Pituitary Disease Research Articles

Urinary free cortisol is an independent predictive factor for early distinction between ectopic ACTH secretion and pituitary Cushing's disease

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Pituitary and growth disorders of pediatric survivors of head and neck tumors: a single center study

Objective The aim was to explore the prevalence and risk factors for pituitary and growth disorders in pediatric brain and neck tumor survivors. Methods 203 children with brain or neck tumors that survived 2 years after tumors treatment were included. Demographic data, anthropometric assessments, characteristics of the tumors, tumor treatment modalities, and hormonal profile evaluation were reported. Results After a mean follow-up of 4.77 years, 62 (30.54%) survivors were diagnosed with at least one pituitary disorder. Growth hormone deficiency (GHD) was detected in 17.28% of survivors, moreover, thyroid-stimulating hormone deficiency (TSHD), luteinizing hormone and follicle-stimulating hormone deficiency (LH/FSHD), adrenocorticotropic hormone deficiency (ACTHD)/cortisol deficiency and central precocious puberty were detected in 10.4, 9.09, 8.06, and 1.69% of survivors, respectively. The prevalence of short stature and obesity was 9.1% and 17.05%, respectively among survivors who attended follow-up clinics during data collection. The risk of developing pituitary disorders was associated with craniopharyngioma histology (OR, 6.207; 95% CI, 1.025–37.581) and a history of hydrocephalus at cancer diagnosis (OR, 3.075; 95% CI, 1.402–6.746). Older age at the time of radiotherapy was associated with a lower risk of developing pituitary disorders (OR, 0.928; 95% CI, 0.864–0.997). Conclusion This study observed a high prevalence of pituitary disorders among survivors of pediatric brain and neck tumors. So proper screening of pituitary disorders in survivors of brain and neck tumors is warranted.

Abstract #1403717: Thyro-Adrenal Insufficiency in Severe Hypothyroidism – A Clinical Mirage? A Cross-Sectional, Propensity-Matched Case-Control Study from a Tertiary Care Centre Kalaburgi, Kalyana Karnataka

Assessment of 8:00 AM cortisol levels and predict risk of adrenal insufficiency in treatment naïve severe hypothyroidism. A cross-sectional, observational, case-control study was conducted at tertiary care teaching hospital in Kalaburagi, Kalyana Karnataka, South India between January 2017 and March 2020. We included 71 consecutive adult individuals in the age group of 18-50 years of either gender, referred to the Division of Diabetes and Endocrinology, Department of Internal Medicine. All the cases were treatment naïve, diagnosed with severe hypothyroidism defined as TSH levels > 100 μIU/ml. We excluded patients with a past history of Grave’s disease, those who had ever used anti-thyroid drugs, those who had taken radioactive iodine, received steroids for any reasons, patients with a history of thyroidectomy, pre-existing pituitary or adrenal disorders, pregnancy, patients on oral contraceptives and patients with any underlying malignancies. The control population included individuals without any known thyroid disorder or any other comorbid conditions that are known to affect the function of hypothalmo-pituitary-adrenal axis. The controls were age and gender-matched. We used SAS 9.4 version software to analyze the data. T3, T4, and cortisol have been categorized and summarized descriptively with the actual collected values. Continuous variables are presented with mean and standard deviation. Categorical parameters are summarized with counts and percentages. Correlation coefficients among the T3, T4, and cortisol were generated for the overall population. Seventy-one cases of severe hypothyroidism (TSH >100 mIU/L) were compared with age and gender-matched controls (n=40). The mean age of the patients was 30.0±9.0 years and 88.7% were females. Serum cortisol levels were significantly lower in cases than in controls (8.6±4.2 vs. 16.0±2.22 μg/dl respectively, p<0.0001). Six (8.5%) cases were identified with adrenal insufficiency. After propensity matching, T3 (20.32±16.94 vs. 39.33±38.92 ng/dl, p=0.018) and T4 (0.81±0.55 vs. 1.93±1.17 μg/dl, p=0.005) levels were comparatively lower in adrenal insufficiency cases than those without adrenal insufficiency. Serum T3 (r = -0.243, p=0.041) but not T4 (r = -0.103, p=0.391) had a significant negative correlation with serum cortisol levels. Transient adrenal insufficiency can be seen in treatment naïve severe hypothyroidism. In our cohort, the incidence of adrenal insufficiency was 8.5%. An apt clinical vigilance is needed to identify adrenal insufficiency in such patients. Further studies are needed to understand the implications of severe hypothyroidism with adrenal insufficiency. A short synaecthien test may be needed in with low cortisol at diagnosis of severe hypothyroidism.

