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Desgagnés N, Senior L, Vis D, Alikhani K, Lithgow K. Emergence of De Novo Conditions Following Remission of Cushing Syndrome: A Case Report and Scoping Review. Endocrinol Diabetes Metab 2024; 7:e00476. [PMID: 38597588 PMCID: PMC11005458 DOI: 10.1002/edm2.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVE Onset and exacerbation of autoimmune, inflammatory or steroid-responsive conditions have been reported following the remission of Cushing syndrome, leading to challenges in distinguishing a new condition versus expected symptomatology following remission. We describe a case of a 42-year-old man presenting with new-onset sarcoidosis diagnosed 12 months following the surgical cure of Cushing syndrome and synthesise existing literature reporting on de novo conditions presenting after Cushing syndrome remission. METHODS A scoping review was conducted in Medline, Epub, Ovid and PubMed. Case reports and case series detailing adult patients presenting with new-onset conditions following Cushing syndrome remission were included. RESULTS In total, 1641 articles were screened, 138 full-text studies were assessed for eligibility, and 43 studies were included, of which 84 cases (including our case) were identified. Most patients were female (85.7%), and the median reported age was 39.5 years old (IQR = 13). Thyroid diseases were the most commonly reported conditions (48.8%), followed by sarcoidosis (15.5%). Psoriasis, lymphocytic hypophysitis, idiopathic intracranial hypertension, multiple sclerosis, rheumatoid arthritis, lupus and seronegative arthritis were reported in more than one case. The median duration between Cushing remission and de novo condition diagnosis was 4.1 months (IQR = 3.75). Of those patients, 59.5% were receiving corticosteroid therapy at the time of onset. CONCLUSION Our scoping review identified several cases of de novo conditions emerging following the remission of Cushing syndrome. They occurred mostly in women and within the year following remission. Clinicians should remain aware that new symptoms, particularly in the first year following the treatment of Cushing syndrome, may be manifestations of a wide range of conditions aside from adrenal insufficiency or glucocorticoid withdrawal syndrome.
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Affiliation(s)
| | - Laura Senior
- Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Daniel Vis
- Division of Respirology, Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Katayoun Alikhani
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada
| | - Kirstie Lithgow
- Division of Endocrinology, Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
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Hasenmajer V. Only as strong as the weakest link: Adrenal insufficiency in the COVID-19 storm. J Intern Med 2024; 295:278-280. [PMID: 38160325 DOI: 10.1111/joim.13763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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Nyanyo DD, Mikamoto M, Galbiati F, Remba-Shapiro I, Bode K, Schoenfeld S, Jones PS, Swearingen B, Nachtigall LB. Autoimmune Disorders Associated With Surgical Remission of Cushing's Disease : A Cohort Study. Ann Intern Med 2024; 177:315-323. [PMID: 38373302 DOI: 10.7326/m23-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Glucocorticoids suppress inflammation. Autoimmune disease may occur after remission of Cushing's disease (CD). However, the development of autoimmune disease in this context is not well described. OBJECTIVE To determine 1) the incidence of autoimmune disease in patients with CD after surgical remission compared with patients with nonfunctioning pituitary adenomas (NFPAs) and 2) the clinical presentation of and risk factors for development of autoimmune disease in CD after remission. DESIGN Retrospective matched cohort analysis. SETTING Academic medical center/pituitary center. PATIENTS Patients with CD with surgical remission and surgically treated NFPA. MEASUREMENTS Cumulative incidence of new-onset autoimmune disease at 3 years after surgery. Assessment for hypercortisolemia included late-night salivary cortisol levels, 24-hour urine free cortisol (UFC) ratio (UFC value divided by the upper limit of the normal range for the assay), and dexamethasone suppression tests. RESULTS Cumulative incidence of new-onset autoimmune disease at 3 years after surgery was higher in patients with CD (10.4% [95% CI, 5.7% to 15.1%]) than in those with NFPAs (1.6% [CI, 0% to 4.6%]) (hazard ratio, 7.80 [CI, 2.88 to 21.10]). Patients with CD showed higher prevalence of postoperative adrenal insufficiency (93.8% vs. 16.5%) and lower postoperative nadir serum cortisol levels (63.8 vs. 282.3 nmol/L) than patients with NFPAs. Compared with patients with CD without autoimmune disease, those who developed autoimmune disease had a lower preoperative 24-hour UFC ratio (2.7 vs. 6.3) and a higher prevalence of family history of autoimmune disease (41.2% vs. 20.9%). LIMITATION The small sample of patients with autoimmune disease limited identification of independent risk factors. CONCLUSION Patients achieving surgical remission of CD have higher incidence of autoimmune disease than age- and sex-matched patients with NFPAs. Family history of autoimmune disease is a potential risk factor. Adrenal insufficiency may be a trigger. PRIMARY FUNDING SOURCE Recordati Rare Diseases Inc.
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Affiliation(s)
- Dennis Delasi Nyanyo
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
| | - Masaaki Mikamoto
- The Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (M.M., P.S.J., B.S.)
| | - Francesca Galbiati
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
| | - Ilan Remba-Shapiro
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
| | - Kevin Bode
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
| | - Sara Schoenfeld
- The Division of Rheumatology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (S.S.)
| | - Pamela S Jones
- The Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (M.M., P.S.J., B.S.)
| | - Brooke Swearingen
- The Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (M.M., P.S.J., B.S.)
| | - Lisa B Nachtigall
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
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Gupta J, Chowdhury SR, Jauhari P, Ragunathan K, Chakrabarty B, Jain V, Gulati S. Child Neurology: Allgrove Syndrome: An Intriguing Etiology of Motor Neuron Disease in Children. Neurology 2024; 102:e208049. [PMID: 38271654 DOI: 10.1212/wnl.0000000000208049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/04/2023] [Indexed: 01/27/2024] Open
Abstract
Motor neuron diseases are a rare group of neurodegenerative disorders with considerable phenotypic heterogeneity and a multitude of etiologies in the pediatric population. In this study, we report 2 unrelated adolescents (a boy and a girl) who presented with 4-6 years of progressive difficulty in walking, thinning of limbs, and gradually progressive darkening of the skin. Examination revealed generalized hyperpigmentation of skin and features suggestive of motor neuron involvement such as tongue atrophy, wasting of distal extremities, and brisk deep tendon reflexes. On detailed exploration for systemic involvement, history of dysphagia, inability to produce tears, and Addisonian crises were evident. An etiologic diagnosis of Allgrove syndrome, which is characterized by a triad of achalasia, alacrimia, and adrenal insufficiency was considered. Next-generation sequencing revealed pathogenic variants in the AAAS gene, confirming the diagnosis. Steroid replacement therapy was initiated along with relevant multidisciplinary referrals. The disease stabilized in the boy and a significant improvement was noted in the girl. These cases highlight the value of non-neurologic cues in navigating the etiologic complexities of motor neuron diseases in children and adolescents. It is imperative for neurologists to develop awareness of the diverse neurologic manifestations associated with Allgrove syndrome because they are often the first to be approached. A multidisciplinary team of experts including neurologists, endocrinologists, gastroenterologists, ophthalmologists, and dermatologists is essential for planning comprehensive care for these patients.
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Affiliation(s)
- Juhi Gupta
- From the Department of Pediatrics (J.G.), SMS Medical College Jaipur, Rajasthan; Madhukar Rainbow Children's Hospital (S.R.C.), New Delhi; Child Neurology Division (P.J., K.R., B.C., S.G.), Centre of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, and Division of Pediatric Endocrinology (V.J.), Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sayoni Roy Chowdhury
- From the Department of Pediatrics (J.G.), SMS Medical College Jaipur, Rajasthan; Madhukar Rainbow Children's Hospital (S.R.C.), New Delhi; Child Neurology Division (P.J., K.R., B.C., S.G.), Centre of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, and Division of Pediatric Endocrinology (V.J.), Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Prashant Jauhari
- From the Department of Pediatrics (J.G.), SMS Medical College Jaipur, Rajasthan; Madhukar Rainbow Children's Hospital (S.R.C.), New Delhi; Child Neurology Division (P.J., K.R., B.C., S.G.), Centre of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, and Division of Pediatric Endocrinology (V.J.), Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kaushik Ragunathan
- From the Department of Pediatrics (J.G.), SMS Medical College Jaipur, Rajasthan; Madhukar Rainbow Children's Hospital (S.R.C.), New Delhi; Child Neurology Division (P.J., K.R., B.C., S.G.), Centre of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, and Division of Pediatric Endocrinology (V.J.), Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Biswaroop Chakrabarty
- From the Department of Pediatrics (J.G.), SMS Medical College Jaipur, Rajasthan; Madhukar Rainbow Children's Hospital (S.R.C.), New Delhi; Child Neurology Division (P.J., K.R., B.C., S.G.), Centre of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, and Division of Pediatric Endocrinology (V.J.), Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Vandana Jain
- From the Department of Pediatrics (J.G.), SMS Medical College Jaipur, Rajasthan; Madhukar Rainbow Children's Hospital (S.R.C.), New Delhi; Child Neurology Division (P.J., K.R., B.C., S.G.), Centre of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, and Division of Pediatric Endocrinology (V.J.), Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sheffali Gulati
- From the Department of Pediatrics (J.G.), SMS Medical College Jaipur, Rajasthan; Madhukar Rainbow Children's Hospital (S.R.C.), New Delhi; Child Neurology Division (P.J., K.R., B.C., S.G.), Centre of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, and Division of Pediatric Endocrinology (V.J.), Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Ishikawa S, Ishikawa H, Sato M, Nagasawa A, Suzuki Y, Okayama J, Nakada E, Omoto A, Shozu M, Koga K. Postpartum acute adrenal insufficiency of early-onset Sheehan syndrome: A case series study in a single center. J Obstet Gynaecol Res 2024; 50:205-211. [PMID: 37986644 DOI: 10.1111/jog.15838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023]
Abstract
AIM To identify the symptoms and relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome. METHODS We retrospectively reviewed the charts of 125 women admitted to our intensive care unit because of postpartum hemorrhage between January 2011 and December 2021. Three women developed acute adrenal insufficiency. We investigated the total blood loss, shock status, consciousness level upon arrival, and intensive care provided to the women. We also analyzed the symptoms and laboratory data that led to the diagnosis of acute adrenal insufficiency. Continuous variables were presented by median (minimum-maximum). RESULTS The medians and ranges of age, total blood loss, and shock index [heart rate/systolic blood pressure] on admission were 33.1 (17.2-45.3) years, 3351 (595-20 260) g, and 0.94 (0.55-2.94), respectively. Seven women were older than 40 years, 28 experienced >5000 g blood loss, 17 had shock index >1.5, 27 had impaired consciousness upon arrival, and 15 underwent hysterectomy. Women who developed acute adrenal insufficiency were <40 years old and had a bleeding volume of over 5000 g, impaired consciousness upon arrival, and had undergone hysterectomy. They had experienced lactation failure, presented with hyponatremia-related symptoms on postpartum days 8-9, experienced general malaise, headache, and impaired consciousness, and showed severe hyponatremia. CONCLUSIONS Massive postpartum hemorrhage over 5000 g, impaired consciousness upon arrival, and hysterectomy as a hemostatic measure were relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome. Hyponatremia-related symptoms occurring after lactation failure are indicative of the onset of acute adrenal insufficiency.
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Affiliation(s)
- Shota Ishikawa
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
| | - Hiroshi Ishikawa
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mika Sato
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
| | - Akiko Nagasawa
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
| | - Yoshiya Suzuki
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
| | - Jun Okayama
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
| | - Emiri Nakada
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Akiko Omoto
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makio Shozu
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Evolution and Reproductive Biology, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba, Japan
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Chen Y, Li D, Xu P, Zhang A, Chen X, Chen Y. Adrenomyeloneuropathy manifesting as adrenal insufficiency and bilateral lower extremity spastic paraplegia: A case report and literature review. Medicine (Baltimore) 2024; 103:e36946. [PMID: 38215098 PMCID: PMC10783329 DOI: 10.1097/md.0000000000036946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/11/2023] [Indexed: 01/14/2024] Open
Abstract
RATIONALE Adrenomyeloneuropathy (AMN) is a variant type of X-linked adrenoleukodystrophy, and it is a genetic metabolic disease with strong clinical heterogeneity so that it is easily misdiagnosed and underdiagnosed. Moreover, most patients with AMN have an insidious clinical onset and slow progression. Familiarity with the pathogenesis, clinical features, diagnosis, and treatment of AMN can help identify the disease at an early stage. PATIENT CONCERNS We present a case of 35-year-old male, who was admitted to our hospital due to "immobility of the lower limbs for 2 years and worsening for half a year," accompanied by skin darkening and hyperpigmentation of lips, oral mucosa, and areola since puberty. DIAGNOSIS The level of very long-chain fatty acids was high and genetic testing depicted that exon 1 of the ABCD1 gene had a missense mutation of C.761c>T, which was diagnosed as AMN. INTERVENTIONS Baclofen was administered to improve muscle tension combined with glucocorticoid replacement therapy. OUTCOMES The condition was relieved after half a year. LESSONS The clinical manifestations of AMN are diverse. When patients with adrenocortical dysfunction complicated with progressive spastic paraplegia of lower limbs are involved, AMN should be highly suspected, and the determination of very long-chain fatty acids and genetic testing should be performed as soon as possible to confirm the diagnosis because early treatment can help prevent or delay the progression of the disease.
