Midnight Salivary Cortisol Research Articles

Depression differed by midnight cortisol secretion, alexithymia and anxiety between diabetes types: a cross sectional comparison

BackgroundIncreased prevalence of depression is found in both type 2 diabetes (T2D) and type 1 diabetes (T1D). Melancholia and atypical depression differ by cortisol secretion and clinical features. The aim was to compare the clinical presentation of T1D and T2D patients in relation to self-reported depression, self-reported anxiety, alexithymia, obesity, and midnight salivary cortisol (MSC).MethodsComparative cross-sectional design. The participants were consecutively recruited from one hospital diabetes outpatient clinic: 24 T2D patients (31–59 years) and 148 T1D patients (32–59 years). Self-reported depression, anxiety and alexithymia were assessed by Hospital Anxiety and Depression scale and Toronto Alexithymia Scale-20. MSC, HbA1c, anthropometrics and data from medical records were collected. Multiple logistic regression analyses were performed.ResultsComparisons of prevalence between diabetes types showed for T2D/T1D: depression 25%/12% (P = 0.10); high MSC (≥9.3 nmol/L) 38%/22% (P = 0.13); alexithymia 25%/13% (P = 0.12); anxiety 38%/35% (P = 0.82). The prevalence of high MSC did not differ between depressed and non-depressed T2D patients (17% vs. 44%, P = 0.35), but differed between depressed and non-depressed T1D patients (53% vs. 18%, P = 0.003). The alexithymia prevalence differed between depressed and non-depressed T2D patients (67% vs.11%, P = 0.018), and between depressed and non-depressed T1D patients (47% vs. 11%, P < 0.001). The anxiety prevalence did not differ between depressed and non-depressed T2D patients (67% vs. 28%, P = 0.15), but differed between depressed and non-depressed T1D patients (76% vs. 30%, P < 0.001). The obesity prevalence (BMI ≥30 kg/m2) was 83% for depressed T2D patients and 6% for depressed T1D patients.In the T2D patients, depression was associated with alexithymia (Adjusted odds ratio (AOR) 15.0). In the T1D patients, depression was associated with anxiety (AOR 11.0), foot complications (AOR 8.5), HbA1C >70 mmol/mol (AOR 6.4), and high MSC (≥9.3 nmol/L) (AOR 4.8).ConclusionsThe depressed T2D patients had traits of atypical depression, without associated high MSC (≥9.3 nmol/L) and anxiety, but the association with alexithymia was strong. The depressed T1D patients had traits of melancholia with associated high MSC and anxiety. The obesity prevalence was high in depressed T2D patients and low in depressed T1D patients.

Diagnostic performance of a newly developed salivary cortisol and cortisone measurement using an LC-MS/MS method with simple and rapid sample preparation.

Late-night salivary cortisol level is one of the first-line tests recommended by the Endocrine Society for the diagnosis of endogenous hypercortisolism. Most routine laboratories measure cortisol levels using immunoassay tests which fail to determine low cortisol levels accurately due to the numerous interfering substances. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method with simple and rapid sample preparation was developed for the simultaneous measurement of cortisol and cortisone and its performance in the diagnosis of endogenous hypercortisolism was evaluated. 324 late-night saliva samples were analyzed from which 272 samples were derived from patients with a suspected diagnosis of endogenous hypercortisolism. Salivary cortisol levels were assayed using an electrochemiluminescent immunoassay (ECLIA, Cortisol II, Roche), and simultaneous measurement of cortisol and cortisone was performed using an LC-MS/MS method. A strong correlation between cortisol results measured using ECLIA and LC-MS/MS (r 2=0.892) was demonstrated. Receiver operating characteristics (ROC) analysis showed good diagnostic performance of cortisol and cortisone levels assayed using LC-MS/MS method and for cortisol measured using ECLIA. Late-night salivary cortisol and cortisone are useful parameters for the diagnosis of hypercortisolism. Using samples obtained from patients where the diagnosis of hypercortisolism is extremely challenging cut-off values for midnight salivary cortisol and cortisone measured by LC-MS/MS method were established.