Abstract #1395486: Uncontrolled Acromegaly Resulting in the Need for LVAD as Bridge to Heart Transplant

Acromegaly is an uncommon pituitary disorder with an incidence of six per million persons. While hypertension is often encountered in these patients, heart failure rarely is seen with an incidence rate under 10%. We describe a case of an individual who was diagnosed with acromegaly after an acute exacerbation of heart failure with subsequent management requiring an LVAD to perform Transsphenoidal Surgery (TSS). 37-year-old male otherwise healthy initially presented to an emergency room and was found to be in acute heart failure exacerbation. Concerning acromegaly features included macrognathia, enlarged hands and feet, swollen phalanges, widened spacing of teeth, and frontal bossing. IGF-1 level was found 455 ng/mL. MRI showed a 10mm macroadenoma. A right heart catheterization showed elevated filling pressures. Cardiac MRI showed no defects or enhancement. Endomyocardial biopsy showed no inflammatory infiltrates or evidence of infiltrative diseases. Patient had an ejection fraction of 15% corroborated by cardiac MRI along with the presence of aortic root dilatation and mitral regurgitation. The patient started on 0.5mg of Cabergoline twice weekly and 120mg weekly Lanreotide injections. Patient stabilized with plans for further close monitoring and outpatient neurosurgical evaluation. The COVID-19 pandemic and insurance gaps led the patient to spend two years off his medicines and he was unable to be seen by his medical team. Patient was seen by our system after recurrent hospitalizations for heart failure at our sister hospital, AICD was unable to be placed due to the patient’s anatomy, he was placed on wearable cardiac defibrillator and required milrinone infusion for progression to end-stage heart failure with cardiac cachexia. At our institution, the patient was evaluated for Orthotopic Heart Transplant (OHT) but due to active GH secreting macroadenoma there was concern for OHT failure without TSS. Decision was made to utilize LVAD as Bridge-to-Transplant for OHT so the patient could be stabilized and safely undergo TSS. The patient tolerated surgeries well and is currently on the active transplant list. Heart failure is an uncommon presentation of severe acromegaly requiring multidisciplinary management. We describe a case of a patient who initially presented with heart failure too unstable for surgery. Due to the COVID-19 pandemic the patient’s disease progressed resulting in end-stage heart failure requiring LVAD placement for further treatment. We would like to draw attention to the use of LVAD placement in acromegalic patients who develop severe cardiovascular disease who are not candidates for OHT.

Abstract #1413664: A Case of Familial Isolated Pituitary Adenoma Emphasizing an Often-Overlooked Aspect of Medical History

Familial Isolated pituitary adenoma (FIPA) is a rare cause of pituitary adenoma and underscores the importance of family history and the knowledge of screening guidelines in these patients. A 26-year-old female presented with secondary amenorrhea, galactorrhea, headaches and dizziness. Labs showed Prolactin 501 ng/ml (3.3-26.7 ng/mL) and IGF 391 ng/ml (96-301 ng/mL). MRI of the brain showed a 12 x 14 x 15 mm pituitary mass. Acromegaly was confirmed with glucose suppression test with growth hormone (GH) lowering to 1.08 ng/ml (< 0.8 ng/ml). Further history revealed a paternal cousin with gigantism diagnosed at the age of 17. She underwent transsphenoidal resection of the adenoma which stained positive for GH and prolactin. Post operative labs show improved levels: Prolactin 31 ng/mL (3.3-26.7 ng/mL) and IGF 317 ng/mL (96-301 ng/mL). Genetic evaluation showed a pathogenic mutation in AIP (aryl hydrocarbon receptor-interacting protein). Labs 4 months later- Prolactin 36.1 ng/mL (3.3-26.7 ng/mL), IGF 209 ng/mL (96-301 ng/mL), and GH 0.1 ng/mL (0.05-8.00 ng/mL). She was amenorrheic post surgery and with hormone replacement therapy, regular menstrual cycles ensued. Surveillance showed consistently normal IGF but prolactin levels were trending upwards. Prolactin: 80 ng/mL (3.3-26.7 ng/mL). A repeat MRI brain did not show any adenoma. She was started on Cabergoline and that helped with normalization of prolactin levels. FIPA is a rare hereditary disorder responsible for less than 2% of pituitary adenomas. Mutation of AIP is seen in 20% cases and associated with worse outcomes. The peak age of onset is between 10-30 years of age. Affected patients tend to have larger tumors than non-FIPA which increases the risk of pituitary apoplexy. GH secretion is the most common; followed by prolactin, GH-Prolactin co-secretion, non-functional and rarely TSH secreting. It has an autosomal dominant transmission but with incomplete penetrance often skipping generations making the diagnosis even more challenging. Obtaining detailed family history in any patient with pituitary adenoma is essential in uncovering the inheritance pattern of this disease. Screening for FIPA and AIP is recommended if patients are noted to have- 1. GH secreting adenoma diagnosed before the age of 18 2. Pituitary macroadenoma (>10 mm) diagnosed before the age of 30 3. Any pituitary adenoma with a family history of pituitary adenoma in more than one member First degree family members of patients with FIPA and AIP need to be tested for the mutation. Patients with positive mutation are recommended to undergo screening evaluation as follows- 1. Growth assessment and evaluation for signs and symptoms of pituitary adenoma with pituitary function tests a. Age 4-30 years: annually b. Age 30-50 years: every 5 years 2. Pituitary MRI a. Age 10-30 years: every 5 years Prospective observational data shows genetic testing followed by clinical screening leads to early detection of pituitary disease which results in early interventions and better outcomes. This highlights the importance of recognition of FIPA in patients presenting with any kind of pituitary adenomas.

