Hair cortisol in polycystic ovary syndrome

The aim of the study was to evaluate adrenal axis hyperactivation measuring hair cortisol levels, and its influence on the relationship among metabolic parameters, inflammation markers and androgens in adult women with PCOS. 44 women (18–34 years) with PCOS diagnosis and a control group of 49 healthy women (19–35 years) were included. In both gropus body mass index (BMI) was calculated and waist circumference (WC) was measured. Hair cortisol, total serum testosterone (TT), serum cortisol, 25 OH vitamin D (25OHD), insulin, high sensitivity C-reactive protein (hsCRP), triglycerides (TG), HDL cholesterol (HDL), glucose and leptin were measured. Bioavailable testosterone (bioT) was calculated. Hair cortisol concentration was higher and significantly different in PCOS patients compared to the control group (130 vs 63 pg/mg of hair, p < 0.001). Subsequently, patients with PCOS were divided into two groups according to hair cortisol levels: group 1 with normal hair cortisol concentration and group 2 with levels above the upper limit of the reference values (128 pg/mg of hair). In group 2, TT significantly correlated with 25OHD, hsCRP, TG/HDL index, BMI, WC, insulin and HOMA (p < 0.05); bioT correlated with hsCRP and leptin (p < 0.05). Finally, 25OHD was inversely correlated with leptin and with TG/HDL index (p < 0.05). High hair cortisol concentration in patients with PCOS confirmed hyperactivation of the HPA axis. The associations observed were only found in patients with PCOS with high hair cortisol levels (> 128 pg/mg of hair), showing a possible effect of HPA axis in these associations.

A single-oral bolus of 100,000 IU of cholecalciferol at hospital admission did not improve outcomes in the COVID-19 disease: the COVID-VIT-D-a randomised multicentre international clinical trial

BACKGROUND

Vitamin D status has been implicated in COVID-19 disease. The objective of the COVID-VIT-D trial was to investigate if an oral bolus of cholecalciferol (100,000 IU) administered at hospital admission influences the outcomes of moderate-severe COVID-19 disease. In the same cohort, the association between baseline serum calcidiol levels with the same outcomes was also analysed.

METHODS

The COVID-VIT-D is a multicentre, international, randomised, open label, clinical trial conducted throughout 1 year. Patients older than 18 years with moderate-severe COVID-19 disease requiring hospitalisation were included. At admission, patients were randomised 1:1 to receive a single oral bolus of cholecalciferol (n=274) or nothing (n=269). Patients were followed from admission to discharge or death. Length of hospitalisation, admission to intensive care unit (ICU) and mortality were assessed.

RESULTS

In the randomised trial, comorbidities, biomarkers, symptoms and drugs used did not differ between groups. Median serum calcidiol in the cholecalciferol and control groups were 17.0 vs. 16.1 ng/mL at admission and 29.0 vs. 16.4 ng/mL at discharge, respectively. The median length of hospitalisation (10.0 [95%CI 9.0-10.5] vs. 9.5 [95%CI 9.0-10.5] days), admission to ICU (17.2% [95%CI 13.0-22.3] vs. 16.4% [95%CI 12.3-21.4]) and death rate (8.0% [95%CI 5.2-12.1] vs. 5.6% [95%CI 3.3-9.2]) did not differ between the cholecalciferol and control group. In the cohort analyses, the highest serum calcidiol category at admission (>25ng/mL) was associated with lower percentage of pulmonary involvement and better outcomes.

CONCLUSIONS

The randomised clinical trial showed the administration of an oral bolus of 100,000 IU of cholecalciferol at hospital admission did not improve the outcomes of the COVID-19 disease. A cohort analysis showed that serum calcidiol at hospital admission was associated with outcomes.

TRIAL REGISTRATION

COVID-VIT-D trial was authorised by the Spanish Agency for Medicines and Health products (AEMPS) and registered in European Union Drug Regulating Authorities Clinical Trials (EudraCT 2020-002274-28) and in ClinicalTrials.gov ( NCT04552951 ).

SUN-494 A Case of Hyperthyroidism with Multiple Recurrences of Neutropenia After Stopping Methimazole

Background: The adverse effects of methimazole usually occur in the first 6 months of treatment and they usually are dose dependent. The most severe ones are hepatotoxicity and agranulocytosis, the frequency of the latter is 0.1-0.5% and with a high mortality rate.

