Increased ACTH Levels Research Articles

8169 Bilateral Inferior Petrosal Sinus Sampling Using Metyrapone as a Reliable Alternative to Differentiate Between Cushing Disease and Ectopic ACTH Syndrome- A Single Center Experience

Abstract Disclosure: M. Azmath: None. S. Faisal: None. C. Caetano: None. T. Vedere: None. H. Aftab: None. B. Tendler: None. C. Malchoff: None. Introduction: Bilateral IPSS is a crucial test in accurately diagnosing Cushing disease (CD) and differentiating it from ectopic ACTH syndrome (EAS). [1] CRH stimulated IPSS is the gold standard technique but cannot be performed due to current shortage of CRH. Metyrapone is a safe and reliable alternative to CRH that can stimulate corticotrophs to secrete ACTH and hence used for IPSS. [2] We would like to share a single center experience using a novel low dose metyrapone protocol for IPSS that successfully helped differentiate CD and EAS. Methods: This was a retrospective analysis of patients presenting with Cushing syndrome. Initial diagnosis was confirmed based on standard testing including 24-hour urinary free cortisol (UFC), late night saliva concentrations (LNSC) and MRI. Metyrapone 500 mg every 4 hours for 3 doses was administered orally starting midnight prior to IPSS performed in the morning. ACTH levels drawn during initial evaluation for Cushing syndrome was compared to ACTH values post metyrapone from the peripheral vein sample to calculate a gradient. Ultimately, pituitary CD or EAS was confirmed based on cure following surgery and /or positive ACTH of tumor staining on pathology and/or concordant results with CRH stimulated IPSS. Results: There were 9 patients, out of which 5 had pituitary CD, and 4 had EAS. Pre ACTH levels for patients ranged between 14.5 and1164 pg/ml (normal reference range 6-50). Following metyrapone, ACTH level rose to 40-4705 pg/ml (normal reference range 6-50). The increase in ACTH levels ranged from 81-547% pre and post metyrapone. An average of 5-6 ACTH samples were drawn during IPSS. Catheterization was successful in all patients and was confirmed by IR. The mean central to peripheral (C/P) ACTH ratio for patients with confirmed CD was 20.53 in comparison with a ratio of 1.34 in patients with EAS. IPSS was confirmed to be diagnostic for pituitary CD if the peak ratio after metyrapone administration was more than 3. No adverse effects were observed during or after the procedure and no hospitalization was required pre-procedure. Discussion: We present single center experience with a novel low dose metyrapone protocol for IPSS. Our protocol was successful in increasing ACTH/cortisol secretion by tumorous cells as evidenced by increase in ACTH levels post metyrapone. It is an easy oral protocol which proved to be safe without the risk for adrenal insufficiency that can occur with higher doses. It also mitigates the small thromboembolic risk that can occur with DDAVP administration. A clear distinction in C/P ACTH ratios was observed in patients with CD versus EAS as early as the 3rd sample. In conclusion, our low dose metyrapone protocol was safe and reliable in accurately differentiating between CD and EAS in small sample of patients at our institution. Presentation: 6/1/2024

8411 Ectopic ACTH-dependent Cyclical Cushing’s Syndrome- the Art of Hide-and-seek

Abstract Disclosure: H. Mon: None. A. Kapoor: None. S. Qureshi: None. M. Martineau: None. K. Meeran: None. Case report: A 72-years-old lady was admitted with hypokalaemia, hyperglycaemia with metabolic alkalosis with background hypertension, type2 diabetes, osteoporosis and right-sided breast cancer treated with chemotherapy and radiotherapy 3years ago. She was previously seen in Endocrinology Clinic for similar episode and deemed not having Cushing’s or Conn’s syndrome on workup. During this admission, although there was no obvious Cushingoid appearance, there was refractory hypokalaemia. On further exploration, there were previous admissions with similar episodes in UK and in her home country, within the same year, a few months apart. Therefore, endocrinology workup was conducted for suspected cyclical Cushing’s syndrome. It demonstrated raised 24-hour urinary free cortisol of 5643 nmol/24hour (reference range 0-164 nmol/24hours), unsuppressed low dose dexamethasone suppression test with cortisol level of 800 nmol/L and increased ACTH level of 429 ng/L. MRI (pituitary) showed no pituitary lesion with probable empty sella and CSF filled. However, CT (thorax) showed enlarging lesion (previously from 1cm to 1.6cm) in the left lower lobe, concerning lung metastasis or primary lung malignancy. PET scan showed left lower lobe nodule having low-grade activity with likelihood of indolent malignancy and appearances of physiologic adrenal hyperplasia. Management: Given persistently high cortisol levels during admission with ongoing hyperglycaemia and refractory hypokalaemia, metyrapone was started and titrated accordingly. Her clinical condition including potassium and cortisol levels effectively responded to metyrapone. Gallium scan was booked for detail localization with ongoing lung MDT (multidisciplinary team meeting) and neuroendocrine tumour MDT.However, after starting metyrapone, she had type 1 respiratory failure, not responding to initial antibiotics. After excluding other possible respiratory aetiologies, empirical treatment for Pneumocystosis pneumonia (PCP) was initiated, after which blood test for Beta-D-glucan was found out to be significantly raised, supporting the presumptive diagnosis. Conclusion: Our case highlighted the following interesting points 1. diagnostic challenges, due to the fluctuating nature of cyclical Cushing’s syndrome, presenting with recurrent hypokalaemia. 2. the interesting nature of likely ACTH-dependent cyclical Cushing’s syndrome, progressing into florid Cushing’s syndrome, with efficacy to metyrapone 3. rare and compelling combination of 3 conditions of Cyclical Cushing’s syndrome, being ectopic ACTH-dependent and complicated by Pneumocystosis pneumonia (PCP). Presentation: 6/1/2024

