albanian descent with the history of juvenile myelomonocytic leukemia (JMML). JMML was diagnosed at the age of 17 months and treated by hematopoietic stem cell transplantation (HSCT). At the age of 14.3 years, about 12 years after HSCT, he was hospitalized with an adrenal crisis. Hormone findings were consistent with primary adrenal insufficiency. Autoimmune adrenalitis was confirmed by positive autoantibodies against 21-hydroxylase and adrenal tissue. Since autoimmune Hashimoto thyroiditis was already known from the age of 9 years, we assume that both diseases are part of the spectrum of autoimmune polyglandular syndrome (APS) type 2. APS type 2 is a rare endocrine disease characterized by Addison’s disease along with autoimmune thyroid disease and/or type 1 diabetes.

Comparison of salivary and calculated free cortisol levels during low and standard dose of ACTH stimulation tests in healthy volunteers

Salivary cortisol (SC) has been increasingly used as a surrogate biomarker of free cortisol (FC) for the assessment of hypothalamo-pituitary-adrenal (HPA) axis, but there are not enough data regarding its use during ACTH stimulation tests. Therefore, we aimed to determine the responses of SC, calculated free cortisol (cFC) and free cortisol index (FCI) to ACTH stimulation tests in healthy adults. Forty-four healthy volunteers (24 men and 20 women) were included in the study. Low-dose (1 µg) and standard-dose (250 µg) ACTH stimulation tests were performed on two consecutive days. Basal and stimulated total cortisol (TC) and cortisol-binding globulin (CBG) levels and SC levels were measured during both doses of ACTH stimulation tests. cFC (by Coolens' equation) and FCI levels were calculated from simultaneously measured TC and CBG levels. The minimum SC, cFC, FCI levels after low-dose ACTH stimulation test were 0.21, 0.33, 16.06 µg/dL, and after standard-dose ACTH were 0.85, 0.46, 26.11 µg/dL, respectively, in healthy individuals who all had TC responses higher than 20 µg/dL. Peak CBG levels after both doses of ACTH stimulation tests were found to be higher in women than in men. So, by its effect, peak cFC and FCI levels were found to be lower in female than in male group. Neither TC nor SC levels were affected by gender. cFC and FCI levels depend on CBG levels and they are affected by gender. Cut-off levels for SC, cFC, FCI levels after both low- and standard-dose ACTH stimulation are presented. Studies including patients with adrenal insufficiency would be helpful to see the diagnostic value of these suggested cut-off levels.

Hypopituitarism: growth hormone and corticotropin deficiency

This article presents an overview of adult growth hormone deficiency (AGHD) and corticotropin deficiency (central adrenal failure, CAI). Both conditions can result from various ailments affecting the hypothalamus or pituitary gland (most frequently a tumor in the area or its treatment). Clinical manifestations are subtle in AGHD but potentially life-threatening in CAI. The diagnosis needs dynamic testing in most cases. Treatment of AGHD is recommended in patients with documented severe deficiency, and treatment of CAI is mandatory in all cases. Despite significant progress in replacement hormonal therapy, more physiologic treatments and more reliable indicators of treatment adequacy are still needed.

Hypopituitarism after subarachnoid haemorrhage, do we know enough?

Background

Fatigue, slowness, apathy and decrease in level of activity are common long-term complaints after a subarachnoid haemorrhage (SAH). They resemble the symptoms frequently found in patients with endocrine dysfunction. Pituitary dysfunction may be the result of SAH or its complications. We therefore hypothesized that it may explain some of the long-term complaints after SAH.

We reviewed the literature to clarify the occurrence, pattern and severity of endocrine abnormalities and we attempted to identify risk factors for hypopituitarism after SAH. We also assessed the effect of hypopituitarism on long-term functional recovery after SAH.

Methods

In a MEDLINE search for studies published between 1995 and 2014, we used the term subarachnoid haemorrhage in combination with pituitary, hypopituitarism, growth hormone, gonadotropin, testosterone, cortisol function, thyroid function and diabetes insipidus. We selected all case-series and cohort studies reporting endocrine function at least 3 months after SAH and studied their reported prevalence, pathogenesis, risk factors, clinical course and outcome.

Results

We identified 16 studies describing pituitary function in the long term after SAH. The reported prevalence of endocrine dysfunction varied from 0 to 55% and the affected pituitary axes differed between studies. Due to methodological issues no inferences on risk factors, course and outcome could be made.

Conclusions

Neuroendocrine dysfunction may be an important and modifiable determinant of poor functional outcome after SAH. There is an urgent need for well-designed prospective studies to more precisely assess its incidence, clinical course and effect on mood, behaviour and quality of life.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-014-0205-0) contains supplementary material, which is available to authorized users.

Risk of adrenal crisis in dental patients: results of a systematic search of the literature

BACKGROUND

The authors performed a systematic search of the literature to identify the frequency of, risk of experiencing and factors associated with adrenal crises in dental patients.

METHODS

The authors searched PubMed and Ovid MEDLINE (1947-June 20, 2012) and Embase (1974-2012) for English-language articles related to cases of adrenal crisis in dentistry and extracted and analyzed data from the articles. The six authors determined whether the cases identified met a consensus definition of adrenal crisis.