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Affiliation(s)
- Yan Chen
- Department of Clinical Medicine, Jining Medical University, Jining, China
| | - Daojing Li
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Peng Xu
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Aimei Zhang
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Xu Chen
- Department of Clinical Medicine, Jining Medical University, Jining, China
| | - Yun Chen
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, China
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Chifu I, Quinkler M, Altieri B, Hannemann A, Völzke H, Lang K, Reisch N, Pamporaki C, Willenberg HS, Beuschlein F, Burger-Stritt S, Hahner S. Morbidity in Patients with Chronic Adrenal Insufficiency - Cardiovascular Risk Factors and Hospitalization Rate Compared to Population Based Controls. Horm Metab Res 2024; 56:20-29. [PMID: 37827510 DOI: 10.1055/a-2190-3735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Patients with adrenal insufficiency (AI) have been found to have increased cardiovascular morbidity, partly associated with nonphysiologic glucocorticoid replacement. We included two separate cohorts (cohort 1 n=384 patients, cohort 2 n=180 patients) of patients with chronic primary and secondary AI under standard replacement therapy and compared them to two age- and sex-matched population-based studies (SHIP-TREND/DEGS). Odds ratios with 95% CI for hypertension, hyperlipidemia/HLP, type 2 diabetes/T2DM, obesity, and hospitalization with adjustment for confounders were evaluated by logistic regression. Patient cohort 1 had significantly lower ORs for obesity [0.4 (0.3-0.6), p<0.001] and hypertension [0.5 (0.3-0.6), p<0.001] compared to SHIP-TREND and for obesity [0.7 (0.5-0.9), p=0.01], hypertension [0.4 (0.3-0.5), p<0.001] and HLP [0.4 (0.3-0.6), p<0.001] compared to DEGS. In cohort 2, ORs were significantly lower for HLP compared to both SHIP-TREND [0.4 (0.2-0.7), p=0.001] and DEGS [0.3 (0.2-0.5), p<0.001] and for hypertension [0.7 (0.4-0.9), p=0.04] compared to SHIP-TREND. In patients with SAI from cohort 2, ORs for DM2 [2.5 (1.3-4.9) p=0.009], hypertension [2.5 (1.4-4.5), p=0.002] and obesity [1.9 (1.1-3.1), p=0.02] were significantly higher compared to DEGS, whereas ORs for HLP were significantly lower compared to both SHIP [0.3 (0.1-0.6), p=0.002] and DEGS [0.3 (0.1-0.6), p<0.001]. In most of our AI patients treated with conventional glucocorticoid doses, the risk for T2DM, obesity, hypertension, and HLP was not increased. The number of hospitalizations was significantly higher in AI patients compared to controls, which might reflect increased susceptibility but also a more proactive management of concomitant diseases by physicians and patients.
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Affiliation(s)
- Irina Chifu
- Endocrinology and Diabetes Unit, Department of Medicine I, University of Wuerzburg, Wuerzburg, Germany
| | | | - Barbara Altieri
- Endocrinology and Diabetes Unit, Department of Medicine I, University of Wuerzburg, Wuerzburg, Germany
| | - Anke Hannemann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Katharina Lang
- Endocrinology and Diabetes Unit, Department of Medicine I, University of Wuerzburg, Wuerzburg, Germany
- Endocrinology in Charlottenburg/Berlin, Berlin, Germany
| | - Nicole Reisch
- Department of Endocrine Research, Department of Medicine IV, Ludwig-Maximilians-University, Munich, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Felix Beuschlein
- Department of Endocrine Research, Department of Medicine IV, Ludwig-Maximilians-University, Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ), and University of Zurich (UZH), Zurich, Switzerland
- LOOP Zurich - Medical Research Center, Zurich, Switzerland
| | - Stephanie Burger-Stritt
- Endocrinology and Diabetes Unit, Department of Medicine I, University of Wuerzburg, Wuerzburg, Germany
| | - Stefanie Hahner
- Endocrinology and Diabetes Unit, Department of Medicine I, University of Wuerzburg, Wuerzburg, Germany
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Rajesh M, Omer T, Chinniah S. Anterior hypopituitarism due to primary empty sella syndrome in a critically unwell patient. BMJ Case Rep 2023; 16:e255879. [PMID: 38081743 PMCID: PMC10728910 DOI: 10.1136/bcr-2023-255879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
A previously fit and well male in his early 40s, presented to the emergency department, hypotensive, bradycardic and hypothermic with reduced levels of consciousness after being found diaphoretic and unwell at his home. Despite fluid resuscitation with warmed saline, he remained hypotensive and required vasopressor support leading to intensive care admission. Initially, the patient was managed for suspected meningoencephalitis but was later found to have hypopituitarism leading to secondary hypothyroidism and adrenal insufficiency. Subsequent investigations revealed it is due to empty sella syndrome.
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Affiliation(s)
- Mariya Rajesh
- Foundation School, Northampton General Hospital NHS Trust, Northampton, UK
| | - Tahir Omer
- Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
| | - Sadasivan Chinniah
- Northampton General Hospital NHS Trust, Northampton, Northamptonshire, UK
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Assaleh YA, Tabarki B. Further Characterization of the Neuroendocrine Phenotype Associated With the PPOX-Related Variegate Porphyria. Pediatr Neurol 2023; 149:141-144. [PMID: 37879139 DOI: 10.1016/j.pediatrneurol.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 08/27/2023] [Accepted: 09/14/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Variegate porphyria is caused by mutations in the PPOX gene; it usually presents in adolescents and adults as an autosomal dominant condition, with cutaneous features or acute peripheral and/or central nervous system crises. A rarer variant, homozygous variegate porphyria, presents in childhood with cutaneous manifestations as well as neurophenotypes. This study sought to further characterize the homozygous PPOX-related neuroendocrine phenotype. METHODS This study is a retrospective review of the patients' charts, including their clinical evaluation and molecular genetics, neurodiagnostic, and neuroradiological investigations. RESULTS We describe here three children from a consanguineous family who presented with nystagmus, developmental delay and ataxia, photosensitive skin manifestations, and adrenal insufficiency. Analysis of porphyrins in plasma, urine, and stool together with a genetic study of the PPOX gene confirmed the diagnosis. Interestingly, brain MRI showed severe hypomyelination, a finding rarely reported in variegate porphyria, together with adrenal insufficiency. CONCLUSION We recommend analysis of porphyrins in unexplained hypomyelination disorders. Patients with variegate porphyria should be tested for adrenal insufficiency.
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Affiliation(s)
- Yousef A Assaleh
- Faculty of Medicine, Department of Pediatrics, Zawia University, Libya
| | - Brahim Tabarki
- Division of Neurology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
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10
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Lee SC, Baranowski ES, Sakremath R, Saraff V, Mohamed Z. Hypoglycaemia in adrenal insufficiency. Front Endocrinol (Lausanne) 2023; 14:1198519. [PMID: 38053731 PMCID: PMC10694272 DOI: 10.3389/fendo.2023.1198519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/26/2023] [Indexed: 12/07/2023] Open
Abstract
Adrenal insufficiency encompasses a group of congenital and acquired disorders that lead to inadequate steroid production by the adrenal glands, mainly glucocorticoids, mineralocorticoids and androgens. These may be associated with other hormone deficiencies. Adrenal insufficiency may be primary, affecting the adrenal gland's ability to produce cortisol directly; secondary, affecting the pituitary gland's ability to produce adrenocorticotrophic hormone (ACTH); or tertiary, affecting corticotrophin-releasing hormone (CRH) production at the level of the hypothalamus. Congenital causes of adrenal insufficiency include the subtypes of Congenital Adrenal Hyperplasia, Adrenal Hypoplasia, genetic causes of Isolated ACTH deficiency or Combined Pituitary Hormone Deficiencies, usually caused by mutations in essential transcription factors. The most commonly inherited primary cause of adrenal insufficiency is Congenital Adrenal Hyperplasia due to 21-hydroxylase deficiency; with the classical form affecting 1 in 10,000 to 15,000 cases per year. Acquired causes of adrenal insufficiency can be subtyped into autoimmune (Addison's Disease), traumatic (including haemorrhage or infarction), infective (e.g. Tuberculosis), infiltrative (e.g. neuroblastoma) and iatrogenic. Iatrogenic acquired causes include the use of prolonged exogenous steroids and post-surgical causes, such as the excision of a hypothalamic-pituitary tumour or adrenalectomy. Clinical features of adrenal insufficiency vary with age and with aetiology. They are often non-specific and may sometimes become apparent only in times of illness. Features range from those related to hypoglycaemia such as drowsiness, collapse, jitteriness, hypothermia and seizures. Features may also include signs of hypotension such as significant electrolyte imbalances and shock. Recognition of hypoglycaemia as a symptom of adrenal insufficiency is important to prevent treatable causes of sudden deaths. Cortisol has a key role in glucose homeostasis, particularly in the counter-regulatory mechanisms to prevent hypoglycaemia in times of biological stress. Affected neonates particularly appear susceptible to the compromise of these counter-regulatory mechanisms but it is recognised that affected older children and adults remain at risk of hypoglycaemia. In this review, we summarise the pathogenesis of hypoglycaemia in the context of adrenal insufficiency. We further explore the clinical features of hypoglycaemia based on different age groups and the burden of the disease, focusing on hypoglycaemic-related events in the various aetiologies of adrenal insufficiency. Finally, we sum up strategies from published literature for improved recognition and early prevention of hypoglycaemia in adrenal insufficiency, such as the use of continuous glucose monitoring or modifying glucocorticoid replacement.
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Affiliation(s)
- Shien Chen Lee
- Department of Paediatrics, Princess Royal Hospital, Telford, United Kingdom
| | - Elizabeth S. Baranowski
- Department of Paediatric Endocrinology, Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
| | - Rajesh Sakremath
- Department of Paediatrics, Princess Royal Hospital, Telford, United Kingdom
| | - Vrinda Saraff
- Department of Paediatric Endocrinology, Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, United Kingdom
| | - Zainaba Mohamed
- Department of Paediatric Endocrinology, Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, United Kingdom
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11
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Rushworth RL, Falhammar H, Torpy DJ. Factors underlying a disproportionate increase in hospital admissions for adrenal insufficiency in women aged 20-29 years. Front Endocrinol (Lausanne) 2023; 14:1252577. [PMID: 38027206 PMCID: PMC10656680 DOI: 10.3389/fendo.2023.1252577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/17/2023] [Indexed: 12/01/2023] Open
Abstract
Since the year 2000, admissions for adrenal insufficiency (AI) and adrenal crises (AC) have shown a particular increase in young adult females. We examined data on acute non-surgical hospitalisations for AI/AC from New South Wales, Australia, to determine relevant factors that may have contributed to this increase. Data were analysed to ascertain associations between various comorbid psychosocial issues, identified by relevant ICD-10-AM codes in each record, and ACs. From 2005 to 2021. There were 877 admissions for an acute non-surgical illness in this age group. The average admission rate for females [63.5/million/year] was almost twice that for males [34.0/million/year] (p<0.01), as was the average female AC admission rate [14.7/million/year] relative to that in males [6.75/million/year] (p=NS). Infection was present in 41.6% (n=365) of the admissions and Type 1 diabetes mellitus was present in 12.2% (n=107). Overall, psychosocial factors were considered by the senior clinician to have contributed to the illness episode in 22.1% of all admissions and 29.0% of AC admissions. Having one or more psychosocial problems was associated with an AC in females (37.4%, n=49, in those having an AC, p<0.001) but not males. Females with an AC also had a higher mean composite psychosocial, psychiatric and drug/alcohol score [0.47 (0.67)] than females without an AC [0.32 (0.62) p<0.05]. No comparable associations were found in male patients. An increase in the rates of hospitalisations that included a code for at least one psychosocial problem was highly correlated with increases in admission rates for both ACs (r=0.82, p<0.001) and all AI (r=0.98, p<0.001) in females but there was no such relationship in males. This new evidence suggests that psychosocial factors may play an important role in ongoing rates of ACs in treated AI (incidence approximately 6-8 ACs/100PY) particularly in young adult females. In order to minimize AC episodes, all barriers to self-management need exploration on an individual patient basis and with regard to the patient population as a whole.
