Unilateral Adrenalectomy for Primary Bilateral Macronodular Adrenal Hyperplasia: Analysis of 71 Cases

Objective Primary bilateral macronodular adrenal hyperplasia (PBMAH) is characterized by benign bilateral enlarged adrenal masses, causing Cushing’s syndrome (CS). The aim of the current article is to define the role of unilateral adrenalectomy (UA) in treating patients with CS related to PBMAH.

Methods A PubMed database search was conducted to identify articles reporting UA to treat PBMAH. We also report cases of PBMAH from our medical center treated by UA.

Results A total number of 71 cases of PBMAH (62 cases reported in the literature and 9 cases from our center) are presented. Most patients were women (73.2%) and most UA involved the left side (64.3%). In most cases, the resected gland was the larger one. Following UA, 94.4% of cases had remission of hypercortisolism. Recurrence rate of CS was 19.4% and hypoadrenalism occurred in 29.6%. After UA, when the size of the remained adrenal gland was equal or greater than 3.5 cm, CS persisted in 21.4% of cases, and recurrence occurred in 27.3% of cases (after 20±9.2 months). However, when the size of the remained gland was less than 3.5 cm, CS resolved in all cases and recurrence occurred in 21.2% of cases after a long period (65.6±52.1 months). High levels of urinary free cortisol (UFC) were not correlated with post-surgical CS recurrence or persistence.

Conclusions UA leads to beneficial outcomes in patients with CS related to PBMAH, also in cases with pre-surgical elevated UFC or contralateral large gland.

Role of cytological and ultrasonographic features in predicting the risk of malignancy in thyroid nodules with indeterminate cytology

AIM

The aim of this paper was to examine the diagnostic value of several cytological and ultrasonographic features in predicting malignancy in thyroid follicular neoplasms.

METHODS

The sample of the study consisted of 145 patients, who have had the diagnosis of follicular neoplasm on US guided fine-needle aspiration (FNA), and had undergone thyroidectomy. The cytological slides and the ultrasonographic images were reviewed, and several ultrasonographic and cytological features were evaluated and correlated with final histology.

RESULTS

Histological diagnosis of malignancy was obtained in 14.5% of the patients, papillary carcinoma being the most frequent (66% of malignancies). The cytological and ultrasonographic features that have been associated with malignancy were: micro-fragments (P<0.00001), overlapping (P<0.005), hypercellularity (P<0.009), micronucleoli (P<0.013), atypical features (P<0.027), nodule size larger than 2 cm (P<0.029) and micro-calcifications (P<0.0002). Using the features that were statistically independent ones, which included two cytological features: micro-fragments and micronuclei, and one ultrasonographic feature: micro-calcifications, a statistical model for predicting malignancy was constructed. According to this model, it was found that the risk for malignancy is 2.65% in the absence of the three parameters, and amounts to 93.93% in the presence of all three of them.

CONCLUSION

In a thyroid follicular neoplasm, the cytological and ultrasonographic features that were associated with malignancy were: micro-fragments, overlapping, hypercellularity, micronucleoli, atypical features, nodule size larger than 2 cm and micro-calcifications. In an attempt to predict malignancy, we proposed a simple statistical model using only three features derived from cytological and ultrasonographic tests.

Adrenalectomy for adrenocortical adenoma causing Cushing's syndrome in pregnancy: a case report and review of literature

We present a case of adrenocorticotropic hormone (ACTH)-independent Cushing's syndrome diagnosed in a patient in the third trimester of her pregnancy, with an adrenal mass observed on imaging studies. Laparoscopic adrenalectomy was performed successfully at 32 weeks. To the best of our knowledge, this is the latest gestational age at which laparoscopic adrenalectomy has been reported. We present the various considerations for determining the surgical approach and the optimal timing for surgery. Adrenalectomy during pregnancy for the treatment of Cushing's syndrome caused by adrenocortical adenoma has been reported in 23 patients in the English-language medical literature to date and seems safe and beneficial. According to the data, surgical treatment has led to a reduction in perinatal mortality and maternal morbidity rates, but has not affected the occurrence of preterm birth and intrauterine growth restriction. The best outcome can be achieved by a multidisciplinary approach, with a team comprising a maternal-fetal medicine specialist, an endocrinologist and a surgeon. The timing of surgery and the surgical approach need to be determined according to the surgeon's expertise, the severity of the condition, the patient's preferences, and gestational age. Laparoscopy may prove to be the preferred surgical approach. The small number of cases precludes providing evidence-based recommendations.