Alterations in Serum miR-126-3p Levels over Time: A Marker of Pituitary Insufficiency following Head Trauma

Introduction: Traumatic brain injuries (TBIs) pose a high risk of pituitary insufficiency development in patients. We have previously reported alterations in miR-126-3p levels in sera from patients with TBI-induced pituitary deficiency. Methods: To investigate why TBI-induced pituitary deficiency develops only in some patients and to reveal the relationship between miR-126-3p with hormone axes, we used mice that were epigenetically modified with miR-126-3p at the embryonic stage. These modified mice were subjected to mild TBI (mTBI) according to the Marmarou’s weight-drop model at 2 months of age. The levels of miR-126-3p were assessed at 1 and 30 days in serum after mTBI. Changes in miR-126-3p levels after mTBI of wild-type and miR-126-3p* modified mouse lines validated our human results. Additionally, hypothalamus, pituitary, and adrenal tissues were analyzed for transcripts and associated serum hormone levels. Results: We report that miR-126-3p directly affects hypothalamus-pituitary-adrenal (HPA) axis upregulation and ACTH secretion in the acute phase after mTBI. We also demonstrated that miR-126-3p suppresses Gnrh transcripts in the hypothalamus and pituitary, but this is not reflected in serum FSH/LH levels. The increase in ACTH levels in the acute phase may indicate that upregulation of miR-126-3p at the embryonic stage has a protective effect on the HPA axis after TBI. Notably, the most prominent transcriptional response is found in the adrenals, highlighting their role in the pathophysiology of TBI. Conclusion: Our study revealed the role of miR-126-3p in TBI and pituitary deficiency developing after TBI, and the obtained data will significantly contribute to elucidating the mechanism of pituitary deficiency development after TBI and development of new diagnostic and treatment strategies.

SAT275 Generation And Characterization Of A Humanized CYP21A2 Mouse Model For Congenital Adrenal Hyperplasia

Abstract Disclosure: A. Huebner: None. S. Thirumalasetty: None. T. Schubert: None. R. Naumann: None. I. Reichardt: None. M. Rohm: None. D. Landgraf: None. F. Gembardt: None. M.F. Hartmann: None. S.A. Wudy: None. M. Peitzsch: None. N. Reisch: None. K. Koehler, PhD: None. 21-hydroxylase deficiency (21OHD) is the most common form of congenital adrenal hyperplasia (CAH) and is caused by mutations in the CYP21A2 gene. 21OHD causes a wide array of clinical symptoms that result from gluco- and mineralocorticoid deficiency and adrenal androgen excess. Treatment firstly aims to substitute lacking steroid hormones, and secondly to restore negative feedback towards CRH and pituitary ACTH secretion to diminish adrenal androgen overproduction. In most cases supra-physiological glucocorticoid doses are necessary which may cause short stature, obesity, hypertension, and cardiovascular and metabolic co-morbidity with reduced quality of life. Hence, current steroid substitution regimens have significant limitations, so novel therapeutic strategies are required. In recent years new therapeutic approaches have emerged including new non-glucocorticoid substances interfering with the HPA axis to minimize adrenal androgen production and to lower external glucocorticoid substitution to physiological levels. However, valuable in-vivo models for pre-clinical testing of such drugs are lacking. Here we present the first viable and humanized mouse model in which the mouse gene Cyp21a1 is replaced by the human orthologue CYP21A2 in which the human point mutation R484Q is integrated. Twenty-weeks-old homozygous mice show marked adrenal hyperplasia, enhanced expression of the CYP21A2 gene and a weak increase of Cyp11a1 and Cyp11b2 gene expression. Tandem mass spectrometry measurements of the mice plasma at 20 weeks show decreased corticosterone and 11-deoxycorticosterone levels in the presence of increased ACTH levels in both male and female homozygous animals. Progesterone levels in homozygous mice are significantly higher (p<0.01) than in wildtype mice. We also observed increased aldosterone levels in female mutants whereas blood pressure does not differ between wildtype and mutant mice strains. Histologically, mutants exhibit adrenocortical hyperplasia. While mutant male mice are fertile with normal appearing testes, females are infertile, remain in the diestrus phase and present with a reduced number of ovarian follicles. In parallel, a second mouse strain bearing the I173N mutation was developed. This mutation is frequent in human patients causing simple virilizing or rarely salt wasting CAH. Homozygous mice require dexamethasone treatment during pregnancy and until weaning but are viable without treatment afterwards. Preliminary results show adrenal hyperplasia and alteration in steroidogenic gene expression and steroid profiles. In conclusion, we demonstrate that the humanized mutant CYP21A2 mice may represent an excellent animal CAH model to test novel treatment strategies for CAH patients. We believe that this model(s) will facilitate the transition from basic research into clinical application. Presentation: Saturday, June 17, 2023