Clinical case: A 15-year-old female patient was sent to Endocrinology in May 2017 because of a 4-month history of tremor, palpitations and heat intolerance. Lab tests: WBC: 6,800, neutrophils: 36% (2,448/l), TSH: < 0.06 uU/ml (0.27- 4.7), T4: > 25 ug/dl (4.5 -12), FT4: >7.7 ng/dl (0.93 -1.7), TPO >1,000 UI/ml (<10), TRAb > 40 UI/L (<1.75) which confirmed Graves’ disease. Propranolol 80 mg/day and methimazole 30 mg/day were prescribed. Two months later methimazole dose was increased to 40 mg/d, hematologic lab test was normal. Seven months after starting methimazole the patient presented with febrile neutropenia, methimazole was stopped, methylprednisolone 20 mg/d was prescribed and we increased propranolol to 120 mg/d, neutropenia improved. A month after the first episode of neutropenia, she presented a second episode with a pharyngeal infection, WBC: 6,300, neutrophils: 1%. In December 2017 radioiodine therapy was performed: 15 mCi. Hyperthyroidism was not resolved, she continued with methylprednisolone 20 mg/d and propranolol 120 mg/d, and 6 drops/d of Lugol solution was prescribed. From December 2017 to July 2018, the patient presented 9 episodes of febrile neutropenia, she had a good response to Granulocyte-colony stimulating factor. Serology tests for CMV, VDRL, HIV, Epstein Barr, Toxoplasmosis, hepatitis B and C were all negative. Lab tests for rheumatologic diseases: rheumatoid factor, C3 and C4, electrophoretic proteinogram, antiestreptolysin O, anti-DNA, ANA, anti-Ro/SSA, anti-La/SSB were all negative, and immunoglobulins were normal. Bone marrow aspiration was normal. We could not perform flow cytometry of anti-neutrophil cytoplasmic antibodies (C-ANCA). Hyperthyroidism persisted and a second I-131 treatment was performed (20 mCi) in June 2018. A month later she presented hypothyroidism, levothyroxine was indicated. She continued with episodes of febrile neutropenia until March 2019, 23 months after the diagnosis of hyperthyroidism, 16 months after stopping methimazole and 8 months after having initiated levothyroxine treatment and having normal thyroid levels.

Conclusion: We presented a young female patient with persistent and recurrent neutropenia despite having stopped methimazole, and regardless of her thyroid hormone levels. Although neutropenia usually appears in the first months of treatment, it seldom occurs much later and almost never after stopping the drug. We could not reach an etiological diagnosis of neutropenia, but it is probable that methimazole had triggered an immune-hematological illness associated to Graves’ disease.

MON-432 Symptomatic Pituitary Metastases: A Report of 16 Cases

Introduction: Pituitary Metastases (MTS) are infrequently seen in clinical practice. The incidence ranges from 0.14 to 28%. Breast and lung cancer are the primary sites that most frequently metastasize to sellar region, between the sixth and seventh decades of life. Most cases are diagnosed in patients with advanced malignant disease, however, in 20-30%, symptoms of pituitary involvement can precede the diagnosis of the primary tumor. Objectives: To evaluate symptoms at presentation, hormonal, radiological and histological findings, management and outcome of a series of patients with pituitary MTS. Patients and methods: medical records of 16 patients from eight Endocrine Centers were reviewed. Ten patients had histological confirmation of the pituitary MTS, 6 were not operated, being the diagnostic criteria the presence of sellar mass associated with diabetes insipidus (DI) and / or sudden-onset of neuro-ophthalmological symptoms in patients with confirmed primary neoplasia. Results: The median age was 54 years (range 35-70), 9 women (56.2%). The sites of the primary tumor were: 7 lung (44%), 5 breast (32%), 1 follicular thyroid carcinoma (6%), 1 Hodgkin lymphoma (6%), 1 poorly differentiated carcinoma (6%), and 1 clear cell renal carcinoma (6%). The median time between the diagnosis of the primary neoplasm and the occurrence of the pituitary MTS was 12 months (range: 3-120). In 9 patients (56.2%), the diagnosis of the primary neoplasm was made after the finding of the symptomatic sellar mass. DI was found in 14 patients (87.5%), adenohypophyseal deficit in 12 (75%), visual disorders in 10 (62.5 %), headache in 6 (37.5%) and cranial nerve deficits in 6 (37.5%). In 68.7% (11 patients), other MTS were detected. Fifteen patients were evaluated by MRI and one by CT: 13 (81.3%) harbored supra / parasellar masses, and the remaining 3 had lesions limited to the pituitary gland, with stalk thickening and lack of spontaneous neurohypophysis hyperintensity in 2 of them. In all cases diffuse gadolinium uptake was present. Fourteen patients died (87.5%), with a median survival time of 6,5 months (range: 1-36); the remaining 2 are still alive with a follow-up period of 4 and 12 months respectively. Conclusions: In this series of 16 patients with pituitary MTS, the most frequent primary neoplasms were lung and breast. Median age was lower than in published series. DI was the most common condition at presentation, followed by hypopituitarism and visual disorders. The short survival was related to the extent of the disease at the time of diagnosis. In more than half of the cases the diagnosis of primary neoplasia was made through the symptomatic pituitary mass. In the presence of a pituitary lesion with diffuse gadolinium uptake, associated with DI and / or acute visual deficit, pituitary MTS should be suspected even in patients without a history of oncological disease.