Iatrogenic Cushing's Syndrome in a Small Case Series of HIV Patients on Steroid Inhalation and Antiretroviral Therapies

Cushing's syndrome is uncommon in patients on therapeutic doses of inhaled steroids. We studied 2 cases of human immunodeficiency virus (HIV) infection who had a rapid onset of Cushing's syndrome secondary to fluticasone propionate interacting with their antiretroviral therapy. Case 1 is a 27-year-old woman with a history of drug addiction problems, anxiety disorder, progressive multifocal leukoencephalopathy and asthma. She presented to the emergency room following a 3-week history of frequent fluticasone inhalation for anxiety type symptoms. Her medications included Prezista, Norvir (ritonavir), fluticasone and Bactrim. Clinical findings were abdominal obesity and extensive purple striae. Laboratory results showed normal midnight salivary cortisol, low 24-hour urinary free cortisol and normal overnight dexamethasone suppression of morning cortisol. Case 2 is a 38-year-old woman with history of rapid 50-pound weight gain and painful purple striae associated with fluticasone inhaler abuse for anxiety symptoms. Other medical problems were drug addiction problems, anxiety and asthma. Her medications were Fluoxetine, Olanzapine, Montelukast, Prezista, Norvir, Truvuda, salbutamol inhaler and ranitidine. Laboratory results showed a low 24-hour urinary free cortisol and undetectable plasma adrenocorticotropic hormone (ACTH).

Quantitative Analysis of Salivary Cortisol Using LC-MS/MS.

Cortisol is one of the most important glucocorticoids and plays important roles in regulating human metabolism. Midnight salivary cortisol has been shown to correlate well with free cortisol concentration in serum and is one of the first tests recommended for the diagnosis of Cushing's syndrome.The procedure described here involves centrifugation of the saliva samples to remove solids and mucus strands before they are diluted with buffer and mixed with deuterated internal standard D4-cortisol. The samples are then subjected to reverse phase separation on a C18 column and analyzed by a tandem mass spectrometry method (LC-MS/MS). Quantification is achieved by comparing the responses of a given sample to the responses of the calibrators of known concentrations. The calibrators are prepared and analyzed along with the patient samples. Analytical specificity is ensured by using multiple reaction monitoring with fragment ions that are unique to cortisol and deuterated internal standard.

Screening for ACTH-dependent hypercortisolism in patients affected with pituitary incidentaloma.

Pituitary incidentalomas (PIs) are commonly encountered in clinical practice. The management of these asymptomatic pituitary lesions is still controversial. Systematic screening for subclinical or mild ACTH-dependent hypercortisolism (AH) is not presently recommended, due to the limited data available thus far on the epidemiological and clinical relevance of this condition in patients with PIs. As subclinical hypercortisolism (SH) was considered to be associated with chronic complications of overt cortisol excess, such as hypertension, diabetes, and osteoporosis, this disorder should be diagnosed at the early stage. The objective of this study was to evaluate the prevalence of hypercortisolism in a population of subjects with PIs. A total of 68 consecutive patients (48 females and 20 males, aged 18-82 years) without clinically overt hypercortisolism, who were referred for evaluation of PIs between January 2010 and March 2013, were prospectively investigated for AH. Pituitary hypercortisolism was diagnosed in the presence of cortisol >50 nmol/l after 1 mg dexamethasone suppression test, non-suppressed ACTH, and the additional finding of one of the following: urinary free cortisol (UFC) >193 nmol/24 h, and midnight serum and salivary cortisol levels >207 and 2.8 nmol/l respectively. Among patients with PIs, we found a 7.3% rate of pituitary hypercortisolism diagnosed with biochemical criteria and a 4.4% rate of histologically confirmed AH. Subclinical or mild hypercortisolism may be more common than generally perceived in patients with PIs.