Modelling of the thyroid hormone synthesis as a part of nonlinear reaction mechanism with feedback

The synthesis of thyroid hormones in the hypothalamic-pituitary-thyroid (HPT) axis was studied. For this purpose, a reaction model for HPT axis with stoichiometric relations between the main reaction species was postulated. Using the law of mass action, this model has been transformed into a set of nonlinear ordinary differential equations. This new model has been examined by stoichiometric network analysis (SNA) with the aim to see if it possesses the ability to reproduce oscillatory ultradian dynamics founded on the internal feedback mechanism. In particular, a feedback regulation of TSH production based on the interplay between TRH, TSH, somatostatin and thyroid hormones was proposed. Besides, the ten times larger amount of produced T4 with respect to T3 in the thyroid gland was successfully simulated. The properties of SNA in combination with experimental results, were used to determine the unknown parameters (19 rate constants of particular reaction steps) necessary for numerical investigations. The steady-state concentrations of 15 reactive species were tuned to be consistent with the experimental data. The predictive potential of the proposed model was illustrated on numerical simulations of somatostatin influence on TSH dynamics investigated experimentally by Weeke et al. in 1975. In addition, all programs for SNA analysis were adapted for this kind of a large model. The procedure of calculating rate constants from steady-state reaction rates and very limited available experimental data was developed. For this purpose, a unique numerical method was developed to fine-tune model parameters while preserving the fixed rate ratios and using the magnitude of the experimentally known oscillation period as the only target value. The postulated model was numerically validated by perturbation simulations with somatostatin infusion and the results were compared with experiments available in literature. Finally, as far as we know, this reaction model with 15 variables is the most dimensional one that have been analysed mathematically to obtain instability region and oscillatory dynamic states. Among the existing models of thyroid homeostasis this theory represents a new class that may improve our understanding of basic physiological processes and helps to develop new therapeutic approaches. Additionally, it may pave the way to improved diagnostic methods for pituitary and thyroid disorders.

Decreased mannan-binding lectin level in adults with hypopituitarism; dependence on appropriate hormone replacement therapies.