[Summary of the Israeli Endocrine Society's consensus statement on the diagnosis, treatment and follow-up of well-differentiated thyroid cancer]

Well differentiated epithelial cell thyroid cancer is not classified amongst the most aggressive diseases. Notwithstanding, it can potentially both impair quality of life and affect life expectancy. Appropriate treatment has been shown to be crucial in obtaining optimal outcomes on the course of the disease. Successful treatment rests upon strict adherence to confirmed principles of diagnosis, treatment and follow-up. The aim of the position paper is to present the Israeli medical community with a set of commonly accepted principles for the diagnosis, treatment and follow-up of patients with well differentiated epithelial thyroid cancer and in addition to highlight areas of legitimate differences in approach where those differences occur. We have attempted to provide a link between the various medical disciplines involved in care of these patients: family physicians, surgeons, nuclear medicine specialists, oncologists, pathologists, radiologists and endocrinologists; and have attempted to decrease to a minimum areas of uncertainty and to offer a common approach for the best possible care of thyroid cancer patients in Israel. In addition, we find it our duty to point out those areas and resources which, in our opinion, need to be upgraded in Israel and even included in the Israeli official "health basket".

Low-dose and high-dose adrenocorticotropin testing: indications and shortcomings

PURPOSE OF REVIEW

The 250 microg adrenocorticotropin test (high-dose test) is the most commonly used adrenal stimulation test, though the use of physiologic doses (1.0 microg or 0.5 microg/1.73 m) (low-dose test) has recently gained wider acceptance. These variants and the use of adrenocorticotropin test in the ICU, however, remain controversial. The validity of the low-dose test and the parameters for evaluation of high- and low-dose tests in different situations need reevaluation.

RECENT FINDINGS

In the last few years, numerous studies have used the low-dose test as a single test following previous findings that it is more sensitive and accurate than the high-dose test. It is used mainly in secondary adrenal insufficiency and after treatment with therapeutic glucocorticosteroids to define hypothalamo-pituitary-adrenal suppression. Unless there is a very recent onset of disease, the results are interpreted by most researchers as diagnostic. The treatment of relative adrenal insufficiency, based on delta cortisol, has not yielded proof of correlation between this diagnosis and better prognosis with glucocorticoid treatment.

SUMMARY

For interpretation of an adrenocorticotropin test, only peak - and not delta - cortisol should be used. The use of 240-300 mg of hydrocortisone daily in ICU patients, including septic shock, should be considered as pharmacologic, rather than as a replacement dose. Using the low-dose test for this purpose will lead to further misdiagnosis.

Hepatosplenic gamma/delta T-cell lymphoma masquerading as alcoholic hepatitis and methadone withdrawal

Hepatosplenic gamma/delta T-cell lymphoma is a rare neoplasm of mature gamma/delta T-cells with sinusoidal infiltration of spleen, liver, and bone marrow. Patients are predominantly adolescent and young adult males and usually present with marked hepatosplenomegaly. Pancytopenia is another common finding. Despite an initial response to treatment, patients have a median survival of one to two years. In this report, we document a case of alcoholic hepatitis and methadone withdrawal masquerading unsuspected, hepatosplenic gamma/delta T-cell lymphoma with unusual CD20 positivity.

[Does hypothyroidism contribute to the etiology of primary open angle glaucoma or is it just a coincidence?]

In a prospective study 83 consecutive patients with progressive primary open angle glaucoma (research group) and 62 patients scheduled for cataract surgery (control group), were evaluated for the presence of hypothyroidism by history, blood levels of TSH and free T4 when necessary. In the research group, nine patients (10.8%) had hypothyroidism, 6 of them already known. In group 2 only one patient (1.6%) had known hypothyroidism, this difference was statistically significant (p < 0.005). The association between primary open glaucoma and hypothyroidism is discussed.

The assessment of the hypothalamo-pituitary-adrenal axis in pituitary disease: are there short cuts?

The main task of the hypothalamo-pituitary-adrenal (HPA) axis is to enable sufficient cortisol release under regular and stressful situations. Therefore, to prove its being intact in pituitary disease, stimulation tests are usually needed. Cortisol level has to be shown to exceed a threshold level, which has to be defined on normal subjects in each lab, as results may differ greatly. Insulin tolerance test (ITT) is considered the "gold standard". Hypoglycemia induces a severe stress, which stimulates the HPA axis maximally. However, for regularly accepted cut-off points (18-20 microg/dl, 500-550 nmol/l), false positive results are documented, even in normal volunteers, and reproducibility is far from perfect. The metyrapone test, by blocking cortisol production, stimulates ACTH release to overcome the blockade. In this test 11-DOC levels are usually measured, and a cut-off point of 7.0 microg/dl (200 nmol/l) used. Measuring ACTH and/or cortisol + 11-DOC levels may improve the test, both in reasoning and reliability. The CRH test yields unsatisfactory results, and its use is usually saved for differential diagnosis of hypercortisolism. The ACTH test is the easiest to perform, and usually used as a screening test. Abnormal responses should be considered diagnostic, while normal responses, especially in newly onset or recent pituitary disease, should be followed by either ITT or metyrapone test. Most studies show superiority of the 1.0 microg (so called "low dose") ACTH test over the high dose (250 microg) test. The physiologic dose test should replace the pharmacologic dose test whenever ACTH test is considered. In every test there are limitations and pitfalls. Knowing them, and using best clinical judgment, will reduce and minimalize mistakes.