Evaluation of Midnight Salivary Cortisol as a Predictor Factor for Common Carotid Arteries Intima Media Thickness in Patients with Clinically Inapparent Adrenal Adenomas.

Purpose. The aim of the present study was to investigate the atherosclerotic vascular damage in a consecutive series of patients with AI and to correlate it with MSC. Methods. We studied 32 patients with AI matched with control subjects for age, sex, and cardiovascular risk factors. Either patients or control subjects underwent MSC measurement as outpatients and carotid arteries ultrasound (US) imaging studies. Results. The patients with AI had higher mean carotid artery IMT values and higher MSC levels than control subjects. In a multivariate analysis performed in AI age was the best predictor for IMT. We have stratified patients and control subjects by age (<60 yrs and ≥60 yrs). The patients showed significantly higher MSC levels than controls in both groups, whereas significantly higher IMT values were observed only in older subjects. Conclusions. Patients with AI have signs of accelerated atherosclerosis. Patients older than 60 years seem more susceptible to the possible detrimental effect of subclinical hypercortisolism on cardiovascular system. The MSC levels are not a strong predictor of the accelerated atherosclerosis, but they seem to indicate the subtle but not autonomous cortisol excess that may potentially raise the cardiovascular risk.

Visual Vignette

Case Presentation: A 55-year-old female presented with a 5-year history of progressive weight gain, fatigue, easy bruising, abdominal striae, and central obesity; she appeared cushingoid. Her medical history included hypertension, gout, diabetes mellitus, and restrictive lung disease. Endocrine evaluation revealed: 24-hour urine free cortisol 124.2 mg (20-100), 2 consecutive elevated midnight salivary cortisol levels of 541 and 459 ng/dL (<100), and a random adrenocorticotrophic hormone (ACTH) level of 65 pg/mL (5-50). Two 8 am serum cortisol measurements were 28.6 and 15.1 mg/dL after 1-mg low-dose and 8-mg high-dose overnight dexamethasone suppression tests, respectively. Magnetic resonance imaging of the sella did not reveal a sellar or parasellar adenoma, and the pituitary appeared normal (Fig. 1A, black arrow); incidentally, a soft tissue mass (Fig. 1A, white arrow) was identified in the sphenoid sinus. On noncontrast computed tomographic (CT) scanning of the sinuses, an isointense lesion with areas of punctate calcification was re-identified (Fig. 1B, white arrow); the sellar floor was intact and there was no evidence of bony destruction. Inferior petrosal sinus sampling demonstrated more than a 3-fold increase in the central to peripheral gradient of ACTH after administration of corticotrophic-releasing hormone, which was consistent with Cushing’s disease. A 4 x 4 mm pituitary microadenoma was identified and resected during transsphenoidal exploration. Postoperatively, the patient became hypocortisemic consistent with remission, and replacement hydrocortisone was administered. The pituitary adenoma was immunohistochemically positive for ACTH. The sphenoid mass was also removed completely during surgery. What is the diagnosis?

Depression, smoking, physical inactivity and season independently associated with midnight salivary cortisol in type 1 diabetes.