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Affiliation(s)
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - David J. Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Medicine, The University of Adelaide, Adelaide, SA, Australia
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12
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Aloini ME, Manella S, Biondo I, Maggio R, Roberto G, Ricci F, Lardo P, Addario Chieco P, Stigliano A. Bilateral adrenal hemorrhage: learning notes from clinical practice and literature review. Front Endocrinol (Lausanne) 2023; 14:1233710. [PMID: 38027193 PMCID: PMC10656610 DOI: 10.3389/fendo.2023.1233710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/09/2023] [Indexed: 12/01/2023] Open
Abstract
Adrenal hemorrhage is a rare, but important, diagnosis to recognize, in particular when there is involvement of both adrenal glands. Bilateral adrenal hemorrhage can in fact lead to adrenal insufficiency, with dramatic consequences if not promptly recognized and treated. It is normally caused by systemic conditions that lead to the vasoconstriction and thrombosis of the adrenal vein. Oftentimes, the clinical diagnosis of this condition can be very challenging, as its signs and symptoms are generalized and nonspecific (abdominal pain, nausea, and fatigue). Here, we present the cases of two patients admitted to the Emergency Department in 2016 and 2022 with acute abdominal pain, having recently undergone surgery and subsequently prescribed low-molecular-weight heparin. In both cases, laboratory results revealed neutrophilic leukocytosis and an unexplained anemia. Due to the persistence of abdominal pain despite medication, a CT scan was performed, showing an enlargement of both adrenal glands suggestive of bilateral adrenal hemorrhage. Adrenal function was tested that correlated with a diagnosis of adrenal insufficiency, and both patients were promptly treated with parenteral hydrocortisone as a result. On 5 years' follow-up from the acute event, the second patient's adrenal function had returned to normal, and he has not needed further adrenal replacement therapy; the first patient however demonstrated persistence of adrenal failure requiring replacement therapy. In this paper, through our experience and a literature analysis, we will aim to outline some clues to identify patients at potential risk of bilateral adrenal hemorrhage.
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Affiliation(s)
- Maria Elena Aloini
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Sara Manella
- Surgery, Department of Medical Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Irene Biondo
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Roberta Maggio
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Guido Roberto
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Francesca Ricci
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Pina Lardo
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Paola Addario Chieco
- General Surgery, Department of Surgical Sciences, Sant’Andrea University Hospital, Rome, Italy
| | - Antonio Stigliano
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy
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13
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Go A, Lee BH, Choi JH, Jeong J, Jung E, Lee BS. Case report: a premature infant with severe intrauterine growth restriction, adrenal insufficiency, and inflammatory diarrhea: a genetically confirmed case of MIRAGE syndrome. Front Endocrinol (Lausanne) 2023; 14:1242387. [PMID: 37745698 PMCID: PMC10516543 DOI: 10.3389/fendo.2023.1242387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction MIRAGE syndrome is a rare disease characterized by myelodysplasia, infection, growth restriction, adrenal hypoplasia, genital phenotypes, and enteropathy. Herein, we report the case of a girl with MIRAGE syndrome who presented with adrenal insufficiency and chronic diarrhea. Case presentation The patient was born at 29 + 6 weeks of gestational age with a birth weight of 656 g (<3p). Her height and head circumference were also <3p. At birth, she presented with respiratory distress, meconium staining, and pneumomediastinum, which were managed with high-frequency ventilation and empirical antibiotics. Physical examination showed generalized hyperpigmentation and normal female genitalia. A few days after birth, polyuria and hypotension developed, and laboratory findings revealed hypoglycemia, hyponatremia, and hyperkalemia. Plasma adrenocorticotropic hormone levels were elevated with low serum cortisol levels and high plasma renin activity, which were suggestive of adrenal insufficiency. Hydrocortisone and fludrocortisone were introduced and maintained, and hyperpigmentation attenuated with time. Both kidneys looked dysplastic, and adrenal glands could not be traced on abdominal ultrasound. From the early days of life, thrombocytopenia and anemia were detected, but not to life-threatening level and slowly recovered up to the normal range. Despite aggressive nutritional support, weight gain and growth spurt were severely retarded during the hospital stay. Additionally, after introducing enteral feeding, she experienced severe diarrhea and subsequent perineal skin rashes and ulcerations. Fecal calprotectin level was highly elevated; however, a small bowel biopsy resulted in non-specific submucosal congestion. The patient was diagnosed with MIRAGE syndrome with SAMD9 gene mutation. She was discharged with tube feeding and elemental formula feeding continued, but chronic diarrhea persisted. By the time of the last follow-up at 15 months of corrected age, she was fortunately not subjected to severe invasive infection and myelodysplastic syndrome. However, she was dependent on tube feeding and demonstrated a severe developmental delay equivalent to approximately 5-6 months of age. Conclusion The early diagnosis of adrenal crisis and hormone replacement therapy can save the life of -patients with MIRAGE syndrome; however, chronic intractable diarrhea and growth and developmental delay continue to impede the patient's well-being.
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Affiliation(s)
| | | | | | | | | | - Byong Sop Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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14
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Riggs AH, Rhinehart J, Cooper ES. Possible development and resolution of dilated cardiomyopathy phenotype secondary to atypical hypoadrenocorticism in a dog. J Vet Emerg Crit Care (San Antonio) 2023; 33:606-612. [PMID: 37577957 DOI: 10.1111/vec.13321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 06/10/2022] [Accepted: 06/20/2022] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To report the possible occurrence of dilated cardiomyopathy phenotype associated with atypical hypoadrenocorticism and subsequent marked improvement with treatment in a mixed breed dog. CASE SUMMARY A 4.5-year-old, neutered male mixed breed dog was evaluated for a history and clinicopathological changes consistent with atypical hypoadrenocorticism. The dog was being fed a grain-free diet. While hospitalized for supportive care and diagnostics, the patient developed and was diagnosed with biventricular congestive heart failure secondary to dilated cardiomyopathy phenotype and IV fluid administration. The left-sided congestive heart failure resolved with discontinuation of IV fluid therapy and short-term administration of diuretics. After treatment of atypical hypoadrenocorticism with glucocorticoid supplementation, and while continuing to be fed varying grain-free diets, the patient's dilated cardiomyopathy phenotype largely resolved. The patient fully recovered and did not require any long-term cardiac medications. NEW OR UNIQUE INFORMATION PROVIDED Development of dilated cardiomyopathy phenotype has not been described in dogs as a sequela of untreated hypoadrenocorticism but has been reported in human literature. Given the fact that standard management of hypoadrenocorticism typically involves aggressive fluid resuscitation, awareness of this potential sequela is important for patients that fail to respond or develop signs consistent with volume overload.
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Affiliation(s)
- Alexandra H Riggs
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Jaylyn Rhinehart
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Edward S Cooper
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
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15
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Ko JW, Lee SE, Park JH, Kim B. Risk factors that are associated with adrenal insufficiency among patients with fever of unknown origin. Postgrad Med 2023; 135:734-740. [PMID: 37725479 DOI: 10.1080/00325481.2023.2261355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 09/18/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Adrenal insufficiency is one of the causes of fever of unknown origin (FUO). The purpose of this study is to find out risk factors that are associated with adrenal insufficiency in FUO patients. METHODS This study was conducted retrospectively in a tertiary hospital with 846 beds in South Korea. All adult inpatients (age ≥19 years) who have requested a consult with the department of infectious disease for FUO between 1 July 20191 July 2019 and 30 June 202030 June 2020 were included in the study. Among them, those who underwent an adrenocorticotropic hormone (ACTH) stimulation test and had a fever of 37.8°C or higher within 48 hours of the ACTH stimulation test were finally included in the study subjects. RESULTS A total of 202 FUO patients were enrolled and 61 (30.1%) were finally diagnosed with adrenal insufficiency. In a multivariate analysis, use of immunosuppressant within 3 months (OR 6.06, 95% CI 1.82-20.13, P = 0.003), use of corticosteroid within 3 months (OR 8.23, 95% CI 1.35-50.17, P = 0.022), sodium ≥ 136.7 (OR 3.43, 95% CI 1.49-7.88, P = 0.004), and calcium ≥ 8.4 (OR 0.31, 95% CI 0.14-0.71, P = 0.005) were proven to be factors associated with adrenal insufficiency in FUO patients. CONCLUSION In conclusion, 30.1% of FUO patients were diagnosed with adrenal insufficiency. The risk factors that are associated with adrenal insufficiency in FUO patients were immunosuppressive prescription or systemic steroid prescription within 3 months, or with sodium ≥ 136.7 or calcium < 8.4.
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Affiliation(s)
- Ji Won Ko
- School of Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Seung Eun Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Jung Hwan Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Infectious Diseases, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
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16
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Bouki K, Venetsanaki V, Chrysoulaki M, Pateromichelaki A, Betsi G, Daraki V, Sbyrakis N, Spanakis K, Bertsias G, Sidiropoulos PI, Xekouki P. Primary adrenal insufficiency due to bilateral adrenal hemorrhage-adrenal infarction in a patient with systemic lupus erythematosus and antiphospholipid syndrome: case presentation and review of the literature. Hormones (Athens) 2023; 22:521-531. [PMID: 37436639 PMCID: PMC10449959 DOI: 10.1007/s42000-023-00463-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/22/2023] [Indexed: 07/13/2023]
Abstract
Primary adrenal insufficiency (PAI) is a rare disease which represents the end stage of a destructive process involving the adrenal cortex. Occasionally it may be caused by bilateral adrenal hemorrhagic infarction in patients with antiphospholipid syndrome (APS). We herein report the challenging case of a 30-year-old female patient with systemic lupus erythematosus (SLE) and secondary APS who was admitted to the emergency department (ED) due to fever, lethargy, and syncopal episodes. Hyponatremia, hyperkalemia, hyperpigmentation, shock, altered mental status, and clinical response to glucocorticoid administration were features highly suggestive of an acute adrenal crisis. The patient's clinical status required admission to the intensive care unit (ICU), where steroid replacement, anticoagulation, and supportive therapy were provided, with a good outcome. Imaging demonstrated bilateral adrenal enlargement attributed to recent adrenal hemorrhage. This case highlights the fact that bilateral adrenal vein thrombosis and subsequent hemorrhage can be part of the thromboembolic complications seen in both primary and secondary APS and which, if misdiagnosed, may lead to a life-threatening adrenal crisis. High clinical suspicion is required for its prompt diagnosis and management. A literature search of past clinical cases with adrenal insufficiency (AI) in the setting of APS and SLE was conducted using major electronic databases. Our aim was to retrieve information about the pathophysiology, diagnosis, and management of similar conditions.
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Affiliation(s)
- K Bouki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - V Venetsanaki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - M Chrysoulaki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - A Pateromichelaki
- Rheumatology and Clinical Immunology, University General Hospital of Heraklion, Crete, Greece
| | - G Betsi
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - V Daraki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - N Sbyrakis
- Emergency Department, University General Hospital of Heraklion, Crete, Greece
| | - K Spanakis
- Interventional Radiology Unit, Department of Medical Imaging, University General Hospital of Heraklion, Crete, Greece
| | - G Bertsias
- Rheumatology and Clinical Immunology, University General Hospital of Heraklion, Crete, Greece
| | - P I Sidiropoulos
- Rheumatology and Clinical Immunology, University General Hospital of Heraklion, Crete, Greece
| | - Paraskevi Xekouki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece.
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Rodriguez Tebar A, Panza-Nduli J, Gubin B, Rogghe PA, Oriot P. An unusual cause of abdominal pain: spontaneous bilateral adrenal hemorrhage. Acta Gastroenterol Belg 2023; 86:495-498. [PMID: 37814568 DOI: 10.51821/86.3.11251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Bilateral adrenal hemorrhage (BAH) is a rare condition that can lead to acute adrenal insufficiency and death if not recognized and treated promptly. We report the case of a 30-year-old male who presented to the emergency department with acute abdominal pain, nausea, and vomiting. On emergency room admission, the first abdominal CT revealed normal adrenal glands without enlargement, but with the development of hypotension and hypoglycemia, a second CT performed four days later showed enlargement due to hemorrhage in both adrenals. The diagnosis of BAH associated with acute adrenal insufficiency was retained. Prompt treatment with intravenous and oral corticosteroids resulted in successful conservative management. We describe the clinical, biological, radiological and etiological features of this condition based on a review of the literature.