Classic and Recent Etiologies of Cushing??s Syndrome

Endogenous Cushing's syndrome can result from excess adrenocorticotropic hormone (ACTH; corticotropin) production by a pituitary adenoma (Cushing's disease) or by ectopic tumors secreting ACTH or corticotro- pin-releasing hormone (CRH). ACTH-independent Cushing's syndrome is caused by adrenocortical tumors or hyperplasias. Initial diagnosis is performed using 24-hour urinary free cortisol, low-dose dexamethasone tests, salivary cortisol, or night-time plasma cortisol values. A dexamethasone CRH test can discriminate between Cushing's syndrome and pseudo-Cushing's syndrome. If ACTH is elevated, combinations of high-dose dexamethasone tests, CRH/desmopressin tests, and pituitary magnetic resonance imaging can indicate a pituitary source. Discrimination from an ectopic ACTH tumor often requires inferior petrosal sinus sampling to confirm the ACTH source. If ACTH is low, adrenal computed tomography scan will identify the adrenal lesion(s) implicated. Some cortisol-producing adrenal tumors or, more frequently, bilateral macronodular hyperplasias, are under the control of aberrant membrane hormone receptors, or altered activity of eutopic receptors. The initial therapy of choice for patients with Cushing's disease is the selective transsphenoidal removal of the corticotroph adenoma; this induces remission in approximately 80% of patients, but long-term relapse occurs in up to 30% of these cases. The choice of second-line therapy remains controversial. Repeat surgery can be successful when residual tumor is detectable on magnetic resonance imaging, but carries a high risk of hypopituitarism. Bilateral adrenalectomy may be a better choice in patients without visible residual tumors, particularly in women desiring fertility. Radiotherapy combined with ketoconazole or radiosurgery was recently found effective, but longer-term evaluation of hypopituitarism and brain function is required. Current studies do not support the systematic use of prophylactic radiotherapy after bilateral adrenalectomy to decrease the risk of Nelson's syndrome; however, as soon as the residual tumor progresses, surgery and radiotherapy should be initiated. Various drugs which inhibit steroid synthesis (ketoconazole, metyrapone, aminoglutethimide, mitotane) are often effective for rapidly controlling hypercortisolism either in preparation for surgery, after unsuccessful removal of the etiologic tumor, or while awaiting the full effect of radiotherapy or more definitive therapy. Surgery is usually the treatment of choice for removal of cortisol-secreting adrenal tumors or ectopic ACTH/CRH-secreting tumors. The identification of aberrant adrenal receptors has recently allowed normalization of cortisol secretion by specific ligand receptor antagonists in limited cases of Cushing's syndrome secondary to bilateral macronodular adrenal hyperplasia. The long-term follow-up of patients treated for Cushing's syndrome should include the adequate replacement of glucocorticoids and other hormones, treatment of osteoporosis, and detection of long-term relapse of Cushing's syndrome.

False positive metaiodobenzylguanidine scan in a patient with a huge adrenocortical carcinoma

We report a case of a 17-cm cortisol-secreting adrenocortical carcinoma in which [123I] metaiodobenzylguanidine (MIBG) scan showed accumulation of the isotope in the area of the tumor. Catecholamine levels were normal, and no chromaffin cells were found in histological examination of the tumor. A literature review of previously described cases of false positive MIBG scans in the adrenal region is offered. We conclude that MIBG scans might not be as specific as previously thought in differentiating pheochromocytoma from adrenocortical carcinoma. They should be performed only when clinical suspicion and abnormalities in catecholamines advocate the need.

A prospective trial of colchicine and methotrexate in the treatment of primary biliary cirrhosis

BACKGROUND & AIMS

The aim of this study was to determine if colchicine or methotrexate improves blood test results, symptoms, and/or liver histology in patients with primary biliary cirrhosis.

METHODS

Patients with histologically confirmed primary biliary cirrhosis whose serum alkaline phosphatase (ALP) levels were at least 2 times above normal and who were not yet candidates for liver transplantation received colchicine or methotrexate and were followed up for 2 years.