Mannan-binding lectin (MBL) is a main component of the lectin pathway of the complement system. Although there are some studies showing links between endocrine and immune systems, the ones concerning hypopituitarism are limited. The aim of this study was to check whether there is any association between blood MBL level and pituitary hormone deficiencies and whether this relationship is affected by appropriate hormone replacement therapies. One hundred and twenty (120) inpatients, aged 18-92, were divided into two main groups, i.e. control individuals (21/120) and patients with pituitary diseases (99/120). The latter were diagnosed either with hypopituitarism (n=42) or with other pituitary diseases (not causing hypopituitarism) (n=57). Additionally, hypopituitary patients on appropriate replacement therapies (compensated hypopituitarism) were compared to patients on inappropriate replacement therapies (non-compensated hypopituitarism). Several parameters in blood serum were measured, including MBL level, pituitary and peripheral hormones and different biochemical parameters. Serum MBL level was significantly lower in patients with hypopituitarism comparing to controls (1358.97 ± 244.68 vs. 3199.30 ± 508.46, p<0.001) and comparing to other pituitary diseases (1358.97 ± 244.68 vs. 2388.12 ± 294.99, p=0.015) and this association was confirmed by univariate regression analysis. We evaluated the distribution of patients with relation to MBL level; there was a clear difference in this distribution between control individuals (among whom no subjects had MBL level <500 ng/mL) and patients with hypopituitarism (among whom 43% of patients had MBL level <500 ng/mL). Moreover, patients with non-compensated hypopituitarism had lower mean and median MBL levels comparing to patients with compensated hypopituitarism (1055.38 ± 245.73 vs. 2300.09 ± 579.93, p=0.027; 488.51 vs. 1951.89, p=0.009, respectively) and this association was confirmed in univariate regression analysis. However, mean and median MBL levels in patients with compensated hypopituitarism vs. controls did not differ significantly (2300.09 ± 579.93 vs. 3199.30 ± 508.46, p=0.294; 1951.90 vs. 2329.16; p=0.301, respectively). Hypopituitarism in adults is associated with a decreased blood concentration of mannan-binding lectin, a phenomenon which does not exist in hypopituitary patients on the appropriate hormone replacement therapies. Therefore measurement of mannan-binding lectin level in patients with hypopituitarism may be considered as a parameter contributing to adjust optimal doses of hormone replacement therapies.

A survey on the perception of the specialty of Endocrinology and Nutrition among students preparing for the entrance exam for medical specialty training in Spain

Introduction and aimsPrevious studies have shown that there is decreasing interest in E&N among medical students. The aim of our study was to evaluate the perception of E&N among a sample of medical students. Material and methodsWe surveyed 2252 students prior to taking the exam that allows access to specialised training in Spain. ResultsOverall, 9.9% (222 participants) would probably choose E&N. The most positive aspects in includes of the specialty are its logical pathophysiological basis (54%) and that the work is dynamic and varied (27%), while the least attractive aspects are the few interventional techniques. The parts of the specialty that most attract students are hypothalamic–pituitary disease and diabetes mellitus. ConclusionsThe proportion of candidates who want to study E&N as their first choice is adequate in relation to the number of places available.

Pituitary and adrenal disorders induced by immune checkpoint inhibitors

Over the past decade, the development of ICI (immune checkpoint inhibitors) has constituted a revolution in the treatment of many cancers, but with a specific toxicity profile including endocrine IRAEs (immune-related adverse events). As the indications for these molecules are constantly increasing due to their efficacy, it is important that endocrinologists and oncologists know how to detect, manage and monitor this type of toxicity. Many guidelines and recommendations have been proposed in the last few years for the management of endocrinopathies. French guidelines on immunotherapy-related endocrine IRAEs were published in 2018, with a specific algorithm for hypophysitis and primary adrenal insufficiency (PAI), based on clinical suspicion followed by biochemical and imaging evaluation, and are still relevant today. Here we present the general pathophysiological mechanisms of these toxicities, and discuss the incidence, diagnosis, treatment, progression, management and monitoring of pituitary and adrenal disorders in patients treated by immunotherapy, with emphasis on hypophysitis, which is much more frequent than PAI with this type of molecule. We also highlight several key points, such as the need for emergency treatment by hydrocortisone with the possibility of continuing immunotherapy in these endocrinopathies, and the long-term persistence of corticotropin or adrenal deficiency in most cases, requiring specific “hydrocortisone education”. These points should be kept in mind by oncologists and endocrinologists who treat and monitor patients treated by immunotherapy.

A survey on the perception of the specialty of Endocrinology and Nutrition among students preparing for the entrance exam for medical specialty training in Spain

Introduction and aimsPrevious studies have shown that there is decreasing interest in E&N among medical students. The aim of our study was to evaluate the perception of E&N among a sample of medical students. Material and methodsWe surveyed 2252 students prior to taking the exam that allows access to specialised training in Spain. ResultsOverall, 9.9% (222 participants) would probably choose E&N. The most positive aspects in includes of the specialty are its logical pathophysiological basis (54%) and that the work is dynamic and varied (27%), while the least attractive aspects are the few interventional techniques. The parts of the specialty that most attract students are hypothalamic–pituitary disease and diabetes mellitus. ConclusionsThe proportion of candidates who want to study E&N as their first choice is adequate in relation to the number of places available.