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Affiliation(s)
- A Rodriguez Tebar
- Department of Endocrinology, Mouscron Hospital Centre, Mouscron, Belgium
| | - J Panza-Nduli
- Department of Emergency, Mouscron Hospital Center, Mouscron, Belgium
| | - B Gubin
- Department of Radiology, Mouscron Hospital Centre, Mouscron, Belgium
| | - P-A Rogghe
- Department of Critical Care Unit, Mouscron Hospital Centre, Mouscron, Belgium
| | - P Oriot
- Department of Endocrinology, Mouscron Hospital Centre, Mouscron, Belgium
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18
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Kanno A, Sumitomo K, Narai D, Suzuki K, Katsuta Y, Kurosawa E, Oizumi T, Mashiko S, Ohara T, Furukawa K. Significant dysphagia and abdominal distension were caused by central adrenal insufficiency in an elderly man. Geriatr Gerontol Int 2023; 23:450-451. [PMID: 37114674 DOI: 10.1111/ggi.14587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/25/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Atsuhiro Kanno
- Division of Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kazuhiro Sumitomo
- Department of Internal Medicine, Wakabayashi Hospital, Sendai, Japan
| | - Daiki Narai
- Division of Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kohei Suzuki
- Division of Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yoshihisa Katsuta
- Division of Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Emiko Kurosawa
- Division of Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Tomoya Oizumi
- Department of Internal Medicine, Wakabayashi Hospital, Sendai, Japan
| | - Shigeto Mashiko
- Division of Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takahiro Ohara
- Division of Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Katsutoshi Furukawa
- Division of Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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19
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Gensous N, Jourde W, Salles K, James C, Guy A, Duffau P. Adrenal insufficiency revealing bilateral adrenal hemorrhage related to JAK2 V617F-positive essential thrombocythemia: about two cases. Blood Coagul Fibrinolysis 2023; 34:228-231. [PMID: 36719803 DOI: 10.1097/mbc.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Bilateral adrenal hemorrhage is a rare cause of adrenal insufficiency which has been rarely associated with myeloproliferative neoplasms. Here, we report two cases of bilateral adrenal hemorrhage revealed by abdominal pain, malaise, and fatigue in two octogenarian males previously diagnosed with JAK2 V617F-positive essential thrombocythemia. Both patients were on long-term direct oral anticoagulant treatment for atrial fibrillation. Evolution was favorable under steroid replacement therapy, associated with cytoreduction, aspirin, and switch of direct oral anticoagulants for vitamin K antagonists.
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Affiliation(s)
- Noémie Gensous
- Department of Internal Medicine and Clinical Immunology, CHU Bordeaux (Groupe Hospitalier Saint-André)
- UMR/CNRS 5164, ImmunoConcEpT, CNRS, University of Bordeaux
| | - Wendy Jourde
- Department of Internal Medicine and Clinical Immunology, CHU Bordeaux (Groupe Hospitalier Saint-André)
| | - Kévin Salles
- Department of Internal Medicine and Clinical Immunology, CHU Bordeaux (Groupe Hospitalier Saint-André)
| | - Chloé James
- Laboratory of Hematology, CHU Bordeaux, Bordeaux
- INSERM UMR 1034, « Biology of Cardiovascular Diseases », University of Bordeaux, Pessac, France
| | - Alexandre Guy
- Laboratory of Hematology, CHU Bordeaux, Bordeaux
- INSERM UMR 1034, « Biology of Cardiovascular Diseases », University of Bordeaux, Pessac, France
| | - Pierre Duffau
- Department of Internal Medicine and Clinical Immunology, CHU Bordeaux (Groupe Hospitalier Saint-André)
- UMR/CNRS 5164, ImmunoConcEpT, CNRS, University of Bordeaux
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20
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Elhassan YS, Ronchi CL, Wijewickrama P, Baldeweg SE. Approach to the Patient With Adrenal Hemorrhage. J Clin Endocrinol Metab 2023; 108:995-1006. [PMID: 36404284 PMCID: PMC9999363 DOI: 10.1210/clinem/dgac672] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
Abstract
Adrenal hemorrhage is an uncommon, underrecognized condition that can be encountered in several clinical contexts. Diagnosing adrenal hemorrhage is challenging due to its nonspecific clinical features. Therefore, it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion. Adrenal hemorrhage can follow abdominal trauma or appear on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy. Adrenal hemorrhage is also increasingly reported in patients with COVID-19 infection and in the context of vaccine-induced immune thrombocytopenia and thrombosis. Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage. Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment. In this article, we highlight the clinical circumstances that are associated with higher risk of adrenal hemorrhage, encouraging clinicians to prospectively consider the diagnosis, and we share a diagnostic and management strategy.
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Affiliation(s)
- Yasir S Elhassan
- Correspondence: Yasir Elhassan, MBBS, MRCP, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK
- Division of Endocrinology and Diabetes, University Hospital University Würzburg, Würzburg 97080, Germany
| | - Piyumi Wijewickrama
- Department of Diabetes and Endocrinology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK
| | - Stephanie E Baldeweg
- Department of Diabetes and Endocrinology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK
- Centre for Obesity and Metabolism, Department of Experimental and Translational Medicine, Division of Medicine, University College London, London WC1E 6BT, UK
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21
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Giannakopoulos A, Sertedaki A, Efthymiadou A, Chrysis D. Addison's disease without hyperpigmentation in pediatrics: pointing towards specific causes. Hormones (Athens) 2023; 22:143-148. [PMID: 36348260 DOI: 10.1007/s42000-022-00415-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Hyperpigmentation of skin and mucous membranes comprises a hallmark of the clinical diagnosis of Addison's disease. However, there have been reports of patients with adrenal insufficiency from diverse causes who did not develop hyperpigmentation. The pathophysiology responsible for the absence of increased pigmentation is not clearly defined in many cases. CASE PRESENTATION We present a patient with isolated glucocorticoid deficiency due to two novel heterozygous variants in the sphingosine-1-phosphate lyase 1 (SPGL1) gene that did not develop any hyperpigmentation. DISCUSSION We elaborate on the presumed mechanism of the absence of hyperpigmentation in adrenal insufficiency due to SPGL1 deficiency and discuss the other reported cases of Addison's disease without hyperpigmentation and the possible mechanism accounted for. CONCLUSION Absence of hyperpigmentation, a basic component of the clinical diagnosis of Addison's disease, may lead to delay of a critical diagnosis, while causes that result in adrenal insufficiency without hyperpigmentation should explicitly be considered in pediatric cases where adrenal failure is documented by clinical symptomatology and biochemistry.
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Affiliation(s)
- Aristeidis Giannakopoulos
- Division of Pediatric Endocrinology, Department of Pediatrics, Medical School of Patras, University Hospital, 26504, Rio, Patras, Greece.
| | - Amalia Sertedaki
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandra Efthymiadou
- Division of Pediatric Endocrinology, Department of Pediatrics, Medical School of Patras, University Hospital, 26504, Rio, Patras, Greece
| | - Dionisios Chrysis
- Division of Pediatric Endocrinology, Department of Pediatrics, Medical School of Patras, University Hospital, 26504, Rio, Patras, Greece
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22
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Wentworth BJ, Schliep M, Novicoff W, Siragy HM, Geng CX, Henry ZH. Relative adrenal insufficiency in the non-critically ill patient with cirrhosis: A systematic review and meta-analysis. Liver Int 2023; 43:660-672. [PMID: 36354293 PMCID: PMC9974795 DOI: 10.1111/liv.15473] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/05/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND & AIMS Characterization of relative adrenal insufficiency (RAI) in cirrhosis is heterogeneous with regard to studied patient populations and diagnostic methodology. We aimed to describe the prevalence and prognostic importance of RAI in non-critically ill patients with cirrhosis. METHODS A systematic review and meta-analysis was performed using MeSH terms and Boolean operators to search five large databases (Ovid-MEDLINE, ScienceDirect, Web of Science, Cochrane Library and ClinicalTrials.gov). The population of interest was patients with cirrhosis and without critical illness. The primary outcome was the pooled prevalence of RAI as defined by a peak total cortisol level <18 μg/dl, delta total cortisol <9 μg/dl or composite of the two thresholds in response either a standard-dose or low-dose short synacthen test. Odds ratios and standardized mean differences from random-effects models estimated important clinical outcomes and patient characteristics by adrenal functional status. RESULTS Twenty-two studies were included in final analysis, comprising 1991 patients with cirrhosis. The pooled prevalence of RAI was 37% (95% CI 33-42%). The prevalence of RAI varied by Child-Pugh classification, type of stimulation test used, specific diagnostic threshold and by severity of illness. Ninety-day mortality was significantly higher in patients with RAI (OR 2.88, 95% CI 1.69-4.92, I2 = 15%, p < 0.001). CONCLUSIONS Relative adrenal insufficiency is highly prevalent in non-critically ill patients with cirrhosis and associated with increased mortality. Despite the proposed multifactorial pathogenesis, no studies to date have investigated therapeutic interventions in this specific population.
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Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
| | - Matthew Schliep
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA
| | - Wendy Novicoff
- Departments of Public Health Sciences and Orthopaedic Surgery, School of Medicine, University of Virginia Charlottesville, VA
| | - Helmy M Siragy
- Division of Endocrinology & Metabolism, School of Medicine, University of Virginia, Charlottesville, VA
| | - Calvin X Geng
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA
| | - Zachary H Henry
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
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23
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Sakurai Y, Ohara N, Fukai Y, Seki Y, Akiyama K, Yoneoka Y, Takada T, Tani T, Terajima K, Ozawa T, Sone H. Hypoglycemic Hemiplegia Associated with Reversible Narrowing of the Contralateral Middle Cerebral Artery in a Patient with Adrenal Insufficiency. Intern Med 2023; 62:751-756. [PMID: 35871581 PMCID: PMC10037026 DOI: 10.2169/internalmedicine.0038-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 56-year-old man with a 2.5-month history of anorexia developed sweating, weakness, and left hemiplegia and hemispatial neglect. Brain magnetic resonance imaging detected no abnormalities, but magnetic resonance angiography revealed narrowing of the right middle cerebral artery (MCA). The focal neurological signs and narrowing of the MCA resolved after detection and correction of hypoglycemia. Endocrinological examinations indicated adrenal insufficiency. Hemiplegia is a rare but important neurological manifestation of hypoglycemia, although the mechanisms involved remain unknown. Combined hypoglycemia and decreased MCA blood flow associated with vasospasm probably induced regionally severe neuroglycopenia with ischemia, which presented as focal neurological symptoms.