BackgroundDisturbances of the circadian rhythm of cortisol secretion are associated with depression, coronary calcification, and higher all-cause and cardiovascular mortality.The primary aim of this study was to test the associations between midnight salivary cortisol (MSC), depression and HbA1c, and control for behavioural, environmental and intra individual factors with possible impact on cortisol secretion, like smoking, physical inactivity, season, medication, diabetes duration, severe hypoglycemia episodes, age and gender in patients with type 1 diabetes. Secondary aims were to present MSC levels for a reference group of non-depressed type 1 diabetes patients with a healthy life style (physically active and non-smoking), and to explore seasonal variations.MethodsA cross-sectional population based study of 196 patients (54% men and 46% women) aged 18–59 years that participated in a randomized controlled trial targeting depression in type 1 diabetes. Depression was assessed by the Hospital Anxiety and Depression Scale-depression subscale. MSC, HbA1c, serum-lipids, blood pressure, waist circumference and data from medical records and the Swedish National Diabetes Registry were collected.ResultsThirty four patients (17%) had MSC ≥9.3 nmol/L, which was associated with smoking (AOR 5.5), spring season (AOR 4.3), physical inactivity (AOR 3.9), self-reported depression (AOR 3.1), and older age (per year) (AOR 1.08). HbA1c >70 mmol/mol (>8.6%) (AOR 4.2) and MSC ≥9.3 nmol/L (AOR 4.4) were independently linked to self-reported depression. Season was strongly associated with MSC levels and no other variables studied showed seasonal variations. In a reference group of 137 non-depressed patients with a healthy life style (physically active, non-smoking) the median MSC level was 4.6 nmol/L (range 1.9–23.0).ConclusionsIn this study of patients with type 1 diabetes high MSC was linked to smoking, physical inactivity, depression, season and older age. Thus a high cortisol value identified three major targets for treatment in type 1 diabetes.

Cushing syndrome.

Cushing syndrome.