RESULTS

In patients receiving colchicine (n = 43), mean pruritus score decreased from 1.63 to 1.12 (P = 0.04), ALP level from 494 to 355 U/L (P < 0.0001), and alanine aminotransferase (ALT) level from 79 to 61 U/L (P < 0.0001). In patients receiving methotrexate (n = 42), pruritus score decreased from 1.25 to 0.44 (P = 0.0001), ALP from 478 to 235 U/L (P < 0.0001), and ALT from 96 to 61 U/L (P = 0.0001). Methotrexate but not colchicine significantly improved liver histology (P = 0.005) and serum immunoglobulin G levels (P = 0.0002). Methotrexate improved most blood test results more than colchicine. Serum bilirubin levels increased slightly with each drug, and albumin levels decreased slightly.

CONCLUSIONS

Both colchicine and methotrexate improved biochemical test results and symptoms in primary biliary cirrhosis, but the response to methotrexate was greater.

Is there a role for low doses of mitotane (o,p'-DDD) as adjuvant therapy in adrenocortical carcinoma?

Four patients suffering from adrenocortical carcinoma were treated with low doses (1.5-2.0 g) of mitotane (o,p'-DDD) for the complete follow-up time following surgery (21-68 months). Treatment with mitotane was started shortly after surgical removal of the tumor (three patients) or the tumor and multiple lung metastasis (one patient). No significant side effects or complications from the medication were noted. Two patients remain disease free after 57 and 21 months on treatment. A third patient died of an unrelated reason (varicose vein bleeding) after 68 months on mitotane without evidence of tumor recurrence or metastasis. In the fourth patient, two lung metastasis were successfully removed after 48 months of follow-up. The patient is doing well and is disease free 6 months later. Though our series is too small to draw final conclusions, we suggest that low doses of mitotane, which are well tolerated, might offer prolonged disease-free survival in adrenocortical carcinoma. To be beneficial treatment has to be started early after surgical removal of the tumor and metastasis, and be continued for long periods of time.

Pituitary mass and inflammatory pseudotumours of lung and peritoneum

Images

Late complications in remission from Cushing disease. Recurrence of tumor with reinfarction or transformation into a silent adenoma

Two of 4 patients who underwent spontaneous remission from Cushing disease (CD) demonstrated regrowth of the pituitary adenoma 2 and 5 years later. In the first patient, the recurrent tumor also secreted corticotropin, with subsequent relapse of fulminant cushingoid features. However, after 14 more months, it again became infarcted, and the patient underwent complete clinical remission, which has persisted for about 3 years. In the second patient, the regrowth of the tumor occurred silently, as no clinical cushingoid features or rise in cortisol levels were noticed. Because of its size, the tumor was resected and found to have immunoreactivity for corticotropin (silent corticotroph adenoma). About 4 years after the first operation, a second surgical procedure was performed because of massive regrowth of the tumor. Again, there was no concomitant elevation of cortisol levels or endocrinologic symptoms. This time, the tumor did not even stain for corticotropin. While spontaneous remission in CD is rare, recurrence is even rarer. Reremission of CD and the change from a corticotropin-secreting adenoma to a silent one are described herein for the first time (to our knowledge). These cases demonstrate that patients with CD have to receive careful follow-up, even if they undergo remission, and that the long-term outcome of such remission is unpredictable.

One microgram is the lowest ACTH dose to cause a maximal cortisol response. There is no diurnal variation of cortisol response to submaximal ACTH stimulation

There are many suggestions in the literature that the adrenal gland is more sensitive to ACTH in the evening than in the morning. However, all these studies in humans were conducted when the basal cortisol level was not suppressed, and were based on the observation that, after stimulation, the increases in cortisol differed, though the peak values were the same. To examine this, we established the lowest ACTH dose that caused a maximal cortisol stimulation even when the basal cortisol was suppressed, and used a smaller dose of ACTH for morning and evening stimulation. The lowest ACTH dose to achieve maximal stimulation was found to be 1.0 microgram, with which dose cortisol concentration increased to 607.2 +/- 182 nmol/l, compared with 612.7 +/- 140.8 nmol/l with the 250 micrograms test (P > 0.3). The use of smaller doses of ACTH (0.8 and 0.6 microgram) achieved significantly lower cortisol responses (312 +/- 179.4 and 323 +/- 157.3 nmol/l respectively; both P < 0.01 compared with the 1 microgram test). When a submaximal ACTH dose (0.6 microgram) was used to stimulate the adrenal at 0800 and 1600 h, after pretreatment with dexamethasone, no difference in response was noted at either 15 min (372.6 +/- 116 compared with 394.7 +/- 129.7 nmol/l) or 30 min (397.4 +/- 176.6 compared with 403 +/- 226.3 nmol/l; P > 0.3 for both times). These results show that 1.0 microgram ACTH, used latterly as a low-dose test, is very potent in stimulating the adrenal, even when baseline cortisol is suppressed; smaller doses cause reduction of this potency. Our data show that there is probably no diurnal variation in the response of the adrenal to ACTH, if one eliminates the influence of the basal cortisol level and uses physiologic rather than superphysiologic stimuli.