Abstract #1393024: A Rare Case of ACTH-Producing Pituitary Carcinoma in Nelson’s Syndrome

A 55-year-old male with Nelson's Syndrome was originally diagnosed with Cushing’s disease 5 years prior after the identification of a 15 x 13 mm pituitary adenoma and ACTH 174 pg/mL. He had typical symptoms including proximal weakness, easy bruising, abdominal striae, weight gain, and atraumatic vertebral fractures. Pathology following TSRPT at that time showed an ACTH-producing tumor with MIB1 index 20%. He had initial improvement of his Cushing's stigmata but one year later developed proximal muscle weakness, hypokalemia requiring replacement, worsening diabetes, and weight gain. Repeat MRI was negative for new/recurring lesion. One and a half years after initial TSRPT, he started on ketoconazole 400 mg three times daily and cabergoline 1 mg TID as a repeat MRI showed a recurring pituitary lesion measuring 13 x 14 x 9 mm with corresponding ACTH level 159 pg/mL. He underwent radiotherapy with 20 Gy in one fraction and two months later underwent bilateral adrenalectomy with cessation of ketoconazole and cabergoline. Two years later, his ACTH level increased to 1,342 pg/mL and he underwent another fraction of radiotherapy of 20 Gy. A repeat MRI showed a decrease in the size of pituitary lesion. However, eight months later, his ACTH levels peaked at 45,510 pg/mL and he underwent a second TSRPT and a stereotactic radiosurgery series of 54 Gy in 30 fractions over three months. Surgical pathology showed a low-grade neuroendocrine neoplasm without any mitotic figures and an MIB-1 index 15% Two months following the SRS series, his ACTH levels peaked at 188,567 pg/mL. He presented to the ED for abdominal pain and CT Abdomen showed possible metastatic lesions in the liver, one of which was subsequently biopsied and positive for pituitary carcinoma. He is currently undergoing capecitabine chemotherapy and an SRS series to the liver with plans to add temozolomide upon completion of the SRS. A key learning point is to suspect metastatic disease with drastic ACTH increases. PET scan imaging is recommended in a patient with rapid or significant increase in ACTH level with or without progression of a lesion centrally. Additionally, although the original histology did not show carcinoma, the elevated MIB-1 index should raise the suspicion for malignant possibility and therefore, increased surveillance. Functional pituitary carcinoma has the twofold task of treating the excess hormone production and controlling the spread of metastatic disease. Given the rarity of this type of cancer, a multi-disciplinary approach best serves the patient including endocrinology, oncology, (neurological) surgery, and radiation oncology. More data and studies are needed to definitively assess efficacy of chemotherapeutics including capecitabine and temozolomide for these types of tumors.

PMON98 High-dose dexamethasone suppression test in ACTH-dependent Cushing's syndrome: Lessons learned on the lack of cortisol suppression

Abstract Background The overnight 8-mg high-dose dexamethasone suppression test (HDDST) has been used to discern Cushing's disease from ectopic ACTH production. However, because of its reported low diagnostic accuracy, its use is limited to the assessment of ACTH-dependent Cushing's disease when combined with a corticotropin releasing hormone (CRH) or a desmopressin stimulation test. We evaluated a patient with Cushing's disease in whom the HDDST failed to identify the pituitary source. We point to limitations in test interpretation and highlight the need of future studies to enhance understanding of the clinical utility of this non-invasive test. Clinical Case A 42-year-old male presented with lower extremity cellulitis and hypertensive emergency. He reported increased abdominal girth, easy bruising, severe back pain and proximal muscle weakness and noted headache and blurred vision. Exam was pertinent for obesity (body mass index 31.5 kg/m2), moon facies, dorso-cervical hump and prominent abdominal striae. Lumbar and thoracic compression fractures were noted on imaging. The elevated 24-hour urinary free cortisol level (198 ug/dL; reference: 10-100 ug/24hr) and lack of suppression on the overnight 1-mg dexamethasone suppression test (morning cortisol 23.7 ug/dL) confirmed Cushing's syndrome; a high ACTH level of 92 pg/dL defined it as ACTH-dependent. The 8-mg HDDST resulted in only a 9.7% reduction of his baseline morning cortisol. The patient was not on any medications that enhanced dexamethasone clearance. Serum dexamethasone levels were measured to aid in test interpretation and, although a level was provided, reference values for the single overnight 8-mg dose of dexamethasone were lacking. A CRH stimulation test was performed and resulted in a 60% increase in ACTH levels from baseline, supporting the diagnosis of Cushing's disease. Additionally, a pituitary MRI revealed a suprasellar 2.5×1.5×1.3 cm mass. Due to ambiguity posed by the HDDST result, despite tumor size, neurosurgery requested inferior petrosal sinus sampling (IPSS). Prior to this procedure, the patient underwent an overnight 16-mg HDDST. While limited information remains on the diagnostic performance of this test, we observed that the baseline morning cortisol decreased by 53.9%. IPSS confirmed the diagnosis of Cushing's disease and pathology identified a corticotroph adenoma. Conclusion The diagnosis of Cushing's disease is complex and recommendations continue to evolve. Th role of the HDDST in combination with another dynamic test remains clinically relevant. It is important that when considering a HDDST, clinicians review medication history to exclude agents that may interfere with dexamethasone metabolism. Our case highlights the need of studies that determine an appropriate reference range for dexamethasone plasma levels after a single 8-mg overnight dose and that evaluate the diagnostic performance of the HDDST in this context. It also brings attention to the need of further elucidating the diagnostic utility of a higher dexamethasone dose in the evaluation of ACTH-dependent Cushing's syndrome. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Bilateral Synchronous Testicular Mass from Testicular Adrenal Rest Tumors, in a Patient with Congenital Adrenal Hyperplasia, or Testicular Leydig Cell Tumors? Dilemma for Bilateral Orchiectomy or Not