Detecting post-surgical recurrence in a patient with Cushing’s disease

To the Editor, Cushing’s disease (CD), a rare disorder of chronic hypercortisolism caused by an adrenocorticotropic (ACTH)-secreting pituitary adenoma, is associated with increased mortality and complications including central obesity, diabetes mellitus, osteoporosis, and cardiovascular disease [1]. Transsphenoidal adenomectomy is generally first-line treatment for CD but confirmation of surgical success and diagnosis of recurrence can prove challenging [1]. We endeavor to raise awareness of the complex, insidious nature of CD recurrence through this illustrative case report. A 17-year-old female presented in 2006 with signs and symptoms of CD including facial rounding and rubor, hirsutism, alopecia, proximal muscle weakness, acne, stretch marks, weight gain, fatigue, insomnia, emotional fluctuations, headaches, and heartburn. She had elevated 24-hour urinary free cortisol [UFC; 126.5 μg/24 h (normal, <80)], and plasma ACTH [61 pg/mL (normal <48)]. Her dexamethasone suppression/corticotropin-releasing hormone stimulation test (Dex/CRH) was positive (serum cortisol 6.0 μg/dL 15 min after CRH) and magnetic resonance imaging (MRI) showed a 1.1-cm hypoenhancing pituitary lesion, confirming CD diagnosis (Fig. 1a). Fig. 1 a Initial (2006) pre-operative T1 dynamic contrast-enhanced MRI (field strength 1.5 T) showing a 1.1-cm pituitary lesion. b Follow-up (2011) MRI with no lesion noted. c ACTH immunostain confirming recurrent CD After transsphenoidal surgery in December 2006, corticotroph adenoma was histologically confirmed. Consistent with CD remission, nadir serum cortisol measurement of 1.1 μg/dL (normal range 7.0–23.0) was recorded at 8 a.m. within 72 h post-surgery. Over the ensuing months, the patient reported decreased acne, heartburn, and proximal muscle weakness. Her face thinned and she lost 55 pounds. Beginning 6 months after surgery, she reported that her previous symptoms began to return episodically several times per year. In February 2011, her symptoms (weight gain, acne, fatigue, and proximal muscle weakness) became unremitting. At this time, however, 24-h UFC and Dex/CRH tests were normal. She was noted to have elevated morning serum cortisol (peak, 31.5 μg/dL), but levels normalized after oral estrogen was discontinued. A follow-up MRI showed no pituitary lesion (Fig. 1b). Despite consistently normal biochemical assessments (13 salivary cortisol tests, seven 24-h UFCs, three Dex/CRH tests, and one overnight Dex suppression test) over the 5-year period since pituitary surgery, the patient’s Dex/CRH levels ultimately became strongly positive (7.9 μg/dL 15 min after CRH; Dex level: 571 ng/dL) in late 2011. Based on the positive Dex/CRH result plus strong symptomatic and physical features of recurrent CD, the patient underwent repeat pituitary surgery. Corticotroph adenoma was again identified, removed, and confirmed by positive immunohistochemical staining for ACTH (Fig. 1c). Post-surgery, serum cortisol was measured every 6 h and, consistent with remission and possible complete removal of the adenoma, levels decreased to 0.9 μg/dL (normal 6.2–19.0) within 72 h. Her CD symptoms resolved and follow-up biochemistry was negative. This case study illustrates the complexities of identifying patients with post-surgical recurrent CD. Within 4 years of apparent surgical remission, the patient experienced returning symptoms despite normal UFC and Dex/CRH tests. Ultimately, however, once she had biochemical evidence of CD recurrence (i.e., positive Dex/CRH despite continued normal UFC), she underwent repeat pituitary surgery and corticotroph adenoma was histologically confirmed. While subnormal immediate post-operative serum cortisol (as detected in this patient after her initial surgery) generally portends lasting remission, recurrence is still a possibility and occurs in approximately 6–12 % of such cases [2]. Similarly, normal UFC and/or midnight salivary cortisol levels are not reliable predictors of sustained remission per se. Careful follow up is required for all post-surgical CD patients and, if recurrence is suspected, biochemical test results should be interpreted in the context of clinical signs and symptoms. CD has been associated with a 1.84- to 4.8-fold increase in mortality compared with the general population [3, 4]. However, many features of cortisol excess (e.g., obesity, depression, diabetes, hypertension, dyslipidemia) are common in the general population [1]. Given that 10-year post-surgical recurrence rates for CD may be as high as 56 % [5], postoperative CD patients should be meticulously monitored for persistence and recurrence of disease. When this patient presented, no medical therapies were yet indicated for treatment of recurrent CD. Since that time, however, treatment options have expanded and clinicians have more choices for treating refractory cases. The US FDA has approved mifepristone (a glucocorticoid receptor antagonist) for treatment of hyperglycemia associated with Cushing’s syndrome [6], and pasireotide (a multireceptor-targeted somatostatin analog) for treatment of adults with CD who are not surgical candidates [7]. Choice of therapy depends on several factors including the patient’s overall surgical risk, severity of hypercortisolism, and patient preferences—particularly with respect to fertility. Regardless of treatment choice, special attention should be given to recurring symptoms as these may indicate early signs of disease even before biochemical evidence is present. Appropriate management is crucial, even when conflicting results make clinical decisions challenging.

Chapter 12 - Nonfunctioning pituitary tumors

Clinically nonfunctioning adenomas range from being completely asymptomatic, and therefore detected either at autopsy or as incidental findings on head MRI or CT scans performed for other reasons, to causing significant hypothalamic/pituitary dysfunction and visual field compromise due to their large size. Patients with incidental adenomas should be screened for hypersecretion (prolactin, insulin-like growth factor 1, midnight salivary cortisol) and for hypopituitarism (macroadenomas). In the absence of hypersecretion, hypopituitarism, or visual field defects, patients may be followed by periodic screening by MRI for enlargement, at which point surgery may be necessary. Symptomatic patients with clinically nonfunctioning adenomas are generally treated by transsphenoidal surgery. Postoperative MRIs are done at 3-4 months after surgery to assess for completeness of resection and then repeated yearly for 3-5 years and subsequently less frequently to assess for regrowth. For those with no visible tumor on MRI, the tumor regrowth rate is about 13% and such patients may be followed with periodic MRIs. For those with visible tumor, the tumor regrowth rate is about 40%. This regrowth rate may be substantially reduced with the use of dopamine agonists and radiotherapy.

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.