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Affiliation(s)
- Yuhki Sakurai
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Japan
| | - Nobumasa Ohara
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
| | - Yumi Fukai
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
| | - Yasuhiro Seki
- Department of Neurosurgery, Uonuma Kikan Hospital, Japan
| | | | | | - Toshinori Takada
- Department of Respiratory Medicine, Uonuma Kikan Hospital, Japan
| | - Takashi Tani
- Department of Neurology, Uonuma Kikan Hospital, Japan
| | | | | | - Hirohito Sone
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Japan
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24
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Giri S, Angadi S, Morupoju G, Bhrugumalla S. Intractable vomiting as a presentation of adrenal insufficiency - a case report. Trop Doct 2023; 53:179-180. [PMID: 36062734 DOI: 10.1177/00494755221122621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An array of pathophysiological processes can lead to chronic nausea and vomiting, including gastrointestinal and non-gastrointestinal disorders. Initial symptoms of adrenal insufficiency are usually non-specific, but intractable nausea and vomiting are infrequently associated, posing a diagnostic dilemma for clinicians. Here we present such a patient, who responded to glucocorticoid replacement with complete improvement.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, 28605Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Sumaswi Angadi
- Department of Gastroenterology, 28605Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Gautham Morupoju
- Department of Gastroenterology, 28605Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Sukanya Bhrugumalla
- Department of Gastroenterology, 28605Nizam's Institute of Medical Sciences, Hyderabad, India
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25
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Andrysiak-Mamos E, Sagan KP, Zwarzany Ł, Poncyljusz W, Syrenicz A. The 1 μg Synacthen stimulation test in the diagnosis of secondary adrenal insufficiency in patients with Rathke's cleft cyst and empty sella syndrome. Endokrynol Pol 2023; 74:VM/OJS/J/98271. [PMID: 38159204 DOI: 10.5603/ep.98271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Rathke's cleft cyst (RCC) and primary empty sella syndrome (PESS) are usually incidental findings on magnetic resonance imaging (MRI) scans. In most cases, these lesions do not cause mass effect symptoms and do not require surgical intervention. In patients with RCC or PESS, it is important to exclude secondary adrenal insufficiency (SAI), which may be a life-threatening condition. MATERIAL AND METHODS The incidence of SAI was assessed in patients with RCC or PESS detected by MRI, using the 1 μg Synacthen stimulation test. A total of 38 patients were analysed. Test results were linked to clinical symptoms and the type of cystic lesion. RESULTS Assuming that cortisol levels < 14.6 μg/dL in Synacthen test are the criterion of SAI diagnosis, SAI was diagnosed only in 2 patients (5%). Adopting the traditional criterion of cortisol levels < 18 μg/dL, SAI would be diagnosed in 7 patients (18.4 %). Dizziness (Chi2 = 3.89; p = 0.049) and apathy (Chi2 = 3.87; p = 0.049) were significantly more frequent in the PESS group than in the RCC group. CONCLUSIONS The incidence of SAI in the general patient population with empty sella syndrome and Rathke's cleft cysts is low. The 1 μg Synacthen test seems to be a valuable tool in the diagnosis of SAI among patients with RCC and PESS. Further studies are necessary to determine the sensitivity and specificity of the 1 μg Synacthen test with the standardization of test protocol and considering the cortisol level at the 20-minute timepoint. PESS patients report dizziness and apathy more frequently than RCC patients, which does not result from the disturbance of the hypothalamic-pituitary-adrenal axis, but probably from the different pathogenesis of these cystic lesions.
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Affiliation(s)
- Elżbieta Andrysiak-Mamos
- Department of Endocrinology, Metabolic Diseases, and Internal Diseases, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Karol Piotr Sagan
- Department of Endocrinology, Metabolic Diseases, and Internal Diseases, Pomeranian Medical University in Szczecin, Szczecin, Poland.
| | - Łukasz Zwarzany
- Diagnostic Imaging and Interventional Radiology Unit, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Wojciech Poncyljusz
- Diagnostic Imaging and Interventional Radiology Unit, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Anhelli Syrenicz
- Department of Endocrinology, Metabolic Diseases, and Internal Diseases, Pomeranian Medical University in Szczecin, Szczecin, Poland
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26
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Eskandari D, Ziaee A, Amirfarhangi Anbardan A, Zeinali E, Tirkan A. Primary adrenal insufficiency and myocarditis in COVID-19 disease: a case report. BMC Endocr Disord 2022; 22:336. [PMID: 36587233 PMCID: PMC9805346 DOI: 10.1186/s12902-022-01257-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/16/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND COVID-19 has different manifestations from respiratory to GI problems, and some of them are more common, but some are rare. Reporting rare cases can significantly advance our understanding of the disease. CASE PRESENTATION In this case, we report an 18-year-old teenage boy with chest pain and resistant hypotension following COVID-19 infection, finally diagnosed as primary adrenal insufficiency and COVID-19 myocarditis. CONCLUSION Adrenal insufficiency can be life-threatening due to its adverse effects on hemodynamic and electrolyte equilibrium. In addition, COVID-19 induced myocarditis can make the situation more complicated.
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Affiliation(s)
- Delaram Eskandari
- Department of Endocrinology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Ziaee
- Department of Endocrinology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Abdollah Amirfarhangi Anbardan
- Department of Endocrinology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Elahe Zeinali
- Department of Endocrinology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Cardiology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Atefe Tirkan
- Department of Endocrinology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Internal Medicine, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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27
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Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
| | - Zachary H Henry
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
| | - Helmy M Siragy
- Division of Endocrinology & Metabolism, School of Medicine, University of Virginia, Charlottesville, VA
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28
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Menzies-Gow A, Gurnell M, Heaney LG, Corren J, Bel EH, Maspero J, Harrison T, Jackson DJ, Price D, Lugogo N, Kreindler J, Burden A, de Giorgio-Miller A, Faison S, Padilla K, Martin UJ, Garcia Gil E. Adrenal function recovery after durable oral corticosteroid sparing with benralizumab in the PONENTE study. Eur Respir J 2022; 60:2103226. [PMID: 35896216 PMCID: PMC9791910 DOI: 10.1183/13993003.03226-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/04/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Oral corticosteroid (OCS) dependence among patients with severe eosinophilic asthma can cause adverse outcomes, including adrenal insufficiency. PONENTE's OCS reduction phase showed that, following benralizumab initiation, 91.5% of patients eliminated corticosteroids or achieved a final dosage ≤5 mg·day-1 (median (range) 0.0 (0.0-40.0) mg). METHODS The maintenance phase assessed the durability of corticosteroid reduction and further adrenal function recovery. For ∼6 months, patients continued benralizumab 30 mg every 8 weeks without corticosteroids or with the final dosage achieved during the reduction phase. Investigators could prescribe corticosteroids for asthma exacerbations or increase daily dosages for asthma control deteriorations. Outcomes included changes in daily OCS dosage, Asthma Control Questionnaire (ACQ)-6 and St George's Respiratory Questionnaire (SGRQ), as well as adrenal status, asthma exacerbations and adverse events. RESULTS 598 patients entered PONENTE; 563 (94.1%) completed the reduction phase and entered the maintenance phase. From the end of reduction to the end of maintenance, the median (range) OCS dosage was unchanged (0.0 (0.0-40.0) mg), 3.2% (n=18/563) of patients experienced daily dosage increases, the mean ACQ-6 score decreased from 1.26 to 1.18 and 84.5% (n=476/563) of patients were exacerbation free. The mean SGRQ improvement (-19.65 points) from baseline to the end of maintenance indicated substantial quality-of-life improvements. Of patients entering the maintenance phase with adrenal insufficiency, 32.4% (n=104/321) demonstrated an improvement in adrenal function. Adverse events were consistent with previous reports. CONCLUSIONS Most patients successfully maintained maximal OCS reduction while achieving improved asthma control with few exacerbations and maintaining or recovering adrenal function.
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Affiliation(s)
- Andrew Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, UK
| | - Mark Gurnell
- Wellcome-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge Biomedical Campus, Cambridge, UK
| | - Liam G Heaney
- Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Jonathan Corren
- David Geffen School of Medicine at UCLA and Allergy Medical Clinic Inc., Los Angeles, CA, USA
| | - Elisabeth H Bel
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Timothy Harrison
- Nottingham Respiratory NIHR BRC, University of Nottingham, Nottingham, UK
- BioPharmaceuticals R&D Digital, AstraZeneca, Cambridge, UK
| | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, UK
- Asthma UK Centre, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Njira Lugogo
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - James Kreindler
- Global Medical Respiratory, BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | - Annie Burden
- BioPharmaceuticals R&D, Late Respiratory and Immunology, Biometrics, AstraZeneca, Cambridge, UK
| | | | - Sarai Faison
- Late Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Durham, NC, USA
| | - Kelly Padilla
- Late Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Durham, NC, USA
| | - Ubaldo J Martin
- Late Stage Development, Respiratory and Immunology Therapeutic Area, AstraZeneca, Gaithersburg, MD, USA
| | - Esther Garcia Gil
- Global Medical Respiratory, BioPharmaceuticals Medical, AstraZeneca, Barcelona, Spain
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29
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Minnetti M, Hasenmajer V, Sbardella E, Angelini F, Simeoli C, Di Paola N, Cozzolino A, Pivonello C, De Alcubierre D, Chiloiro S, Baldelli R, De Marinis L, Pivonello R, Pofi R, Isidori AM. Susceptibility and characteristics of infections in patients with glucocorticoid excess or insufficiency: the ICARO tool. Eur J Endocrinol 2022; 187:719-731. [PMID: 36102827 PMCID: PMC9641788 DOI: 10.1530/eje-22-0454] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Registry data show that Cushing's syndrome (CS) and adrenal insufficiency (AI) increase mortality rates associated with infectious diseases. Little information is available on susceptibility to milder forms of infections, especially those not requiring hospitalization. This study aimed to investigate infectious diseases in patients with glucocorticoid disorders through the development of a specific tool. METHODS We developed and administered the InfeCtions in pAtients with endocRinOpathies (ICARO) questionnaire, addressing infectious events over a 12-month observation period, to 1017 outpatients referred to 4 University Hospitals. The ICARO questionnaire showed good test-retest reliability. The odds of infection (OR (95% CI)) were estimated after adjustment for confounders and collated into the ICARO score, reflecting the frequency and duration of infections. RESULTS In total, 780 patients met the inclusion criteria: 43 with CS, 32 with adrenal incidentaloma and mild autonomous cortisol secretion (MACS), and 135 with AI, plus 570 controls. Compared to controls, CS was associated with higher odds of urinary tract infections (UTIs) (5.1 (2.3-9.9)), mycoses (4.4 (2.1-8.8)), and flu (2.9 (1.4-5.8)). Patients with adrenal incidentaloma and MACS also showed an increased risk of UTIs (3.7 (1.7-8.0)) and flu (3.2 (1.5-6.9)). Post-dexamethasone cortisol levels correlated with the ICARO score in patients with CS. AI was associated with higher odds of UTIs (2.5 (1.6-3.9)), mycoses (2.3 (1.4-3.8)), and gastrointestinal infections (2.2 (1.5-3.3)), independently of any glucocorticoid replacement dose. CONCLUSIONS The ICARO tool revealed a high prevalence of self-reported infections in patients with glucocorticoid disorders. ICARO is the first of its kind questionnaire, which could be a valuable tool for monitoring infections in various clinical settings.
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Affiliation(s)
- Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome – Policlinico Umberto I Hospital, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome – Policlinico Umberto I Hospital, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome – Policlinico Umberto I Hospital, Rome, Italy
| | - Francesco Angelini
- Department of Experimental Medicine, Sapienza University of Rome – Policlinico Umberto I Hospital, Rome, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Nicola Di Paola
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome – Policlinico Umberto I Hospital, Rome, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Dario De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome – Policlinico Umberto I Hospital, Rome, Italy
| | - Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto Baldelli
- Endocrinology Unit, Department of Oncology and Medical Specialties, A.O. San Camillo-Forlanini, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome – Policlinico Umberto I Hospital, Rome, Italy
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
- Correspondence should be addressed to R Pofi or A M Isidori; or
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome – Policlinico Umberto I Hospital, Rome, Italy
- Correspondence should be addressed to R Pofi or A M Isidori; or
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30
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Pastores SM. Steroids in the acutely ill: Evolving recommendations and practice. Cleve Clin J Med 2022; 89:505-511. [PMID: 37907440 DOI: 10.3949/ccjm.89gr.22002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Critical illness-related corticosteroid insufficiency (CIRCI) is a state of systemic inflammation involving dysregulation of the hypothalamic-pituitary-adrenal axis, altered cortisol metabolism, and tissue resistance to corticosteroids. Many conditions may be associated with CIRCI, including sepsis, septic shock, acute respiratory distress syndrome, and severe community-acquired pneumonia. Recommendations and practice for diagnosing and treating this condition have evolved as information has emerged. Here, the author reviews the current thinking.
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Affiliation(s)
- Stephen M Pastores
- Program Director, Critical Care Medicine; Vice-Chair of Education, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center; Professor of Medicine in Anesthesiology and Medicine, Weill Cornell Medical College, New York, NY; researcher and member of guidelines committees on the use of corticosteroids in acutely ill patients
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31
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Kuhn E, Sanchez JR, Shakir MK, Hoang TD. Primary adrenal insufficiency masking as an adrenal B-cell lymphoma. BMJ Case Rep 2022; 15:15/9/e250973. [PMID: 36167431 PMCID: PMC9516216 DOI: 10.1136/bcr-2022-250973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We report here a woman in her 70s presenting with adrenal insufficiency secondary to a primary adrenal lymphoma. The patient had a previous history of aphthous ulcers on dexamethasone and was referred to endocrinology with symptoms of fatigue and orthostasis. Subsequent Cosyntropin stimulation showed primary adrenal insufficiency and adrenal CT demonstrated large infiltrative masses. Adrenal biopsy confirmed the diagnosis of primary adrenal lymphoma of the B-cell type. This case demonstrates the importance of including lymphoma in the differential diagnosis of adrenal insufficiency, particularly in the elderly population and in the setting of negative 21-hydroxlyase antibody results.