Congenital adrenal hyperplasia (CAH) refers to a group of autonomic disorders due to enzyme deficiency for the biosynthesis of steroid hormones. These disorders entail an increase in ACTH levels and as followed by adrenal hyperplasia. CAH is categorized into two types, classic and non-classic. In the common type we have a deficiency of 21-hydroxylase observed in a prevalence of 1 per 5000 per 145,000 births. We have insufficient aldosterone and cortisol production and as a result, elevated plasma ACTH levels, with subsequent disorders that this entails, depending on the level of deficiency. Testicular adrenal rest tumor (TART) develops from isletsectopic adrenal tissue within the gonads, directly affected by ACTH overproductions a complication of CAH, with a prevalence ranging from 27% to 47%. These are benign tumors that are recognized as palpable masses. A biopsy of these tumors is recommended as well as their surgical removal, so as to rule out malignancy. In this case report we present a case of bilateral synchronous TART tumor in association with medullolipoma in a patient with CAH. The dilemma arises regarding the decision of bilateral orchiectomy.

Histological and Hormonal Study of the Protective Effect of the Calotropis Procera Against the Toxicity of Mercury Chloride

We undertook this study with the aim of investigating the detoxification of an extreme toxic metal mercury chloride by the Calotropis procera plant taken from the Algerian Sahara. We studied the protective effects of the plant Calotropis procera against renal toxicity and Mercury chloride-induced hepatic. Ten male and female albino rats Wistar were divided into four equal groups. Group (I) served as a healthy control group, group (II) were intra-peritoneal administered with 10 ml of Calotropis procera, group (III) were intra-peritoneal administrated with both 10 ml of the plant Calotropis procera and 0.2 mg of mercuric chloride (HgCl2) and group (IV) were intraperitoneal administrated with both 0.2 mg of mercuric chlorid (HgCl2) and 10 ml of the plant Calotropis. All groups were treated for 20 days. Mercury chloride causes a slight increase in glomerular cellularitis in the kidneys of male and female rats. Treatment with Calotropis procera had significantly improving protective effects of kidney of female rats from toxicity of mercuric chloride. Calotropis procera causes a thyroid-like appearance in the glomeruli of the male kidneys to hide the lesions of mercury chloride. Our results have shown that the plant Calotropis procera completely protects the liver of female rats against the toxicity of mercury chloride. In the liver of male rats, mercury chloride causes macro-vacuolar steatosis. Treatment with Calotrpois procera hid the hepatic steatosis of male rats and centralized them in the center under the aspect of peri-centro-lobular medio-vacuolar steatosis. Mercuric chloride caused a decrease in the secretion of the hormone ACTH in the group of male and female rats. Treatment with Calotropis procera caused increased ACTH levels in female rats and did not cause ACTH changes in male rats. Our results demonstrate from hormone analyzes of the hormone ACTH that female rats are resistant more than male rats via the toxicity of mercury chloride.

Impaired dexamethasone resorption in two patients with pseudo‐Cushing after bariatric surgery: Implications for immunosuppressive treatment

Two cases of middle-aged female patients treated by gastric bypass surgery for weight loss presented to our clinic for a follow-up examination 3-6 months after the surgical procedure (a mini gastric bypass and a modified single anastomosis sleeve-ileostomy). In both patients increased ACTH levels and either high serum cortisol or an increased urinary cortisol excretion was apparent and triggered further endocrine testing. Serum cortisol could not be suppressed adequately by 2 and 4 mg dexamethasone in the standardized oral overnight suppression test while midnight salivary cortisol dropped well below the desired cut-off. This led to the hypothesis of an impaired dexamethasone resorption and could be further substantiated by suppression of serum cortisol below the cut-off by an intravenous dexamethasone application. The data presented point to an impairment of enteral synthetic corticosteroid resorption in patients after gastric bypass surgery and could be of importance for individuals in need for immunosuppressive treatment. In view of the growing number of bariatric procedures, pharmacokinetics of corticosteroids and other drugs should be tested in clinical trials.