Factitious Cushing's syndrome masquerading as Cushing's disease

Factitious Cushing's syndrome is extremely rare. The diagnosis is challenging as cross-reactivity of synthetic corticosteroids or their metabolites in immunoassay measurements of plasma or urinary cortisol can make distinguishing between true and factitious Cushing's syndrome difficult. Adrenocorticotropin (ACTH) is usually suppressed in factitious Cushing's syndrome. A 54-year-old woman presented with clinical and biochemical features of Cushing's syndrome and an unsuppressed ACTH concentration. She denied recent exogenous corticosteroid use. Initial investigations revealed a markedly elevated urinary free cortisol, mildly elevated midnight salivary cortisol and normal morning cortisol concentration. Plasma ACTH was not suppressed at 13 ng/l (RR 10-60 ng/l). A pituitary MRI was normal, but inferior petrosal sinus sampling (IPSS) revealed a post corticotrophin releasing hormone ACTH ratio >20:1 in the left petrosal sinus. Ketoconazole therapy amplified discordance between the urinary free and morning plasma cortisol concentrations. Further investigation of this discordance using high-pressure liquid chromatography tandem mass spectrometry (HPLC-MS/MS) revealed a urinary free cortisol excretion of only 20 nmol/24 h, but prednisolone excretion of 16,200 nmol/24 h. Factitious Cushing's syndrome can mimic endogenous ACTH-dependent hypercortisolism during initial investigations and IPSS. This case highlights the importance of (i) recognizing the significance of discordant results; (ii) using an ACTH assay capable of reliably differentiating ACTH-dependent from ACTH-independent Cushing's syndrome; and (iii) appreciating that IPSS is only useful to localize the source of ACTH in confirmed ACTH-dependent Cushing's syndrome. In this case, measurement of corticosteroids by HPLC-MS/MS was essential in reaching the correct diagnosis.

Benign adrenal adenomas secreting excess mineralocorticoids and glucocorticoids

Objective: To recognize that benign adrenal adenomas can co-secrete excess aldosterone and cortisol, which can change clinical management.Methods: We reviewed the clinical and histological features of an adrenal tumor co-secreting aldosterone and cortisol in a patient. Biochemical testing as well as postoperative immunohistochemistry was carried out on tissue samples for assessing enzymes involved in steroidogenesis.Results: A patient presented with hypertension, hypokalemia, and symptoms related to hypercortisolism. The case demonstrated suppressed renin concentrations with an elevated aldosterone:renin ratio, abnormal dexamethasone suppression test results, and elevated midnight salivary cortisol concentrations. The patient had a right adrenal nodule with autonomous cortisol production and interval growth. Right adrenalectomy was carried out. Postoperatively, the patient tolerated the surgery, but he was placed on a short course of steroid replacement given a subnormal postoperative serum cortisol concentration. Long-term follow-up of the patient showed that his blood pressure and glucose levels had improved. Histopathology slides showed positive staining for 3β-hydroxysteroid dehydrogenase, 11β-hydroxylase, and 21 hydroxylase.Conclusion: In addition to the clinical manifestations and laboratory values, the presence of these enzymes in this type of tumor provides support that the tumor in this patient was able to produce mineralocorticoids and glucocorticoids. The recognition of patients with a tumor that is co-secreting aldosterone and cortisol can affect decisions to treat with glucocorticoids perioperatively to avoid adrenal crisis.Learning points Recognition of the presence of adrenal adenomas co-secreting mineralocorticoids and glucocorticoids.Consideration for perioperative and postoperative glucocorticoid use in the treatment of co-secreting adrenal adenomas.