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Affiliation(s)
- Eric Kuhn
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - John R Sanchez
- Pathology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Mohamed Km Shakir
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
| | - Thanh Duc Hoang
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
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Mourinho Bala N, Gonçalves RS, Serra Caetano J, Cardoso R, Dinis I, Mirante A. Autoimmune Primary Adrenal Insufficiency in Children. J Clin Res Pediatr Endocrinol 2022; 14:308-312. [PMID: 35633647 PMCID: PMC9422918 DOI: 10.4274/jcrpe.galenos.2022.2021-11-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
Objective Primary adrenal insufficiency (PAI) is a rare condition in children, and is potentially life-threatening. The most common cause is congenital adrenal hyperplasia, and autoimmune etiology is the most frequent acquired cause in this age group. Symptoms are usually non-specific and, when suspected, investigation should include adrenocorticotropin hormone (ACTH) and morning serum cortisol measurement and, in some cases, a cosyntropin test to confirm the diagnosis. Prompt treatment is essential to prevent an adverse outcome. Methods We retrospectively collected clinical and laboratory data from adrenal insufficiency due to autoimmune adrenalitis, observed from 2015 to 2020 in a pediatric endocrinology department of a tertiary care hospital. Results Eight patients were identified, seven males and one female, with age at diagnosis between 14 and 17 years. The symptoms at presentation ranged from non-specific symptoms, such as chronic fatigue and weight loss, to a severe presentation, with altered mental status and seizures. The median duration of symptoms was 4.5 months. The diagnosis was confirmed by serum cortisol and plasma ACTH measurement and all were confirmed to have autoimmune etiology (positive anti-adrenal antibodies). At diagnosis, the most common laboratory abnormality was hyponatremia. All patients were treated with hydrocortisone and fludrocortisone. One patient presented with evidence of type 2 autoimmune polyglandular syndrome. Conclusion PAI is a rare condition in the pediatric age group. Due to non-specific symptoms, a high index of suspicion is necessary to establish a prompt diagnosis. Once an autoimmune etiology is confirmed, it is important to initiate the appropriate treatment and search for signs and symptoms of other autoimmune diseases during follow-up.
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Affiliation(s)
| | | | - Joana Serra Caetano
- Pediatric Hospital of Coimbra, Department of Pediatric Endocrinology, Diabetes and Growth, Coimbra, Portugal
| | - Rita Cardoso
- Pediatric Hospital of Coimbra, Department of Pediatric Endocrinology, Diabetes and Growth, Coimbra, Portugal
| | - Isabel Dinis
- Pediatric Hospital of Coimbra, Department of Pediatric Endocrinology, Diabetes and Growth, Coimbra, Portugal
| | - Alice Mirante
- Pediatric Hospital of Coimbra, Department of Pediatric Endocrinology, Diabetes and Growth, Coimbra, Portugal
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Suntharalingham JP, Ishida M, Del Valle I, Stalman SE, Solanky N, Wakeling E, Moore GE, Achermann JC, Buonocore F. Emerging phenotypes linked to variants in SAMD9 and MIRAGE syndrome. Front Endocrinol (Lausanne) 2022; 13:953707. [PMID: 36060959 PMCID: PMC9433874 DOI: 10.3389/fendo.2022.953707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background Heterozygous de novo variants in SAMD9 cause MIRAGE syndrome, a complex multisystem disorder involving Myelodysplasia, Infection, Restriction of growth, Adrenal hypoplasia, Genital phenotypes, and Enteropathy. The range of additional clinical associations is expanding and includes disrupted placental development, poor post-natal growth and endocrine features. Increasingly, milder phenotypic features such as hypospadias in small for gestational age (SGA) boys and normal adrenal function are reported. Some children present with isolated myelodysplastic syndrome (MDS/monosomy 7) without MIRAGE features. Objective We aimed to investigate: 1) the range of reported SAMD9 variants, clinical features, and possible genotype-phenotype correlations; 2) whether SAMD9 disruption affects placental function and leads to pregnancy loss/recurrent miscarriage (RM); 3) and if pathogenic variants are associated with isolated fetal growth restriction (FGR). Methods Published data were analyzed, particularly reviewing position/type of variant, pregnancy, growth data, and associated endocrine features. Genetic analysis of SAMD9 was performed in products of conception (POC, n=26), RM couples, (couples n=48; individuals n=96), children with FGR (n=44), SGA (n=20), and clinical Silver-Russell Syndrome (SRS, n=8), (total n=194). Results To date, SAMD9 variants are reported in 116 individuals [MDS/monosomy 7, 64 (55.2%); MIRAGE, 52 (44.8%)]. Children with MIRAGE features are increasingly reported without an adrenal phenotype (11/52, 21.2%). Infants without adrenal dysfunction were heavier at birth (median 1515 g versus 1020 g; P < 0.05) and born later (median 34.5 weeks versus 31.0; P < 0.05) compared to those with adrenal insufficiency. In MIRAGE patients, hypospadias is a common feature. Additional endocrinopathies include hypothyroidism, hypo- and hyper-glycemia, short stature and panhypopituitarism. Despite this increasing range of phenotypes, genetic analysis did not reveal any likely pathogenic variants/enrichment of specific variants in SAMD9 in the pregnancy loss/growth restriction cohorts studied. Conclusion MIRAGE syndrome is more phenotypically diverse than originally reported and includes growth restriction and multisystem features, but without adrenal insufficiency. Endocrinopathies might be overlooked or develop gradually, and may be underreported. As clinical features including FGR, severe infections, anemia and lung problems can be non-specific and are often seen in neonatal medicine, SAMD9-associated conditions may be underdiagnosed. Reaching a specific diagnosis of MIRAGE syndrome is critical for personalized management.
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Affiliation(s)
- Jenifer P. Suntharalingham
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Miho Ishida
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Ignacio Del Valle
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Susanne E. Stalman
- Department of Pediatrics, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Nita Solanky
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Emma Wakeling
- North East Thames Regional Genetic Service, Great Ormond Street Hospital, London, United Kingdom
| | - Gudrun E. Moore
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - John C. Achermann
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Federica Buonocore
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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Zawadzka K, Wilczyńska M, Sokołowski G, Hubalewska-Dydejczyk A, Trofimiuk-Müldner M. Adrenal crisis prompted by SARS-CoV-2 infection in a patient with autoimmune polyglandular syndrome type 1 (APS type 1). Endokrynol Pol 2022; 73:786-787. [PMID: 35971934 DOI: 10.5603/ep.a2022.0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 06/15/2023]
Abstract
Not required for Clinical Vignette.
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Affiliation(s)
- Karolina Zawadzka
- Students' Scientific Group of Endocrinology at the Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - Maja Wilczyńska
- Students' Scientific Group of Endocrinology at the Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Sokołowski
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
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Kim JH. Time to Care for Adrenal Insufficiency in Cancer Patients. J Korean Med Sci 2022; 37:e232. [PMID: 35851865 PMCID: PMC9294499 DOI: 10.3346/jkms.2022.37.e232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Falhammar H, Koskinen SK, Kistner A. Adrenal trauma experience at a major tertiary centre in Sweden: Clinical and radiological findings. Clin Endocrinol (Oxf) 2022; 97:28-35. [PMID: 35174528 PMCID: PMC9307021 DOI: 10.1111/cen.14697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Information on the incidence of adrenal trauma and its association with other injuries is limited. Our objective was to study the incidence of adrenal haemorrhage, its association with other injuries, clinical parameters, and long-term outcomes. PATIENTS AND MEASUREMENTS All patients treated for severe abdominal trauma (Level 1) at Karolinska University Hospital, Solna, between January 1, 2013 and December 31, 2018 were included. Patients with a radiological picture of adrenal haematoma were selected. The injury severity score (ISS) was analysed in the entire cohort. Data were collected from the electronic medical files. RESULTS In total, 1.7% (n = 29/1743) was affected by adrenal trauma. Right adrenal trauma (n = 20/29;69%) was more common than left (n = 6/29;21%, p < 0.01), and 10% were bilateral (n = 3/29). There was no difference in volume in right versus left adrenal trauma [(median 13 (interquartile range (IQR) (7-15) versus 8 (5-13)] ml, p = 0.30). ISS was 23.4 (17-43) in adrenal haematoma patients, higher compared with other trauma patients 16 (8-27) (n = 1714)(p < 0.001). Rib fractures, pneumothorax, and liver lacerations were the three most common findings in association with adrenal trauma. The underlying cause in 48% of the cases was falling from height (≥3 m). Biochemical data demonstrated normal sodium and potassium levels while the lowest haemoglobin level was 72 g/l. At follow-up, 4 (2-6) years after the trauma, except for three patients who died as in-patients, all other persons were still living. None seemed to have adrenal insufficiency. CONCLUSIONS Adrenal trauma is rare and does not seem to be associated with clinical features of adrenal insufficiency, even if the bleeding is bilateral.
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Affiliation(s)
- Henrik Falhammar
- Department of EndocrinologyKarolinska University HospitalStockholmSweden
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Seppo K. Koskinen
- Department of Clinical Science, Intervention, and Technology, Division for Radiology, Karolinska InstitutetStockholmSweden
| | - Anna Kistner
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Medical Radiation Physics and Nuclear Medicine, Karolinska University HospitalStockholmSweden
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Hsu CC, Lin HD, Huang CY, Chiang YL. Unusual manifestations of adrenal insufficiency: A case report of hypopituitarism and Well's syndrome after apoplexy of a silent pituitary gonadotropic adenoma. Medicine (Baltimore) 2022; 101:e29274. [PMID: 35665730 PMCID: PMC9276179 DOI: 10.1097/md.0000000000029274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/25/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Pituitary apoplexy occurs in about 8% of those with nonfunctioning pituitary adenoma. Subsequent hormone deficiency, especially corticotropic deficiency, is the most common finding. We describe the unusual manifestations of adrenal insufficiency that are usually overlooked in such cases, with the aim of raising awareness of this disease. PATIENT CONCERNS A 53-year-old male with a history of hyponatremia came to our hospital with intermittent fever and generalized pruritic skin rash. He also reported general weakness, abdominal pain, poor appetite, and severe retroorbital headache. DIAGNOSES Laboratory data revealed hypereosinophilia, hypotonic hyponatremia, and hypopituitarism, including secondary adrenal insufficiency. Sellar magnetic resonance imaging revealed a pituitary macroadenoma, 2 cm in height, with mild displacement of the optic chiasm. Pathologic report and immunohistochemical stains of surgical specimen showed pituitary gonadotropic adenoma with apoplexy. INTERVENTIONS Transsphenoidal removal of the pituitary adenoma was performed. The patient received intravenous hydrocortisone then oral form cortisone acetate regularly. OUTCOMES His symptoms and laboratory data recovered after the operation and medical treatment. LESSONS This case highlights that eosinophilia, pruritic skin rash and fever can be manifestations of adrenal insufficiency, and that they may initially be regarded as cellulitis.
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Affiliation(s)
- Chia-Chen Hsu
- Division of Endocrinology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Hong-Da Lin
- Department of Medicine, Taipei-Veterans General Hospital, Taipei, Taiwan
| | - Chung-Yen Huang
- Division of Endocrinology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Yi-Lun Chiang
- Division of Endocrinology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
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Abstract
INTRODUCTION Adrenal insufficiency is a disorder characterized by the failure of adrenocortical function because of distorted function of hypothalamic-pituitary- adrenal (HPA) axis. Pregnancy is a state of a physiological glucocorticoid excess as the HPA axis is functioning at a higher level. PURPOSE OF REVIEW The aim of the present review was to shed light on current evidence of adrenal insufficiency management during pregnancy, along with maternal and neonatal outcomes. RECENT FINDINGS A recent multicenter study under the auspices of the European Network for the Study of Adrenal Tumours (ENSAT) presented real-life data of pregnant women with adrenal insufficiency documenting an increased use of hydrocortisone (or mineralocorticoids when needed according to the level of disorder) replacement treatment, increased rates of caesarean section, preterm delivery and adrenal crises along with peripartum and postpartum complications but no maternal or neonatal fatality. These data were in agreement with those obtained from previously published studies. CONCLUSION The limited published evidence is in line with the present guidelines as real-life data did not document any increased fatality among pregnant women or newborns. Prospective data with prolonged follow-up are needed to shed more light on appropriate dose adjustments to avoid the risks of under-replacement or over-replacement of glucocorticoid and/or mineralocorticoid drugs and their sequelae. SUMMARY A recent multicenter study by ENSAT presented real-life data of pregnant women with adrenal insufficiency documenting an increased use of hydrocortisone as replacement treatment during pregnancy, along with an increased rate of caesarean section and preterm delivery, adrenal crises, peripartum and postpartum complications but no maternal or neonatal fatality. These data are in agreement with those of a previously published study and also confirm the statements made by the recent guidelines. Prospective data are needed aiming to develop precise therapeutic protocols during each trimester of pregnancy according to the different causes of adrenal insufficiency.