GENETICS IN ENDOCRINOLOGY: Glucocorticoid resistance syndrome

Glucocorticoids (GC) such as cortisol regulate multiple physiological functions, notably those involved in development, metabolism, inflammatory processes and stress, and exert their effects upon binding to the glucocorticoid receptor (GR, encoded by NR3C1 gene in humans). GC signaling follows several consecutive steps leading to target gene transactivation, including ligand binding, nuclear translocation of ligand-activated GR complexes, DNA binding, and recruitment of functional transcriptional machinery. Generalized glucocorticoid resistance syndrome, due to GR loss-of-function mutations, may be related to the impairment of one of the GC signaling steps. To date, 31 NR3C1 loss-of-function mutations have been reported in patients presenting with various clinical signs such as hypertension, adrenal hyperplasia, hirsutism or metabolic disorders associated with biological hypercortisolism but without Cushing syndrome signs and no negative regulatory feedback loop on the hypothalamic-pituitary-adrenal axis. Functional characterization of GR loss-of-function mutations often demonstrates GR haploinsufficiency and a decrease of GR target gene induction in relevant cell types. The main signs at presentation are very variable from resistant hypertension, bilateral adrenal hyperplasia likely related to increased ACTH levels but not exclusively, hirsutism to isolated renin-angiotensin-aldosterone system abnormalities in a context of 11βHSD2 deficiency. Some mutated GR patients are obese or overweight together with a healthier metabolic profile that remains to be further explored in future studies. Deciphering the molecular mechanisms altered by GR mutations should enhance our knowledge on GR signaling and ultimately facilitate management of GC-resistant patients. This review also focuses on the criteria facilitating identification of novel NR3C1 mutations in selected patients.

Histological study of the effect of tributyltin on the adrenal cortical cells of adult male albino rats.

Background: Tributyltin is widely used as antifouling paint for marine vessels. It is slowly released from the paint to the water and becomes incorporated into soil, animals and plants. TBT has been identified as an endocrine disruptor and induces oxidative damage. Objectives: This study aimed to investigate the probable toxic effect of tributyltin on adrenal cortical cells of adult male albino rats for two different durations. Materials and Methods: Twenty four adult male albino rats were divided into 3 equal groups: Group I: was the control group; Group II: each rat received tributyltin orally at a dose of 1mg daily for one week. Group III: received the same daily dose for successive two weeks. At the end of the experiment, the animals were sacrificed and blood samples were subjected to hormonal assay for aldosterone, corticosterone and ACTH levels. Serum tin levels were assessed. The adrenal tissue was processed for light and electron microscopic examination. In addition, immunoreaction for CD 44 positive was performed. Results: A significant decrease in aldosterone and corticosterone, an increase in ACTH levels and an increase in the mean count of CD44 positive cells in group III have been revealed when compared with the other groups. Histological changes in group II were shown in zona glomerulosa and fasciculata in the form of loss of architecture, cytoplasmic vacuolation and disrupted mitochondrial cristae. Meanwhile, Group III showed few lipid droplets and deeply stained nuclei in both zones. Conclusion: Tributyltin has deleterious effects on cells of zona glomerulosa and zona fasciculata of the adrenal cortex of adult male albino rats which were time-dependent.

SUN-368 Fatty Hypertrophy of the Hip as a Clinical Manifestation of Cushing Syndrome

Background: Increased fat deposition is a hallmark of exogenous and endogenous hypercortisolism (Cushing’s syndrome, CS). Fat accumulates not only in the abdomen and liver, but also in unusual locations such as the temporal and supraclavicular fossae, intrascapular fat pads and spinal epidural space (1). Here we describe, to our knowledge, the first report of intracapsular fat deposition at the hip in a patient (pt) with CS. Case Presentation: A 47 year old African American male presented with a six year history of diabetes and hypertension. He also reported abdominal weight gain, moodiness, facial flushing, blurry vision, fatigue, joint aches (especially knee and hips), muscle weakness leading to falls, difficulty with ambulation, straie, and decreased memory. Physical exam on admission revealed a rounded face with bitemporal fat pads, supraclavicular and dorsocervical fat pads, central obesity, +1 pitting edema of the lower extremities, 4/5 strength in shoulders and hips, ankle flexion and hand grip strength 5/5, wide violaceous striae on the abdomen. Biochemical evaluation revealed urine free cortisol 1460.8 and 1031.2 mcg/24h (ref: 3.5-45 mcg/24h), and plasma ACTH levels of 51.3-158 pg/ml (ref:5-46pg/ml). Pituitary MRI showed an 8mm lesion, CRH stimulation test showed 52% increase in cortisol level (29.8 to 43.1 mcg/dl) and a 79% increase in ACTH level, (95.9 to 175 pg/ml), suggestive of Cushing’s disease. However, cortisol increased by 41% after 8mg dexamethasone (23.2 to 32.8 mcg/dL), and IPSS also was consistent with an ectopic source of ACTH. A 10mm right hilar lesion was identified by CT, MRI, and 68Ga-DOTATATE. While awaiting surgical resection, pt was treated with ketoconazole and metyrapone. Three weeks after initiation of medical therapy, pt reported new unprovoked bilateral hip pain with antalgic gait. MRI hip revealed only bilateral symmetric intracapsular fat abutting the superolateral aspects of the femur in the subcapital region. There was no evidence of avascular necrosis of bone, osteoarthritis, or collagen tear. Physiatry evaluation reported functional hip strength in the 4- range, hip extension bilaterally 2+, unchanged ability from a prior admission to stand from sitting position without the use of upper extremities, and ability to ambulate independently across a room, but necessary use of a single point cane for longer distances. Physical therapy noted a decline in his mobility status since last visit, and recommended use of a wheeled walker. Discussion: This is the first time we have identified a patient with increased fat in the hip joint explained by no other comorbidities other than Cushing’s Syndrome. This new finding adds another unusual location for increased adipose in the clinical presentation of patients with CS. Further studies are needed to better assess the correlation between the finding of intracapsular hip fat, pain and hypercortisolism.