Characterization of persistent and recurrent Cushing’s disease

A case of possible recurrent Cushing's disease (CD) is presented and data on current definitions of CD remission, persistence, and recurrence are reviewed. While prevailing guidelines recommend the use of serum cortisol in the first post-operative week for defining initial remission and predicting sustained remission, with the use of 24h urinary free cortisol measurements if serum cortisol values are equivocal, there is debate as to which methods and thresholds best define CD remission and predict successful outcomes. Other methods used to define remission (and hence persistence and recurrence) include restoration of cortisol suppression after dexamethasone and physiologic diurnal cortisol rhythm as measured by midnight salivary free cortisol. However, the number and degree of abnormal test results needed to define recurrence, and the determination of which biochemical test has more significance when there are discrepancies between markers is inconsistent among studies. Further inquiry is warranted to examine if patients in apparent CD remission who have subtle hypothalamic pituitary adrenal (HPA) axis abnormalities represent distinctive remission subtypes versus mild or early recurrence. Additional investigation could also explore the degree to which these HPA axis abnormalities, such as alterations in cortisol circadian rhythm or partial resistance to dexamethasone, are associated with persistence of CD morbidities, including neuropsychiatric impairments, alterations in body composition, and cardiovascular risk.

Spontaneous remission of hypercortisolism presumed due to asymptomatic tumor apoplexy in ACTH-producing pituitary macroadenoma

Cushing's disease (CD) is usually caused by secretion of ACTH by a pituitary corticotroph microadenoma. Nevertheless, 7%-20% of patients present with ACTH-secreting macroadenomas. Our aim is to report a 36-year-old female patient with CD due to solid-cystic ACTH-macroadenoma followed up during 34 months. The patient presented spontaneous remission due to presumed asymptomatic tumor apoplexy. She showed typical signs and symptoms of Cushing's syndrome (CS). Initial tests were consistent with ACTH-dependent CS: elevated urinary free cortisol, abnormal serum cortisol after low dose dexamethasone suppression test, and elevated midnight salivary cortisol, associated with high plasma ACTH levels. Pituitary magnetic resonance imaging (MRI) showed a sellar mass of 1.2 x 0.8 x 0.8 cm of diameter with supra-sellar extension leading to slight chiasmatic impingement, and showing hyperintensity on T2-weighted imaging, suggesting a cystic component. She had no visual impairment. After two months, while waiting for pituitary surgery, she presented spontaneous resolution of CS. Tests were consistent with remission of hypercortisolism: normal 24-h total urinary cortisol and normal midnight salivary cortisol. Pituitary MRI showed shrinkage of the tumor with disappearance of the chiasmatic compression. She has been free from the disease for 28 months (without hypercortisolism or hypopituitarism). The hormonal and imaging data suggested that silent apoplexy of pituitary tumor led to spontaneous remission of CS. However, recurrence of CS was described in cases following pituitary apoplexy. Therefore, careful long-term follow-up is required.

Neuroendocrine Regulation and Metabolism of Glucose and Lipids in Primary Chronic Insomnia: A Prospective Case-Control Study

ObjectivesTo investigate the relation between primary chronic insomnia and insulin sensitivity, visceral adiposity, non alcoholic fatty liver disease and neuroendocrine hormones.Materials and MethodsIn a case-controlled, prospective clinical trial 13 women with primary chronic insomnia according to DSM-IV criteria were compared to 12 healthy controls matched for age, sex, BMI, body composition and menopausal status. All participants had a sleep assessment including polysomnographic studies and neuropsychiatric evaluation. Insulin sensitivity was evaluated using the euglycaemic hyperinsulinemic clamp. Hepatic fat content, visceral adipose tissue and intramyocellular lipid accumulation were assessed using magnetic resonance imaging and spectroscopy. The hormonal stress axis was evaluated by measurements of midnight and early morning salivary cortisol, urinary catecholamines and plasma metanephrines. Body composition was determined using body impedance analysis and indirect calorimetry.ResultsAlthough the diagnosis of primary chronic insomnia was made by established clinical criteria, standard polysomongraphic studies failed to identify altered sleep continuity and architecture when compared to matched controls. However, women with primary chronic insomnia showed significantly higher midnight salivary cortisol concentrations (1.46 vs. 0.76 nmol/l, p = 0.02), indicating dysregulation of the hypothalamo-pituitary-adrenal (HPA) axis. Plasma glucose and lipid concentrations, insulin sensitivity, hepatic and intramyocellular fat content, visceral adipose tissue mass and body composition did not differ between the two groups.ConclusionHealthy women with clinically diagnosed primary chronic insomnia demonstrate a dysregulation of circadian cortisol secretion despite normal sleep continuity and architecture. Increased midnight cortisol levels, however, were not associated with impaired metabolism of glucose and lipids.