RESULTS

Of 148 articles identified in the initial screening, 34 articles were included in the final review, from which six cases met the criteria of adrenal crisis. The authors categorized four cases as "suggestive of adrenal crisis" and two cases as "consistent with adrenal crisis." Risk factors were significant adrenal insufficiency, pain, infection, having undergone an invasive procedure, having received a barbiturate general anesthetic, and poor health status and stability at the time of presentation. The authors estimated risk to be less than one in 650,000 in patients with adrenal insufficiency.

CONCLUSIONS

Adrenal crisis is rare in dental patients, with only six reports of it having been published in the past 66 years. Risk is associated with unrecognized adrenal insufficiency, poor health status and stability at the time of treatment, pain, infection, having undergone an invasive procedure and having received a barbiturate general anesthetic.

CLINICAL IMPLICATIONS

Risk of adrenal crisis is reduced through proper evaluation of the patient, identification of risk factors and following appropriate preventive measures.

A glucocorticoid education group meeting: an effective strategy for improving self-management to prevent adrenal crisis

OBJECTIVE

To assess self-management in patients receiving glucocorticoid replacement therapy for primary or secondary adrenal failure before and 6 months after a glucocorticoid education group meeting.

METHODS

All patients with primary or secondary adrenal insufficiency, treated at the Department of Medicine, Division of Endocrinology, were invited by their endocrinologist to participate in a 3-h glucocorticoid education group meeting, consisting of a lecture about the disease and glucocorticoid doses adjustments in case of stress, followed by an instruction on how to inject hydrocortisone i.m. Finally, all participants could practise the i.m. injection and discuss their experience with (imminent) adrenal crises with other patients and the health care providers. Two weeks before the meeting and 6 months after the meeting, patients were asked to fill out a questionnaire about how they would act in six different conditions (e.g. febrile illness or vomiting).

RESULTS

Of the 405 patients who were invited, 246 patients (61%) participated. At baseline the response by the participants on the questionnaire was 100% (n=246) and at follow-up 74% (n=183). At follow-up, significantly more participants (P≤0.005) gave the correct answers to how to act in different situations (e.g. self-administration of a glucocorticoid injection and phone contact in case of vomiting/diarrhoea without fever). Moreover, the use of self-management tools, such as having a 'medicine passport (travel document with information about disease and medication) (P=0.007) or SOS medallion (P=0.0007)', increased.

CONCLUSION

A glucocorticoid education group meeting for patients with adrenal failure seems helpful to improve self-management and proper use of stress-related glucocorticoid dose adjustment.

The use of an early postoperative CRH test to assess adrenal function after transsphenoidal surgery for pituitary adenomas

Transsphenoidal surgery (TS) is the treatment of choice for many pituitary tumors. Because TS may cause pituitary insufficiency in some of these patients, early postoperative assessment of pituitary function is essential for appropriate endocrine management. The aim of our study was to evaluate the clinical relevance of the CRH-stimulation test in assessing postoperative pituitary-adrenal function. We performed a retrospective analysis of 144 patients treated by TS between January 1990 and November 2009, in whom a CRH-test and a second stimulation test was performed to assess adrenal function during follow-up. Patients with Cushing's disease were excluded. Hydrocortisone substitution was started if peak cortisol levels were <550 nmol/L. The cortisol response was insufficient in 42(29%) and sufficient in 102 patients at the postoperative CRH-test. Thirteen of 42(30%) demonstrated a normal cortisol response during a second cortisol stimulation test. In 75 of the 102 patients with a sufficient response to CRH repeat testing revealed an insufficient cortisol response in 14 patients (14%). All but one had concomitant pituitary hormone deficits. There were no cases of adrenal crises during follow-up. Additional pituitary insufficiency was significantly more present (P < 0.001) in the group of patients with an abnormal response to CRH directly after surgery. In this study a substitution strategy of hydrocortisone guided by the postoperative cortisol response to CRH appeared safe and did not result in any case of adrenal crises. However, the early postoperative CRH-test does not reliably predict adrenal function after TS for pituitary adenomas in all patients and retesting is mandatory.

Endocrine and metabolic emergencies: hypoglycaemia

Hypoglycaemia is rare in healthy individuals owing to the numerous elegant hormonal and neuronal mechanisms that maintain glucose homeostasis. Glucose is an obligate metabolic fuel for cerebral tissue and therefore hypoglycaemia, if uncorrected, can have disastrous consequences including death. Clinical hypoglycaemia is defined as a plasma (or serum) glucose concentration low enough to cause symptoms and/or signs, including impairment of brain function. However, no single plasma (or serum) glucose concentration categorically defines hypoglycaemia. Hypoglycaemia is probably the most common endocrine and metabolic emergency in clinical practice. The overwhelming majority of occurrences of hypoglycaemia occur in patients with diabetes, either as a result of treatment-induced hypoglycaemia and/or abnormalities that affect the normal counterregulatory response to hypoglycaemia. The differential for nondiabetes-associated hypoglycaemia is broad and includes insulinoma, drugs, hormone deficiencies, and critical illness. The acute management of hypoglycaemia is discussed along with a review of the pathophysiology and aetiology of this commonly encountered clinical problem.