Analysis of clinical manifestations and gene mutations of 13 child patients with rare causes of primary adrenal insufficiency

Objective To analyze the clinical manifestations and gene mutations of rare causes of primary adrenal insufficiency (PAI) in childhood. Methods The clinical features, laboratory tests and gene mutation of 13 patients with PAI in our hospital from September 2010 to August 2017 were analyzed retrospectively. Patients with congenital adrenal hyperplasia, X-linked adrenoleukodystrophy with neurological onset or a clear family history, and autoimmune adrenal insufficiency were excluded. Results The median age of 13 cases (12 males, 1 female) was 3 years and 10 months. Medical history or clinical manifestations on the first visit included hyperpigmentation, electrolyte imbalance/salt-wasting crisis, gastrointestinal symptoms, and fatigue, etc. All developments of external genitalia were normal. All cases presented with decreased serum cortisol and increased ACTH levels. Some of the cases showed decreased aldosterone level and plasma renin activity, while 17α-hydroxyprogesterone, testosterone, and androstenedione were in the normal range. Part of cases revealed delayed bone age and adrenal atrophy. Three gene mutations were detected in 13 patients, including NR0B1 gene (9/13), ABCD1 gene (3/13), and CYP11A1 gene (1/13). NR0B1, and ABCD1 gene mutations were pathogenic mutations, consistent with clinical characteristics. CYP11A1 gene mutation was heterozygote, which cannot fully explain the clinical features. Conclusion PAI in childhood presents common clinical manifestations of adrenal insufficiency, e. g. hyperpigmentation and electrolyte imbalance/salt-wasting crisis, but without specificity. Gene mutational analysis is necessary for precise diagnosis and prognosis estimation. NR0B1 and ABCD1 gene mutations were common in childhood with rare causes of PAI. Key words: Primary adrenal insufficiency; NR0B1 gene; Mutation; Children

Response of the Hypothalamic-Pituitary-Adrenal System to Repeated Moderate Psychoemotional Stress Exposure Is Associated with Behavioral Parameters.

Individual features of the response of the hypothalamic-pituitary-adrenal axis (HPAA) to repeated moderate stress exposure (daily 2-h restraint stress for 10 days) was studied in young female rhesus monkeys with healthy normal behavior and combined group of female rhesus monkeys with abnormal depression-like and anxious behavior. No between-group differences in the response of ACTH and cortisol were found on day 1. On day 10, a rapid and less pronounced increase in ACTH secretion was observed in all animals in comparison with day 1. Analysis of between-group differences in HPAA response showed higher increase in ACTH level and lower increase in cortisol concentration in animals with depression-like and anxious behavior. These changes were similar to the previously described differences in the response of the adenohypophysis and adrenal cortex to acute restraint stress in old monkeys with similar behavior. Thus, individuals with depression-like and anxious behavior demonstrate impaired stress-induced reactivity of HPAA as early as in young age.

Ketamine modulates fetal hemodynamic and endocrine responses to umbilical cord occlusion.