SUN-448 Giant Prolactinomas: A Follow-Up of 25 Years with Dopamine Agonists

Giant prolactinomas are tumors with a large size > 4 cm and/or prolactin levels higher than 3000 ng/ml and/or highly invasive growth. Today dopamine agonists, mainly cabergoline (CAB), are the first-line choice in the treatment of these tumors. Objective: To assess the efficacy, safety and long-term follow-up of patients with giant prolactinomas treated with dopamine agonists. Methods: We retrospectively reviewed the clinical records of 20 patients with giant prolactinomas. Mean age at diagnosis was: 45.2 ± 18.9 years, 75% men. The median follow-up time was 9.05 years (1.5-25.1). At diagnosis the median prolactin level was 6,545 ng/ml (3,238-15,325), the mean maximum diameter of the tumors was 4.60 ± 1.35 cm. At diagnosis, headaches were present in 55% and hypogonadism in 85% of patients; 80% had invasive tumors and 75% had visual field (VF) impairment. Since the diagnosis, almost all patients were treated with CAB except 2, one with bromocriptine LAR and the other one with oral bromocriptine, both were switched to CAB afterwards. Results: Seventy percent of patients normalized prolactin levels, this was achieved in a median time of 7.5 months (2-26) and with a mean dose 2.14 ±1.19 mg/week of CAB. Fifty-four percent of patients reached this prolactin nadir in 2-4 months with a maximum dose < 2 mg/week. The median prolactin level in the last visit was 31.23 ng/ml (12-147). Ninety percent of patients decreased prolactin level during follow-up: 50% normalized prolactin, 25% remained with a mild hyperprolactinemia, 25% with significant hyperprolactinemia. Ninety-five percent of tumors reduced their volume, 60% evolved to empty sella, the remaining achieved a mean decrease of 3.75 cm compared to the initial size (82% of average reduction compared to the initial diameter). The VF remained normal in patients in whom it was not affected, except in 1 whose VF deteriorated because of chiasmatic ptosis; in the patients who presented VF involvement: 47% improved, 40% remained unchanged and 13% worsened. The complications during the follow-up were: Cerebrospinal fluid leak in 2 patients, chiasmatic ptosis in 1 with VF impairment, intra-tumoral hemorrhage in 1. In the follow-up only 1 patient required surgery; 4 patients died, 2 because of the tumor. In 3 (15%) patients CAB was stopped at 96-180-264 months after treatment was initiated, but in all of them CAB was reinitiated due to symptomatic hyperprolactinemia. In 16 patients the treatment could never be discontinued. Conclusions: CAB was effective in the treatment of giant prolactinomas reducing tumor size (some of them evolved to empty sella) and prolactin levels in most patients, with low-moderate doses of CAB and very few complications. In our experience of 25 years of follow-up, we have not had any patients without treatment.

[Pituitary adenomas in elderly patients]

Clinical presentation, treatment and its results were evaluated during long-term follow-up of 37 patients older than 65 years with pituitary adenoma. Causes of death were also evaluated. It was a retrospective and cross-sectional study. Prevalence of incidentalomas was 43% (16), macroadenomas 70.3% (26) and giant adenomas 16.2% (6). The most frequent tumor phenotype was the non-functioning adenoma (76%). The prevalence of visual field defects and neurological symptoms was 56% and 57% respectively. We found normal pituitary function in 54%, partial deficiency in 30% and panhypopituitarism in 16%. Thirty-two patients were treated, 5 were lost to follow-up without receiving treatment. Surgery was indicated in 18. Of those operated by trans-sphenoidal approach, 23% had postsurgical complications and 54% improved the visual field. By trans-craneal approach, 50% had post-surgical complications and 33% visual field improvement. During follow-up (55.1 ± 48.7 months) no tumor regrowth was observed, except in a giant adenoma. Four operated patients died, two due to causes related to tumor. Fourteen were not operated, 11 with non-functioning adenoma and normal visual field were periodically controlled and 3 with secreting adenomas received medical treatment. No tumor growth was observed during follow-up (43.7 ± 38.0 months). We did not observe tumor progression in elderly patients with non-functioning adenoma and normal visual field, so we suggest watchful approach and periodic control. When there are visual field defects, trans-sphenoidal surgery can be considered safe and effective. In secreting adenomas and depending on the associated comorbidities, medical treatment would be the appropriate approach.