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Affiliation(s)
| | - Gregory A Kaltsas
- Endocrine Unit, First Department of Propaedeutic Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Téllez L, Guerrero A. Management of Liver Decompensation in Advanced Liver Disease (Renal Impairment, Liver Failure, Adrenal Insufficiency, Cardiopulmonary Complications). Clin Drug Investig 2022; 42:15-23. [PMID: 35522396 PMCID: PMC9205830 DOI: 10.1007/s40261-022-01149-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 12/17/2022]
Abstract
Systemic complications often occur in patients with advanced liver disease. In particular, the development of renal complications (acute kidney injury, hepatorenal syndrome), acute-on-chronic liver failure, cardiopulmonary diseases, or relative adrenal insufficiency can be serious in patients with advanced liver disease and may determine the patient’s quality of life and prognosis. Therefore, the early diagnosis of possible complications is the key to the prompt initiation of specific treatments that can improve quality of life and survival. For this purpose, networking with reference centers where multidisciplinary units are available is essential so that every patient is evaluated in clinical discussions involving specialists from different fields.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBERehd), Universidad de Alcalá, Ctra. Colmenar Viejo, km 9,100, 28034, Madrid, Spain.
| | - Antonio Guerrero
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBERehd), Universidad de Alcalá, Ctra. Colmenar Viejo, km 9,100, 28034, Madrid, Spain
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Mizuno T, Takahashi R, Kamiyama T, Suzuki A, Suzuki M. Neuroleptic Malignant Syndrome with Adrenal Insufficiency After BNT162b2 COVID-19 Vaccination in a Man Taking Valproate: A Case Report. Am J Case Rep 2022; 23:e936217. [PMID: 35514081 PMCID: PMC9087139 DOI: 10.12659/ajcr.936217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/03/2022] [Accepted: 03/11/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Considering the ongoing coronavirus disease 2019 (COVID-19) pandemic, sufficient information about common and serious adverse events is needed to rapidly distribute COVID-19 vaccines worldwide. We report a case of neuroleptic malignant syndrome (NMS) with adrenal insufficiency after initial vaccination with Pfizer/BioNTech BNT162b2. CASE REPORT A 48-year-old man presented to the Emergency Department with fever and an altered mental status 7 days after receiving the first dose of the BNT162b2 COVID-19 vaccine. The patient had a history of end-stage renal disease and epilepsy treated with valproate. He was diagnosed with NMS based on the clinical findings of hyperthermia, muscular rigidity, and an elevated creatine kinase level. Additionally, a reduction in the response of cortisol to adrenocorticotropic hormone (ACTH) stimulation was observed in the rapid ACTH stimulation test. The patient was treated with dantrolene, bromocriptine, and hydrocortisone, and he responded well to treatment. Dantrolene and bromocriptine were tapered off over 4 weeks. Hydrocortisone was also tapered, and the patient was discharged on oral hydrocortisone (30 mg). CONCLUSIONS The present case suggests a possible link between the BNT162b2 COVID-19 vaccine and NMS with adrenal insufficiency based on the temporal relationship between vaccine administration and disease onset, although the patient was taking valproate, a potential cause of NMS. Having a high level of suspicion is important because the diagnosis of NMS with adrenal insufficiency is often challenging due to non-specific clinical manifestations. However, this case does not negate the utility of vaccination because these complications are extremely rare and can be treated with early diagnosis and proper management.
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Mathavan A, Mathavan A, Mathavan M, Altshuler E. Management of adrenal insufficiency in the setting of chronic HIV and advanced extra-adrenal Hodgkin lymphoma. BMJ Case Rep 2022; 15:e249269. [PMID: 35246441 PMCID: PMC8900016 DOI: 10.1136/bcr-2022-249269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/04/2022] Open
Abstract
Adrenal insufficiency is one of the most common endocrine disorders that presents in patients with HIV. Aetiologies of adrenal dysfunction include opportunistic infection, malignancy, such as lymphoma or Kaposi sarcoma, and chronic cytokine-mediated disruption of the hypothalamic-pituitary-adrenal axis. In the case of lymphoma, the manifestation of adrenal insufficiency is most often via primary neoplastic infiltration. However, a spectrum of associated cytokine-mediated abnormal immune responses and coagulopathies may independently contribute to adrenal insufficiency. Literature regarding the presence of the endocrine disorder in patients with both HIV and lymphoma is scarce. We report a case of adrenal insufficiency in a patient with well-controlled HIV and advanced Hodgkin lymphoma without primary adrenal involvement with suboptimal response to corticosteroids who exhibited improvement following initiation of chemotherapy, demonstrating that chemotherapy should not be delayed until adrenal insufficiency resolves and in fact may aid in resolution of adrenal dysfunction.
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Affiliation(s)
- Akshay Mathavan
- Internal Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Akash Mathavan
- Internal Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Mohit Mathavan
- Internal Medicine, St George's University School of Medicine, Great River, New York, USA
| | - Ellery Altshuler
- Internal Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
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Kusz MJ, Gawlik AM. Adrenal insufficiency in patients with Prader-Willi syndrome. Front Endocrinol (Lausanne) 2022; 13:1021704. [PMID: 36465638 PMCID: PMC9714690 DOI: 10.3389/fendo.2022.1021704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
The generalized dysfunction of the hypothalamic-pituitary axis in patients with Prader-Willi syndrome (PWS) is the most likely cause of hypogonadism, inadequate growth hormone secretion, excessive appetite and associated obesity, impaired body temperature regulation, and hypothyroidism. The syndrome is also related to an increased risk of central adrenal insufficiency, although its prevalence remains unknown. The results of the studies in which different methods of pharmacological stimulation were used do not provide conclusive outcomes. As a result, there are no clear guidelines with regard to diagnosis, prevention, or long-term care when adrenal insufficiency is suspected in patients with PWS. Currently, most patients with PWS are treated with recombinant human growth hormone (rhGH). It has been confirmed that rhGH therapy has a positive effect on growth, body composition, body mass index (BMI), and potentially on psychomotor development in children with PWS. Additionally, rhGH may reduce the conversion of cortisone to cortisol through inhibition of 11β-hydroxysteroid dehydrogenase type 1. However, its influence on basal adrenal function and adrenal stress response remains unexplained in children with PWS. This paper reviews the literature related to the hypothalamic-pituitary-adrenal axis dysfunction in the PWS patient population with a focus on children.
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Affiliation(s)
- Marcin Jerzy Kusz
- Department of Pediatrics and Pediatric Endocrinology, Medical University of Silesia, Katowice, Poland
- The Faculty of Medical Sciences, The Doctoral School of the Medical University of Silesia, Katowice, Poland
- *Correspondence: Marcin Jerzy Kusz,
| | - Aneta Monika Gawlik
- Department of Pediatrics and Pediatric Endocrinology, Medical University of Silesia, Katowice, Poland
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Chrisp GL, Quartararo M, Torpy DJ, Falhammar H, Rushworth RL. Trends in hospital admissions for adrenal insufficiency in adolescents and young adults in the 21 st century. Front Endocrinol (Lausanne) 2022; 13:986342. [PMID: 36204108 PMCID: PMC9530131 DOI: 10.3389/fendo.2022.986342] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Very little is known about the epidemiology of adrenal crises (AC) and adrenal insufficiency (AI) in adolescents and young adults. METHODS Data on all admissions to Australian hospitals between 2000/1 to 2019/20 for a principal diagnosis of AI (including AC) in 10-24 year olds were extracted from a national repository. Age and sex-specific rates and age-adjusted rates were compared. FINDINGS Over the study, there were 3386 admissions for a principal diagnosis of AI; 24.0% (n=812) were for an AC and 50·7% (n=1718) were for secondary AI. Age-adjusted AI admissions increased from 31·70/million in 2000/1 to 54·68/million in 2019/20 (p<0·0001). Age-adjusted AC admissions also increased, most notably in the second decade (from 5·80/million in 2010/11 to 15·75/million in 2019/20) (p<0·00001). Average AI and AC admission rates were comparable between the sexes, but rates increased significantly in females, especially in those aged 20 to 24 years, whose AC rate in 2019/20 (39·65/million) was significantly higher than the corresponding rate in 2000/1 (3·15/million) (p<0·00001). Average age-adjusted SAI admission rates were higher in males (23·92/million) than females (15·47/million) (p<0·00001). However, SAI admission rates increased only among females (from 11·81/million to 22·12/million in 2019/20), with an increase in 20-24 year old females in the second decade from 5·07/million in 2010 to 20·42/million (p<0·00001). Age adjusted admissions for congenital adrenal hyperplasia, primary AI (PAI) and drug-induced AI did not change significantly over the study. INTERPRETATION AC/AI admissions increased over the first two decades of this century in the emerging adult population, particularly among females who also experienced a marked increase in AC admission rates, most evident in the second decade. Although uncertain, possible explanations include: dose of glucocorticoid replacement; non-adherence to therapy; psychosocial factors; and difficulty in transition to adult services. Admissions for SAI also increased, while rates of PAI and CAH remained constant.
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Affiliation(s)
| | - Maria Quartararo
- The University of Notre Dame, Australia, Darlinghurst, NSW, Australia
| | - David J. Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - R. Louise Rushworth
- The University of Notre Dame, Australia, Darlinghurst, NSW, Australia
- *Correspondence: R. Louise Rushworth,
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Zorko DJ, Samaan MC, Gupta R. Vomiting and Cardiac Arrest in a 10-Year-Old Girl. Pediatr Emerg Care 2021; 37:e1747-e1749. [PMID: 32011558 DOI: 10.1097/pec.0000000000001957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Primary adrenal insufficiency is a potentially life-threatening condition that provides a diagnostic challenge because many patients have months to years of insidious symptomatology. Adrenal crisis is the extreme acute manifestation of primary adrenal insufficiency, presenting with any, or all, of severe weakness, altered mental status, hypotension, and rarely cardiorespiratory arrest. Primary adrenal insufficiency should be considered in patients with clinical features of glucocorticoid and/or mineralocorticoid deficiency. These features however, such as hyperpigmentation, may be subtle, and so a degree of suspicion is needed to make the diagnosis. In extremis, children may present with fluid and catecholamine refractory shock. The management of an adrenal crisis includes prompt delivery of stress-dose corticosteroids together with aggressive organ support and correction of metabolic and electrolyte disturbances. We report the case of a previously healthy 10-year-old child that presented to a community emergency department in pulseless arrest, in whom adrenal crisis was suspected as well as treated early, and was subsequently successfully resuscitated.
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Affiliation(s)
- David J Zorko
- From the Department of Pediatrics, McMaster University
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Reece SW, Varikuti S, Kilburg-Basnyat B, Dunigan-Russell K, Hodge MX, Luo B, Madenspacher JH, Thomas SY, Tokarz DA, Tighe RM, Cook DN, Fessler MB, Gowdy KM. Scavenger Receptor BI Attenuates IL-17A-Dependent Neutrophilic Inflammation in Asthma. Am J Respir Cell Mol Biol 2021; 64:698-708. [PMID: 33647226 PMCID: PMC8456883 DOI: 10.1165/rcmb.2020-0007oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/26/2021] [Indexed: 12/20/2022] Open
Abstract
Asthma is a common respiratory disease currently affecting more than 300 million worldwide and is characterized by airway inflammation, hyperreactivity, and remodeling. It is a heterogeneous disease consisting of corticosteroid-sensitive T-helper cell type 2-driven eosinophilic and corticosteroid-resistant, T-helper cell type 17-driven neutrophilic phenotypes. One pathway recently described to regulate asthma pathogenesis is cholesterol trafficking. Scavenger receptors, in particular SR-BI (scavenger receptor class B type I), are known to direct cellular cholesterol uptake and efflux. We recently defined SR-BI functions in pulmonary host defense; however, the function of SR-BI in asthma pathogenesis is unknown. To elucidate the role of SR-BI in allergic asthma, SR-BI-sufficient (SR-BI+/+) and SR-BI-deficient (SR-BI-/-) mice were sensitized (Days 0 and 7) and then challenged (Days 14, 15, and 16) with a house dust mite (HDM) preparation administered through oropharyngeal aspiration. Airway inflammation and cytokine production were quantified on Day 17. When compared with SR-BI+/+ mice, the HDM-challenged SR-BI-/- mice had increased neutrophils and pulmonary IL-17A production in BAL fluid. This augmented IL-17A production in SR-BI-/- mice originated from a non-T-cell source that included neutrophils and alveolar macrophages. Given that SR-BI regulates adrenal steroid hormone production, we tested whether the changes in SR-BI-/- mice were glucocorticoid dependent. Indeed, SR-BI-/- mice were adrenally insufficient during the HDM challenge, and corticosterone replacement decreased pulmonary neutrophilia and IL-17A production in SR-BI-/- mice. Taken together, these data indicate that SR-BI dampens pulmonary neutrophilic inflammation and IL-17A production in allergic asthma at least in part by maintaining adrenal function.