Lithium treatment in amiodarone-induced thyrotoxicosis

PURPOSE

Amiodarone hydrochloride is an iodine-rich drug effective in the control of various tachyarrhythmias. It is known to cause refractory to thyrotoxicosis, which usually does not respond to regular antithyroid drugs. Lithium bicarbonate is a medication used to treat psychiatric disorders; it also influences thyroid production and release of hormones. We tried it in combination with propylthiouracil (PTU) for the treatment of amiodarone-induced thyrotoxicosis.

PATIENTS AND METHODS

Twenty-one patients were studied. The first group (n = 5) was treated by amiodarone withdrawal only. The second group (n = 7) received PTU (300 to 600 mg), and the third (n = 9) PTU (300 mg) and lithium (900 to 1350 mg) daily. Patient selection was not randomized. The PTU + lithium group had more severe symptoms and signs of thyrotoxicosis, as well as thyroxine levels at least 50% above the upper limit of normal. They also had been on a longer course of amiodarone treatment (34.3 +/- 11.9 months) than the PTU-only (11.4 +/- 7.5) and the no-treatment (7.8 +/- 4.2) groups.

RESULTS

While there was no difference between the first two groups in time until recovery (10.6 +/- 4.0 versus 11.6 +/- 0.5 weeks, respectively), the group receiving lithium normalized their thyroid function tests in only 4.3 +/- 0.5 weeks (P < 0.01 versus both other groups). T3 levels normalized even earlier-by 3 weeks of lithium treatment. No adverse effects of lithium were encountered, and the medication was stopped 4 to 6 weeks after achieving a normal clinical and biochemical state.

CONCLUSIONS

We conclude that lithium is a useful and safe medication for treatment of iodine-induced thyrotoxicosis caused by amiodarone. We would reserve this treatment for severe cases only. Further studies are needed to find out whether in patients with this troublesome complication lithium therapy could permit continuation of amiodarone treatment.

Plasma corticotropin and cortisol responses to ovine corticotropin-releasing hormone (CRH), arginine vasopressin (AVP), CRH plus AVP, and CRH plus metyrapone in patients with Cushing's disease

The CRH test may sometimes be useful in the differential diagnosis of Cushing's syndrome, because most patients with pituitary ACTH-dependent Cushing's syndrome (Cushing's disease) respond to CRH, but those with other causes of Cushing's syndrome usually do not. However, about 10% of Cushing's disease patients fail to respond to CRH. We wondered if we could eliminate these false negative results either by exploiting the potential additive or synergistic effects of another ACTH secretagogue or by reducing glucocorticoid inhibition of CRH's ACTH-releasing effect. We compared the effect on plasma ACTH and cortisol in 51 patients with Cushing's disease of administering ovine CRH (1 microgram/kg BW, i.v.) alone, arginine vasopressin (AVP; 10 U, i.m.) alone, the combination of CRH and AVP, and CRH after pretreatment with metyrapone (1 g, orally, every 4 h for three doses; CRH + MET). The rates of nonresponse (ACTH increment, < 35%; cortisol increment, < 20%) to AVP and CRH alone were 26% and 8%, respectively; all patients responded to CRH + AVP. The lack of response was not due to improper administration or rapid metabolism of the agonist, because plasma CRH and AVP concentrations were similar in responders and nonresponders. A synergistic ACTH response to CRH + AVP occurred in 65% of the patients. MET pretreatment increased basal plasma ACTH levels in most patients and induced the greatest mean peak ACTH response to CRH, but 8% of the patients did not respond to CRH + MET with an ACTH increment of 35% or more. Because all of the Cushing's disease patients tested in this study responded to the combination of CRH + AVP, whereas 8% failed to respond to CRH alone, we conclude that CRH + AVP administration may provide a more reliable test for the differential diagnosis of ACTH-dependent Cushing's syndrome than administration of CRH alone. Whether this improved sensitivity is accompanied by unaltered specificity for Cushing's disease must be tested in patients with chronic ectopic ACTH syndrome.