Umbilical cord occlusion (UCO) is a hypoxic insult that has been used to model birth asphyxia and umbilical cord compression in utero. UCO triggers vigorous neural and endocrine responses that include increased plasma ACTH and cortisol concentrations, increased blood pressure (BP), and decreased heart rate (HR). We have previously reported that ketamine, a noncompetitive N‐methyl‐D‐aspartate receptor antagonist, can modify the fetal hemodynamic and ACTH responses to ventilatory hypoxia and cerebral ischemia‐reperfusion. We performed the present experiments to test the hypothesis that ketamine has similar effects on the neuroendocrine and cardiovascular responses to UCO. Fetal sheep were chronically catheterized at gestational day 125. Ketamine (3 mg/kg) was administered intravenously to the fetus 10 min prior to the insult. UCO was induced for 30 min by reducing the umbilical vein blood flow until fetal PaO2 levels were reduced from 17 ± 1 to 11 ± 1 mm Hg. UCO produced an initial increase on fetal BP in both control and ketamine groups (P = 0.018 time), followed by a decrease in the control group, but values remained higher with ketamine. HR decreased after UCO (P = 0.041 stimulus*time) in both groups, but the reduction was greater initially in control compared to ketamine groups. Fetal Pa CO 2 levels increased after UCO (P < 0.01 stimulus*time), but values were higher in the control versus ketamine groups. UCO significantly decreased fetal pH values (P < 0.01 stimulus*time) with a greater effect on the control versus ketamine group. Ketamine delayed the cortisol responses to UCO (P < 0.001 stimulus*time), and UCO produced a robust increase in ACTH levels from 19 ± 2 to 280 ± 27 pg/mL (P < 0.001 stimulus*time), but there were no differences in ACTH levels between UCO groups. We conclude that ketamine augmented the cardiovascular response to UCO, but did not alter the ACTH response to UCO.

Desmopressin test in the diagnosis and follow-up of cyclical Cushing's disease

To assess the utility of the desmopressin (DDAVP) test in the diagnosis and follow-up of a cyclical Cushing's disease (CCS) case. Laboratory tests included morning and midnight serum cortisol levels, 24h urine free cortisol excretion, midnight salivary cortisol levels, serum cortisol levels after low (1 mg) and high (8 mg) dexamethasone, plasma ACTH and serum cortisol levels after DDAVP. Magnetic resonance imaging (MRI) was used to assess the presence of a pituitary adenoma. The resected tumor specimen was studied by histological, immunohistochemical and cell biology techniques. A patient was referred to our unit with a diagnosis of Cushing's syndrome (CS) for further evaluation and treatment. However, no biochemical evidence of hypercortisolism was observed in the follow-up evaluations. Furthermore, the typical features of CS fluctuated throughout this period. A consistent positive response to the DDAVP stimulation test was observed during the diagnostic work-up, even when overt clinical features of CS were not apparent, raising suspicion for CCS. After two years of follow-up a definitive diagnosis of hypercortisolism was established. An MRI scan revealed a pituitary adenoma, as the source of ACTH production. After transphenoidal surgery, clinical signs of CS resolved and the response to DDAVP became negative. DDAVP induced a significant increase in ACTH levels in cultured pituitary adenoma cells, consistent with the in vivo DDAVP test results. Our case illustrates the utility of the DDAVP test in the evaluation of patients with suspected CCS. The DDAVP test could facilitate the management of CCS by shortening the time of diagnosis.

Effect of Maternal Probiotic Intervention on HPA Axis, Immunity and Gut Microbiota in a Rat Model of Irritable Bowel Syndrome

ObjectiveTo examine whether maternal probiotic intervention influences the alterations in the brain-immune-gut axis induced by neonatal maternal separation (MS) and/or restraint stress in adulthood (AS) in Wistar rats.DesignDams had free access to drinking water supplemented with Bifidobacterium animalis subsp lactis BB-12® (3×109 CFU/mL) and Propionibacterium jensenii 702 (8.0×108 CFU/mL) from 10 days before conception until postnatal day (PND) 22 (weaning day), or to control ad lib water. Offspring were subjected to MS from PND 2 to 14 or left undisturbed. From PND 83 to 85, animals underwent 30 min/day AS, or were left undisturbed as controls. On PND 24 and 86, blood samples were collected for corticosterone, ACTH and IgA measurement. Colonic contents were analysed for the composition of microflora and luminal IgA levels.ResultsExposure to MS significantly increased ACTH levels and neonatal fecal counts of aerobic and anaerobic bacteria, E. coli, enterococci and clostridia, but reduced plasma IgA levels compared with non-MS animals. Animals exposed to AS exhibited significantly increased ACTH and corticosterone levels, decreased aerobic bacteria and bifidobacteria, and increased Bacteroides and E. coli counts compared to non-AS animals. MS coupled with AS induced significantly decreased anaerobes and clostridia compared with the non-stress adult controls. Maternal probiotic intervention significantly increased neonatal corticosterone levels which persisted until at least week 12 in females only, and also resulted in elevated adult ACTH levels and altered neonatal microflora comparable to that of MS. However, it improved plasma IgA responses, increased enterococci and clostridia in MS adults, increased luminal IgA levels, and restored anaerobes, bifidobacteria and E. coli to normal in adults.ConclusionMaternal probiotic intervention induced activation of neonatal stress pathways and an imbalance in gut microflora. Importantly however, it improved the immune environment of stressed animals and protected, in part, against stress-induced disturbances in adult gut microflora.