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Affiliation(s)
- Sky W. Reece
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Sanjay Varikuti
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Brita Kilburg-Basnyat
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Katelyn Dunigan-Russell
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Myles X. Hodge
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Bin Luo
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Jennifer H. Madenspacher
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina
| | - Seddon Y. Thomas
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina
| | - Debra A. Tokarz
- Center for Human Health and the Environment, Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina; and
| | - Robert M. Tighe
- Department of Medicine, Duke University, Durham, North Carolina
| | - Donald N. Cook
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina
| | - Michael B. Fessler
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina
| | - Kymberly M. Gowdy
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Kannenberg S, Meyhöfer S, Lehnert H, Schmid SM. Petrifying: ears as hard as stone in adrenal insufficiency. Lancet Diabetes Endocrinol 2021; 9:406. [PMID: 33891887 DOI: 10.1016/s2213-8587(21)00112-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/03/2021] [Accepted: 04/02/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Swantje Kannenberg
- Institute for Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany; Department of Internal Medicine 1, Endocrinology and Diabetes, University Hospital Schleswig-Holstein Campus Lübeck, University of Lübeck, Lübeck, Germany
| | - Svenja Meyhöfer
- Institute for Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany; Department of Internal Medicine 1, Endocrinology and Diabetes, University Hospital Schleswig-Holstein Campus Lübeck, University of Lübeck, Lübeck, Germany; German Center for Diabetes Research, Neuherberg, Germany
| | - Hendrik Lehnert
- Institute for Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany; Department of Internal Medicine 1, Endocrinology and Diabetes, University Hospital Schleswig-Holstein Campus Lübeck, University of Lübeck, Lübeck, Germany; Paris-Lodron-University Salzburg, Salzburg, Austria
| | - Sebastian M Schmid
- Institute for Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany; Department of Internal Medicine 1, Endocrinology and Diabetes, University Hospital Schleswig-Holstein Campus Lübeck, University of Lübeck, Lübeck, Germany; German Center for Diabetes Research, Neuherberg, Germany.
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Martino M, Aboud N, Cola MF, Giancola G, Ciarloni A, Salvio G, Arnaldi G. Impact of COVID-19 pandemic on psychophysical stress in patients with adrenal insufficiency: the CORTI-COVID study. J Endocrinol Invest 2021; 44:1075-1084. [PMID: 32946078 PMCID: PMC7499003 DOI: 10.1007/s40618-020-01422-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/08/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE COVID-19 is a novel threat to patients with adrenal insufficiency (AI), whose life expectancy and quality (QoL) are impaired by an increased risk of infections and stress-triggered adrenal crises (AC). If infected, AI patients require prompt replacement tailoring. We assessed, in a cohort of AI patients: prevalence and clinical presentation of COVID-19; prevalence of AC and association with intercurrent COVID-19 or pandemic-related psychophysical stress; lockdown-induced emotional burden, and health-related QoL. METHODS In this monocentric (Ancona University Hospital, Italy), cross-sectional study covering February-April 2020, 121 (40 primary, 81 secondary) AI patients (59 males, 55 ± 17 years) completed telematically three questionnaires: the purpose-built "CORTI-COVID", assessing medical history and concern for COVID-19-related global health, AI-specific personal health, occupational, economic, and social consequences; the AddiQoL-30; the Short-Form-36 (SF-36) Health Survey. RESULTS COVID-19 occurred in one (0·8% prevalence) 48-year-old woman with primary AI, who promptly tailored her replacement. Dyspnea lasted three days, without requiring hospitalization. Secondary AI patients were not involved. No AC were experienced, but pandemic-related stress accounted for 6/14 glucocorticoid up-titrations. Mean CORTI-COVID was similar between groups, mainly depending on "personal health" in primary AI (ρ = 0.888, p < 0.0001) and "economy" in secondary AI (ρ = 0.854, p < 0.0001). Working restrictions increased occupational concern. CORTI-COVID correlated inversely with QoL. AddiQoL-30 and SF-36 correlated strongly. Comorbidities worsened patients' QoL. CONCLUSION If educational efforts are made in preventing acute events, AI patients seem not particularly susceptible to COVID-19. The novel "CORTI-COVID" questionnaire reliably assesses the pandemic-related emotional burden in AI. Even under unconventional stress, educated AI patients preserve a good QoL.
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Affiliation(s)
- M Martino
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - N Aboud
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - M F Cola
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - G Giancola
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - A Ciarloni
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - G Salvio
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - G Arnaldi
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy.
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Rushworth RL, Goubar T, Ostman C, McGrath S, Torpy DJ. Interaction between hypotension and age on adrenal crisis diagnosis. Endocrinol Diabetes Metab 2021; 4:e00205. [PMID: 33855208 PMCID: PMC8029553 DOI: 10.1002/edm2.205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/01/2020] [Indexed: 11/11/2022] Open
Abstract
Objective To determine whether adrenal crisis (AC) identification may be affected by the definition of hypotension. Context Delays in AC diagnosis can result in adverse outcomes. AC-related cardiovascular compromise may vary according to baseline blood pressure and may be associated with delayed AC detection in some patients. Design A retrospective study of paired systolic blood pressure (sBP) measurements in hospitalized patients with primary AI (PAI). Patients Patients with PAI and an acute illness admitted for urgent treatment between 2000 and 2017. Measurements A comparison between sBP on hospital arrival and on discharge. Hypotension was classified as either absolute hypotension (sBP 100mg or lower) or relative hypotension (sBP over 100 mg but at least 20 mm Hg lower than discharge sBP). Results Of 152 admissions with paired blood pressure measurements, 46 (30.3%) included a medically diagnosed AC. Absolute hypotension was found in 38 (25.0%) records, and a further 21 (13.8%) patients were classified as having relative hypotension. Patients aged 65 years and older had the lowest (14.8%, n = 8) proportion with absolute hypotension but the highest (27.8%, n = 15) with relative hypotension. Use of either absolute or relative hypotension as the criterion for AC diagnosis increased the proportion of patients with an AC by 28.3% and the proportion of patients with an AC in the oldest age group by 130%. Conclusions Failure to detect cardiovascular compromise is common in older AI patients, may underestimate the AC rate in this group, and delay essential treatment. Relative hypotension may play a role in AC diagnosis.
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Affiliation(s)
- R. Louise Rushworth
- School of Medicine, SydneyThe University of Notre DameDarlinghurstNSWAustralia
| | - Thomas Goubar
- School of Medicine, SydneyThe University of Notre DameDarlinghurstNSWAustralia
| | | | | | - David J. Torpy
- Endocrine and Metabolic UnitRoyal Adelaide Hospital and University of AdelaideAdelaideSAAustralia
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Carosi G, Morelli V, Del Sindaco G, Serban AL, Cremaschi A, Frigerio S, Rodari G, Profka E, Indirli R, Mungari R, Resi V, Orsi E, Ferrante E, Dolci A, Giavoli C, Arosio M, Mantovani G. Adrenal Insufficiency at the Time of COVID-19: A Retrospective Study in Patients Referring to a Tertiary Center. J Clin Endocrinol Metab 2021; 106:e1354-e1361. [PMID: 33107576 PMCID: PMC7665569 DOI: 10.1210/clinem/dgaa793] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Coronavirus disease 2019 (COVID-19) represents a global health emergency, and infected patients with chronic diseases often present with a severe impairment. Adrenal insufficiency (AI) is supposed to be associated with an increased infection risk, which could trigger an adrenal crisis. OBJECTIVE Our primary aim was to evaluate the incidence of COVID-19 symptoms and complications in AI patients. DESIGN AND SETTING We conducted a retrospective case-control study. All patients were on active follow-up and lived in Lombardy, Italy, one of the most affected areas. PATIENTS We enrolled 279 patients with primary and secondary AI and 112 controls (patients with benign pituitary lesions without hormonal alterations). All AI patients had been previously trained to modify their replacement therapy on stress doses. INTERVENTION By administering a standardized questionnaire by phone, we collected data on COVID-19 suggestive symptoms and consequences. RESULTS In February through April 2020, the prevalence of symptomatic patients (complaining at least 1 symptom of viral infection) was similar between the 2 groups (24% in AI and 22.3% in controls, P = 0.79). Highly suggestive COVID-19 symptoms (at least 2 including fever and/or cough) also occurred equally in AI and controls (12.5% in both groups). No patient required hospitalization and no adrenal crisis was reported. Few nasopharyngeal swabs were performed (n = 12), as indicated by sanitary regulations, limiting conclusions on the exact infection rate (2 positive results in AI and none in controls, P = 0.52). CONCLUSIONS AI patients who are adequately treated and trained seem to display the same incidence of COVID-19-suggestive symptoms and disease severity as controls.
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Affiliation(s)
- Giulia Carosi
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Valentina Morelli
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Correspondence and Reprint Requests: Valentina Morelli, Endocrinology Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy. E-mail:
| | - Giulia Del Sindaco
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Andreea Liliana Serban
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Arianna Cremaschi
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Sofia Frigerio
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Giulia Rodari
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Eriselda Profka
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Rita Indirli
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Roberta Mungari
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Veronica Resi
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuela Orsi
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessia Dolci
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Giavoli
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
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Neumann U, Braune K, Whitaker MJ, Wiegand S, Krude H, Porter J, Digweed D, Voet B, Ross RJM, Blankenstein O. A Prospective Study of Children Aged 0-8 Years with CAH and Adrenal Insufficiency Treated with Hydrocortisone Granules. J Clin Endocrinol Metab 2021; 106:e1433-e1440. [PMID: 32888021 PMCID: PMC7947757 DOI: 10.1210/clinem/dgaa626] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT Children with congenital adrenal hyperplasia (CAH) and adrenal insufficiency (AI) require daily hydrocortisone replacement with accurate dosing. OBJECTIVE Prospective study of efficacy and safety of hydrocortisone granules in children with AI and CAH monitored by 17-OHP (17-hydroxyprogesterone) saliva profiles. METHODS Seventeen children with CAH (9 male) and 1 with hypopituitarism (male), aged from birth to 6 years, had their hydrocortisone medication changed from pharmacy compounded capsules to hydrocortisone granules. Patients were followed prospectively for 2 years. In children with CAH, the therapy was adjusted by 17-OHP salivary profiles every 3 months. The following parameters were recorded: hydrocortisone dose, height, weight, pubertal status, adverse events, and incidence of adrenal crisis. RESULTS The study medication was given thrice daily, and the median duration of treatment (range) was 795 (1-872) days, with 150 follow-up visits. Hydrocortisone doses were changed on 40/150 visits, with 32 based on salivary measurements and 8 on serum 17-OHP levels. The median daily mg/m2 hydrocortisone dose (range) at study entry for the different age groups 2-8 years, 1 month to 2 years, <28 days was 11.9 (7.2-15.5), 9.9 (8.6-12.2), and 12.0 (11.1-29.5), respectively, and at end of the study was 10.2 (7.0-14.4), 9.8 (8.9-13.1), and 8.6 (8.2-13.7), respectively. There were no trends for accelerated or reduced growth. No adrenal crises were observed despite 193 treatment-emergent adverse events, which were mainly common childhood illnesses. INTERPRETATION This first prospective study of glucocorticoid treatment in children with AI and CAH demonstrates that accurate dosing and monitoring from birth results in hydrocortisone doses at the lower end of the recommended dose range and normal growth, without occurrence of adrenal crises.
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Affiliation(s)
- Uta Neumann
- Charité Universitaetsmedizin Berlin, Berlin, Germany
- Correspondence and Reprint Requests: Uta Neumann, Charité-Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail:
| | | | | | | | - Heiko Krude
- Charité Universitaetsmedizin Berlin, Berlin, Germany
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