Low-dose adrenocorticotropin test reveals impaired adrenal function in patients taking inhaled corticosteroids

The aim of the present study was to examine the use of low-dose ACTH-(1-24) stimulation for assessment of adrenal function and the detection of mild adrenal insufficiency. The criteria for normal response to ACTH-(1-24) are a peak cortisol level of more than 500 nmol/L (18.1 micrograms/dL) and an increment of the cortisol level above the basal one of more than 200 nmol/L (7.2 micrograms/dL). These criteria were satisfied by 32 of 33 healthy children and adults subjected to an ACTH-(1-24) dose 500 times lower (0.5 micrograms/1.73 m2) than the dose of 250 micrograms in the standard test. At 20 min, the peak cortisol level was the same in the low-dose test [(621 +/- 28 nmol/L) (22.5 +/- 1.0 microgram/dL)] as in the standard ACTH test [(654 +/- 31 nmol/L) (23.7 +/- 1.1 microgram/dL)]. Of 46 asthmatic patients who had been treated with inhaled beclomethasone dipropionate (482 +/- 42 micrograms/m2 daily; n = 32) or budesonide (507 +/- 62 micrograms/m2 daily; n = 14) for over 6 months, 16 (35%) failed to reach a cortisol peak of more than 500 nmol/L (18.1 micrograms/dL) following stimulation with 0.5 micrograms ACTH-(1-24)/1.73 m2. Of these, 11 (24%) showed a cortisol increment of less than 200 nmol/L (7.2 micrograms/dL). These 16 patients, showing insufficient response to low-dose ACTH-(1-24), also had a significantly lower (P < 0.01) mean 24-h urinary free cortisol excretion [(71 +/- 10 nmol/m2.24 h) (25.7 +/- 3.6 micrograms/m2.24 h)] than patients who responded normally [(118 +/- 11 nmol/m2.24 h) (42.8 +/- 4.0 micrograms/m2.24 h). Nonetheless, all but one of the poor responders to a 0.5 microgram ACTH showed normal stimulation with the standard 250 micrograms ACTH test. Therefore, it appears that a low-dose ACTH test is capable of revealing mild adrenal insufficiency, which is not detected by the standard high-dose ACTH test.

Toxic Graves' disease with thyroid hemiagenesis: diagnosis using thyroid-stimulating immunoglobulin measurements

Two patients with hemiagenesis of the thyroid gland experienced thyrotoxicosis. They constituted 1.1% of our clinic's total population of 178 thyrotoxic patients treated in the years 1986-1990 and 1.7% of 120 patients with thyrotoxic Graves' disease encountered during that period. The diagnosis was made on the basis of unilateral homogeneous 99mTcO4 uptake on thyroid scan, no change in the scan after both cessation of propylthiouracil (PTU) treatment for 4 days and TSH stimulation test, and high thyroid-stimulating immunoglobulin (TSI) levels. Both patients went into remission after PTU treatment, and TSI levels returned to normal. The diagnosis of toxic Graves' disease with thyroid hemiagenesis was, therefore, made. This combination is rare but important to recognize because treatment as well as prognosis might be different from that of toxic adenoma.

Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test

Adrenal response to iv administration of 1-24 ACTH (250 micrograms) was examined in normal volunteers under various conditions. The effect of basal cortisol levels was examined by performing the tests at 0800 h with and without pretreatment with dexamethasone. The effect of time of day was evaluated by performing the tests at 0800 h and at 1600 h, eliminating possible basal cortisol influence by pretreatment with dexamethasone. In the first set of tests, despite significantly different baseline levels, 30-min cortisol levels were not different (618 +/- 50 vs. 590 +/- 52 nmol/L). Afternoon cortisol levels in response to ACTH were found to be significantly higher than morning levels at 5 min (254 +/- 50 vs. 144 +/- 36 nmol/L, p less than 0.01) and at 15 min (541 +/- 61 vs. 433 +/- 52 nmol/L, p less than 0.02). This difference in response was no longer notable at 30 min (629 +/- 52 and 591 +/- 52 nmol/L). We tried also to determine the lowest ACTH dose which will elicit a maximal cortisol response. No difference was found in cortisol levels at 30 and 60 min in response to 250 and 5 micrograms 1-24 ACTH. Using 1 micrograms ACTH, the 30-min response did not differ from that to 250 micrograms (704 +/- 72 vs. 718 +/- 55 nmol/L, respectively). However, the 60-min response to 1 microgram was significantly lower (549 +/- 61 vs. 842 +/- 110 nmol/L, p less than 0.01). Using this low dose ACTH test (1 microgram, measuring 30-min cortisol level), we were able to develop a much more sensitive ACTH test, which enabled us to differentiate a subgroup of patients on long-term steroid treatment who responded normally to the regular 250 micrograms test, but had a reduced response to 1 microgram. The stability of 1-24 ACTH in saline solution, kept at 4 C, was checked. ACTH was found to be fully stable after 2 hs in a concentration of 5 micrograms/ml in glass tube and 0.5 micrograms/ml in plastic tube. It was also found to be fully stable, both immunologically and biologically, for 4 months, under these conditions. We conclude that the 30-min cortisol response to ACTH is constant, unrelated to basal cortisol level or time of day. It is therefore the best criterion for measuring adrenal response in the short ACTH test. The higher afternoon responses at 5 and 15 min suggest greater adrenal sensitivity in the afternoon, but further studies are needed to clarify this issue.(ABSTRACT TRUNCATED AT 400 WORDS)