Nearby Construction Influences the Physiology of Research Animals: Beyond Stress Hormones

A dirty little secret in science is that there are many factors beyond the control of researchers that may compromise the results of even carefully controlled experiments. Although the methods sections of scientific papers tend to overlook the fact, researchers are not in complete control of the environment of research animals. Everything from nearby construction (1, 2) to shipping during particular developmental stages has been shown to influence (3) is suspected of influencing (4, 5) a wide variety of dependent variables. In as systematic an experiment as is possible considering the vagaries of building construction or renovation, in this issue of Endocrinology, Raff et al. (6) have again raised the important issue and documented the physiological effects of one serious impediment to animal research, environmental factors that the researcher cannot control. Here the investigators provide positive evidence that nearby construction can be devastating to experiments. During a 3-month construction project near their animal facility, the plasma levels of ACTH, corticosterone, and aldosterone in their rats each doubled or tripled contrasted with the period before or after the construction. In contrast to a previous report of the effects of construction (1), no effect was seen on body weight during construction. Similarly, no effect was seen on plasma renin, CRH mRNA in the hypothalamus, POMC mRNA in the anterior pituitary, or on a variety of genes in the pituitary and adrenal gland. Nevertheless the effects on plasma levels of ACTH, corticosterone, and aldosterone were quite dramatic. The paper by Raff et al. (6) should serve as another wake-up call to researchers, administrators, and planners that the effects of nearby construction can be devastating to experimental results. During nearby construction, the researcher or others in the animal room may not hear noise or feel vibrations, or a construction worker or planner may believe that the work will have no influence on the experiments. Unfortunately, this does not mean that the animals are not influenced physiologically. Often these stressors are ignored by researchers who do not work on stress. It could be argued that only those individuals who study stress should be concerned about the effects of stressors associated with construction, and those who do not study stress need not be concerned. However, it can also be argued that it is unwise to draw the conclusion from studies like that of Raff et al. (6) that construction affects only stress systems. The increase in levels of ACTH, corticosterone, and aldosterone reported by Raff et al. (6) undoubtedly have secondary effects on other systems influenced by these hormones. As one example, corticosterone influences neurogenesis within the hippocampus (7). Consequently, it is likely that the results of experiments on hippocampal-associated memory would also be influenced by the construction stress. Similarly, because prenatal stressors can alter the levels of plasma testosterone in fetal rats (8), and consequently the sexual differentiation of the brain (9) and behavior (10), researchers working on sexual differentiation of the brain or behavior or on any physiological or behavioral endpoint that is sexually differentiated should be concerned about prenatal stress associated with nearby construction. There are sometimes stressors that researchers not only cannot control, but that they may not even know about. A few years ago, my research group was in the middle of a quite large, parametric experiment to determine the ideal paradigms and doses of ovarian hormones for inducing

Thyroid hormone therapy modulates hypothalamo-pituitary-adrenal axis

To observe the influence of thyroid hormone therapy on hypothalamo-pituitary-adrenal (HPA) axis, a group of 14 athyreotic women due to thyroid cancer treatment were studied before and after thyroid suppression therapy with thyroxine (T4). Changes in plasma adrenocorticotropin (ACTH) and cortisol levels in response to human corticotropin-releasing hormone (hCRH; 100µg, i.v.) were estimated under hypothyroid conditions and after T4 suppression therapy with 2.5µg/kg/day for two months (n=14). A group of seven healthy women was evaluated as a control group. A greater increase in ACTH levels by hCRH was observed in patient group both before and after suppression therapy compared than that of control group. Plasma cortisol levels after hCRH stimulation were also greater in patient group both before and after suppression therapy than that of control group. In conclusion, both hypothyroidism and subclinical hyperthyroidism with suppressive doses of thyroid hormone induced a hypersensitivity of ACTH to hCRH. Considering the role of thyroid hormone on HPA axis, the mechanisms of ACTH hypersensitivity may be different between these two conditions.

Role of adenylyl cyclase type VII in signaling through CRFR1α receptors and HPA axis activation during ethanol intoxication: study using male and female animals

Ethanol (Eth) can increase plasma ACTH and glucocorticoids even though Eth is thought to be anxiolytic. Studies using corticotrophs, have indicated that CRF 1α receptors (CRF‐R1α) initiate ACTH release through coupling to adenylyl cyclase type 9 and type 7 (AC7). Prior studies have shown that Eth enhances AC7 responsiveness to Gsα. We hypothesized that Eth through increasing the affinity of the AC7 for Gsα, can increase CRF‐R1α signaling, leading to increased ACTH levels.We measured plasma ACTH and corticosterone (CS) levels after ip injection of Eth (2.25 g/kg) at time points of 0‐75 min in male and female AC7 transgenic (TG) and heterozygous knockdown (HET) mice. TG mice with transgene (human) AC7 mRNA had significantly higher (≈38%) AC7 protein in the pituitary, as measured with our antibody to AC7. HET mice had ≈50% lower levels of AC7 mRNA and significantly lower (≈26%) pituitary amounts of AC7 protein compared to WT mice.After ip Eth TG male mice displayed significantly higher plasma ACTH levels compared to WT and HET group. The HET group displayed significantly lower ACTH levels in plasma. Over‐ or underexpression of AC7 in brains of mice may be a key factor in differential ACTH response of these animals to alcohol.ACTH and especially CS levels were markedly higher in female mice compared to male mice despite the same blood alcohol levels.Supported by NIAAA and Banbury Foundation.