Primary empty sella (PES): a review of 175 cases

The term primary empty sella (PES) makes reference to the herniation of the subarachnoid space within the sella turcica in patients with no history of pituitary tumor, surgery or radiotherapy. To retrospectively assess clinical features, radiological findings and the biochemical endocrine function from the records of 175 patients with a diagnosis of PES. One hundred seventy-five patients (150 females) were studied. The mean age at diagnosis was 48.2 ± 14 year. Most diagnoses were made by magnetic resonance imaging (n = 172). In most patients, the pituitary function was assessed by basal pituitary hormones measurements. Pituitary scans were ordered for different reasons: headache (33.1 %), endocrine disorders (30.6 %), neurological symptoms (12.5 %), visual disturbances (8.75 %), abnormalities on sella turcica radiograph (8.75 %) and others (6.25 %). Multiple pregnancies were observed in 58.3 % of women; headaches, obesity, and hypertension were found in 59.4, 49.5, and 27.3 % of the studied population, respectively. Mild hyperprolactinemia (<50 ng/ml) was present in 11.6 % of women and 17.3 % of men. Twenty-eight percent of our patients had some degree of hypopituitarism. In the male population, hypopituitarism represented 64 % of cases, whereas it accounted for 22 % of all females. PES seems to be more commonly found in middle-aged women, with a history of multiple pregnancies. In most patients, PES was discovered as an incidental finding on imaging studies, while in almost a quarter of patients PES was found during the diagnostic evaluation of anterior pituitary deficiency, which was more common in men.

Invasive giant prolactinoma with loss of therapeutic response to cabergoline: expression of angiogenic markers

The present study reports the case of a 70-year-old Caucasian man who was referred to the Military Hospital of Buenos Aires for evaluation of a giant sellar-extrasellar mass with extension in the right temporal lobe and compression of the third ventricle. Patient was initially responsive to cabergoline with reduction of prolactin levels and shrinkage of tumor burden for at least 36 months. Thereafter, prolactin levels and tumor size increased even though cabergoline dosage was increased. Transcraneal surgery was performed at 56 months of treatment. Prolactin levels and tumor proliferation did not subside and the patient died 14 months later. High GH and IGF-I levels were observed in the late stages of tumor development, with no evidence of acromegalic features. Immunohistochemistry of the excised tumor revealed strong immunoreactivity for VEGF and FGF-2, two potent angiogenic factors, and CD31 (an endothelial marker) indicating high vascularization of the adenoma.

A novel 1297-1304delGCCTGCCA mutation in the exon 10 of the thyroid hormone receptor beta gene causes resistance to thyroid hormone

INTRODUCTION

Resistance to the thyroid hormone (RTH) is an inherited syndrome of reduced tissue responsiveness to hormonal action caused by mutations located in the ligand-binding domain and adjacent hinge region of the thyroid hormone receptor beta (TRbeta) gene.

PATIENT

The patient in this study, a 42-year-old Caucasian male, came to medical attention because he experienced atrial fibrillation. Clinical evaluation showed a small and diffuse goiter and biochemical tests revealed markedly elevated concentrations of total T4, total T3, and free T4, normal thyroid-stimulating hormone (TSH) values and slightly increased I131 thyroid uptake at 24 hours. The thyroperoxidase, thyroglobulin, and TSH receptor antibodies were positive. He was treated with cabergoline plus methimazole. This treatment was stopped because of the inconsistent response, monotherapy with tri-iodothyroacetic acid (TRIAC) was then prescribed after molecular diagnosis confirmed RTH syndrome.

METHODS

The exons 9 and 10 of the TRbeta gene, including splicing signals and the flanking intronic regions of each intron, were amplified with PCR. DNA sequences from each amplified fragment were performed with the Taq polymerase-based chain terminator method and using the specific TRbeta forward and reverse primers.

RESULTS

Direct sequence analysis of the exons 9 and 10 of the TRbeta gene revealed an eight basepair deletion, 1297-1304delGCCTGCCA in exon 10. The mutation produces a frameshift at amino acid 433 and introduces a stop codon TGA at position 461, 85 nucleotides downstream from deletion. This alteration was not detected in either the father or mother of the patient, suggesting a de novo mutation that was confirmed by DNA fingerprint analysis.

CONCLUSIONS

In the present study we have identified a novel sporadic mutation corresponding to 1297-1304delGCCTGCCA deletion in the activating function 2 (AF-2) region of TRbeta. To our knowledge, this is the first time that the presence of a partial deletion of eight nucleotides in the TRbeta has been reported.