Factors predicting the outcome of varicocele repair for subfertility: the value of the luteinizing hormone-releasing hormone test

The mechanism by which varicocele caused infertility is not yet clear. Endocrine factors have been suggested to explain impaired spermatogenesis in patients with varicocele. We conducted a prospective study on testosterone and gonadotropin levels and their response to the luteinizing hormone-releasing hormone test to determine the possible role of a hormonal defect in subfertility. Luteinizing hormone-releasing hormone tests were performed on 11 subfertile men with varicocele preoperatively and 3 months postoperatively. The differences in the luteinizing hormone response were statistically significant. The maximal luteinizing hormone levels also were significantly lower in patients whose spermiogram changed postoperatively. No significant changes were noted in testosterone and other gonadotropin levels postoperatively. A prognostic correlation between the change in response of luteinizing hormone to luteinizing hormone-releasing hormone (preoperatively and postoperatively) and improvement in fertility (pregnancy success) was found. We suggest that the luteinizing hormone-releasing hormone test should be considered to estimate the hormonal derangement and also the prognosis of an operation in subfertile men with varicocele.

Inflammatory bowel disease: specific concerns in the elderly

Despite recent improvements in our knowledge concerning IBD in the elderly, much is still unknown. Fundamental issues which remain unresolved are: the true frequency of disease onset in old age; the natural history and location of disease; the response of these patients to medical therapy; the indications for surgery; the incidence of postoperative recurrence; and the incidence of cancer complicating existing disease. Nevertheless, reasonably successful treatment options are available to many elderly IBD patients, given that an alert and careful diagnostician identifies the problem.

Single-dose metyrapone test at 06.00 h: an accurate method for assessment of pituitary-adrenal reserve

One dose of metyrapone (1.5g) administered at 06.00 h, with subsequent measurement of 11-deoxycortisol and 17-hydroxycorticosteroid (17-OHCS) levels in plasma at 12.00 and 14.00 h, allowed accurate assessment of the pituitary-adrenal reserve. Normal response was defined as achieving a serum 17-OHCS level of more than 10.0 micrograms/100 ml and a 11-deoxycortisol level of more than 6.0 micrograms/100 ml at either 12.00 or 14.00 h. These criteria are based on a group of 18 persons with normal pituitary-adrenal axis, and 86 additional cases responded in this normal range. In this group of 104 subjects, 11-deoxycortisol levels rose to 9.2 +/- 3.5 micrograms/100 ml at noon and 17-OHCS levels to 15.4 +/- 4.7 micrograms/100 ml at 14.00 h. Post-metyrapone 17-OHCS levels were significantly higher than normal cortisol levels at these times (P less than 0.001) and than those observed at 08.00 h on the day of the test, demonstrating stimulation of adrenal corticoid production in addition to blockade of cortisol production by metyrapone. Thirty-one patients found to suffer from secondary adrenal failure showed impaired response. All these patients had limited pituitary-adrenal reserve, either proven by other pituitary-adrenal tests or implicated by severe pituitary disease.

Primary therapy for Cushing's disease with metyrapone

A 13-year-old boy was diagnosed as suffering from pituitary-dependent Cushing's syndrome. He was treated with 2.0 g of metyrapone daily as the sole treatment for four years. All clinical and biochemical stigmata of Cushing's disease disappeared within a few months. The patient grew 23.0 cm in four years and regained normal health. No significant side effects of metyrapone were noticed. Administering the medication at 2 PM and 8 PM allowed higher cortisol levels in the morning and noon hours than in the evening and night, approximating the normal diurnal variation in cortisol production. We conclude that metyrapone may be considered the sole treatment in patients with Cushing's disease.

Thyrotoxicosis induced by amiodarone, a new efficient antiarrhythmic drug with high iodine content

Amiodarone is an antiarrhythmic agent with high iodine content. Ten patients treated with amiodarone developed thyrotoxicosis. I131 uptakes were negligible, and TT3 levels low in relation to TT4 levels, and sometimes even normal. Cessation of amiodarone caused thyroid functions to return to normal in one to five months, unrelated to propylthiouracil treatment. Eight of the patients had normal thyroid glands on radioscan or palpation. All patients tested had normal TRH tests. Thyrotoxicosis is a relatively common complication of amiodarone treatment, probably caused by its high iodine content. It is possible in apparently normal thyroid glands, suggesting failure of the homeostatic mechanisms controlling thyroid synthesis and release in these patients. Amiodarone is very efficient in controlling tachyarrhythmias and angina pectoris, situations in which thyrotoxicosis is dangerous. Thyroid function tests should therefore be drawn periodically, and the complication considered whenever tachyarrhythmias worsen on treatment with amiodarone.