Evaluation of the efficacy of midnight salivary cortisol plus dexamethasone suppression test as screening for the diagnosis of hypercortisolism within an at-risk population

Evaluation of the efficacy of midnight salivary cortisol plus dexamethasone suppression test as screening for the diagnosis of hypercortisolism within an at-risk population

Detection of salivary cortisol at two different time points at night

Objective To compare the detection results of salivary cortisol(SL) at 23:00 and 24:00 to estimate whether the collection of saliva can be taken in advance at 23:00 for the screening and diagnosis of Cushing's syndrome(CS).Methods Saliva samples were collected by a cotton-based sampling approaches Salivettes at 23:00 and 24:00 from 108 normal subjects (NS group),50 patients (NCS group) with type 2 diabetes,primary hypertension or non-functional adrenal adenoma and 7 patients with Cushing' s syndrome(CS group).Then the samples were assayed by ELISA.Results The levels of SC at 23:00 (SC23) and 24:00 (SC24) in different groups were:2.01 ± 0.91 ng/ml,1.96 ± 0.85 ng/ml in NS group,3.55 ± 1.17 ng/ml,3.81 ± 1.49 ng/ml in NCS group,and 12.63 ± 6.14 ng/ml,10.98 ± 3.98 ng/ml in CS group (all P＞0.05).Using Pearson correlation analysis,SC23 and SC24 showed a very good linear correlation (r =0.924,P＜ 0.001).SC23 or SC24 in CS group were obviously higher than NS and NCS group.The areas under the ROC curves of SC23 and SC24 were 0.995 and 0.996 respectively,which displayed good accuracy to diagnosis of CS.Conclusions Midnight salivary cortisol is a convenient and sensitive indicator for the screening and diagnosis of CS.The concentrations of salivary cortisol at 23:00 and 24:00 are close,so collecting saliva at 23:00 is feasible for the clinical screening and diagnosis of CS. Key words: Salivary cortisol(SC) ; Cushing's Syndrome (CS) ; ELISA

Spectral effect: each population must have its own normal midnight salivary cortisol reference values determined

IntroductionThe mesurement of midnight salivary cortisol provides the most sensitive method for screening of Cushing's sendrome. However the clinical significance of spectral error is the requirement for determination of normal reference values in each population for each test, which will be used as the diagnostic method. Salivary cortisol levels may be affected by individual factors such as nutrition, sleep, medication, activity, and gender. Being a non-invasive method, midnight salivary cortisol (MSC) has been used as a valuable indicator of free plasma cortisol.Material and methodsMidnight salivary cortisol was assessed in randomly selected 100 Turkish patents who underwent to a detailed physical examination. Saliva samples were collected at 00:00 to plastic tubes with the help of plastic pipettes, without brushing their teeth, but after rinsing their mouth. Salivary cortisol was measured with luminescense immunoassay kit. Differences and correlations were analysed.ResultsThe mean midnight salivary cortisol of the healthy population was 0.21 ±0.03 µg/dl. Body mass index, age, sex, smoking, exercise, educational status alcohol, had no effect on the MSC.ConclusionsConsequently, normal salivary cortisol reference ranges must be used for different assays and different populations in order to evaluate more accurately pituitary-adrenal axis pathology in clinical practice.