Hypothyroidism secondary to biologically inactive thyroid-stimulating hormone secretion by a pituitary chromophobe adenoma: recovery after removal of the tumor

A 50-year-old man, suffering from a large pituitary adenoma and panhypopituitarism, was found to have severely elevated thyrotrophin (thyroid-stimulating hormone [TSH]) levels (greater than 20.2 microunits/mL). The thyroxine (T4) level was low (less than 3.0 micrograms/dL). Thyroid sodium iodide I 131 uptake was low (5% at 24 hours). A TSH test result was normal, with a 24-hour 131I uptake of 52% and a normal-looking thyroid gland on scintiscan. After surgical removal of the pituitary chromphobe adenoma, T4 levels returned to normal (6.8 micrograms/dL) and TSH levels improved substantially (9.0 microunits/mL). Findings from repeated 131I uptake tests were normal (22% at 24 hours). Other pituitary functions improved also. These results suggest that the patient had biologically inactive TSH produced by the tumor. Removal of the tumor probably enabled recovery of the active TSH with the return of normal thyroid uptake and T4 production. Whenever hypothyroidism and high levels of TSH coexist with pituitary dysfunction, a TSH test is needed to distinguish between primary hypothyroidism and hypothyroidism secondary to biologic inactive TSH.

Induction of spermatogenesis in isolated hypogonadotropic hypogonadism with exogenous human chorionic gonadotropin

A 21-year old male patient with isolated hypogonadotropic hypogonadism (IGD) is described. Basal serum levels of testosterone (0.5 ng/ml), FSH (2.1 mIU/ml) and LH (2.3 mIU/ml) were low and did not respond to administration of clomiphene citrate. The FSH and LH responses to LHRH were normal. Pituitary-thyroid and pituitary-adrenal function as well as GH reserve were also normal. However, prolactin (PRL) response to both TRH and metoclopramide were blunted compared with normal male subjects. The patient was treated with human chorionic gonadotropin (HCG). Within 20 months he developed full testicular maturation with spermatogenesis and full androgenization. Serum testosterone levels rose to 6.5-13.5 ng/ml. Both basal serum PRL levels and the response to TRH and metoclopramide became normal. Spermatogenesis and androgenization proceeded in the absence of FSH. These results suggest further trials of treatment with HCG alone in patients with IGD are warranted.

Bromocriptine-induced pregnancy in an acromegalic patient

A 30-year-old acromegalic woman with amenorrhea and elevated growth hormone and prolactin levels was treated with bromocriptine. Growth hormone levels remained elevated, while prolactin levels decreased to normal. Forty days after initiating treatment the patient menstruated and conceived shortly afterward. The uneventful pregnancy terminated in delivery of a normal baby, who has been developing normally since. No changes in the size of the sella turcica or the visual field were noted during pregnancy and up to one year after delivery. Resumption of ovulatory menses is possible when treating acromegalic women with bromocriptine. Hyperprolactinemia rather than elevated growth hormone levels or reduced gonadotropins reserve is probably the cause for amenorrhea in some of the acromegalic patients.

Improved single-dose metyrapone test

One dose of metyrapone (1.5 g) administered at 6 AM, with subsequent measurement of plasma ACTH, 11-deoxycortisol, or 17-hydroxycorticosteroids (17-OHCS) (cortisol + 11-deoxycortisol) at noon and 2 PM allowed an accurate assessment of the pituitary-adrenal reserve. Eighteen subjects with a normal pituitary-adrenal reserve were studied before and after the administration of this single metyrapone dose. By noon, plasma ACTH rose from a premedication value of 39 +/- 22 (SD) to 193 +/- 104 pg/ml and 11-deoxycortisol, from 0.0 +/- 0.3 (SD) to 9.0 +/- 2.7 microgram/dl. By 2 PM, plasma 17-OHCS had increased from a premedication value of 5.0 +/- 1.5 (SD) to 16.0 +/- 1.8 microgram/dl. The differences between pre- and postmedication values were statistically significant for all indices measured (P less than 0.001). No overlap was found between values before and after metyrapone. This protocol eliminates the need for metyrapone administration every 4 h over a 24-h period. It offers the advantage of low dose and low toxicity. The integrity of the pituitary-adrenal axis can be demonstrated by measuring either plasma ACTH and 11-deoxycortisol or even 17-OHCS 6 to 8 h after the administration of this single metyrapone dose.