Managing Estrogen Therapy in the Pituitary Patient

Growth hormone (GH) regulates metabolic and physical health in the adult human. Because the GH system is regulated by estrogens, therapeutic estrogen compounds are likely to affect metabolic health. Estrogens are available for oral and parenteral use in natural, prodrug, and synthetic formulations including selective estrogen receptor modulators (SERMs). This review covers the pharmacology of estrogen and the effects on GH action to inform judicious use in the pituitary patient. The effects on the GH system are route dependent due to first-pass hepatic metabolism. Oral but not parenteral estrogen compounds inhibit GH action, reducing hepatic insulin-like growth factor-1 (IGF-1) production, protein anabolism, and fat utilization. In patients with GH deficiency, oral estrogen therapy exacerbates the degree of hyposomatotrophism and attenuates the beneficial effects of GH replacement therapy, effects that are greater with contraceptive than replacement doses. Surveys report that less than one-fifth of hypopituitary women are appropriately replaced by a transdermal route and up to half on oral therapy are inappropriately treated with contraceptive steroids. In acromegaly, however, estrogens, especially synthetic formulations of greater potency, reduce IGF-1, improving disease control, an effect also observed in men treated with SERMs. The route-dependent effects and potency of estrogen formulations are important considerations for optimizing the management of hypogonadal patients with pituitary disease, in particular GH deficiency and acromegaly. For hypopituitary women, estrogens should be replaced by a nonoral route. For acromegaly, oral estrogen formulations can be considered as simple adjuvant therapy for disease control.

Management of pituitary incidentalomas

Pituitary incidentalomas are common findings with increasing use of modern neuroradiological imaging undertaken for symptoms unrelated to pituitary disease. The prevalence of these lesions is ∼10% in autopsy studies and the incidence varies from 10% to 38% on magnetic resonance imaging in the published literature. They are almost always benign in nature and most are non-functioning (non-secreting) adenomas. Although many individuals are asymptomatic at diagnosis, some with functioning (secreting) pituitary adenomas or larger non-functioning adenomas have symptoms. All identified cases should have a thorough clinical and endocrinological evaluation to help with precise management, which depends on the size of the lesion, hormonal status (functioning versus non-functioning adenoma) and the presence of visual deficits resulting from optic nerve compression by the pituitary adenoma. Here, we provide an overview of the initial assessment and management of pituitary incidentalomas for clinicians not routinely involved in the management of pituitary disease.

Perspectives in Pituitary Stem Cells: Their Biologic Properties in Pituitary Diseases, Latest Approaches, and Future Aspects

Perspectives in Pituitary Stem Cells: Their Biologic Properties in Pituitary Diseases, Latest Approaches, and Future Aspects

CASE REPORT: PITUITARY APOPLEXY

Pituitary apoplexy is a rare surgical emergency. This condition involves the rapid progression, which can threaten patients’ life and is caused by haemorrhage or infarction in the pituitary gland. In most cases, a pituitary apoplexy occurs on a pre-existing pituitary tumor. The patient presents with a clinical syndrome of headache, visual deficits, ophthalmoplegia, and altered mental status and hormonal dysfunction. We report a 28-year-old male patient with no previous history of pituitary gland disease. There was a sudden onset and rapid progression, and the patient underwent emergency endoscopic nasal surgery. After surgery, the patient's neurological function was improved and stable.

Ectopic lipid metabolism in anterior pituitary dysfunction.

Over the past decades, adapted lifestyle and dietary habits in industrialized countries have led to a progress of obesity and associated metabolic disorders. Concomitant insulin resistance and derangements in lipid metabolism foster the deposition of excess lipids in organs and tissues with limited capacity of physiologic lipid storage. In organs pivotal for systemic metabolic homeostasis, this ectopic lipid content disturbs metabolic action, thereby promotes the progression of metabolic disease, and inherits a risk for cardiometabolic complications. Pituitary hormone syndromes are commonly associated with metabolic diseases. However, the impact on subcutaneous, visceral, and ectopic fat stores between disorders and their underlying hormonal axes is rather different, and the underlying pathophysiological pathways remain largely unknown. Pituitary disorders might influence ectopic lipid deposition indirectly by modulating lipid metabolism and insulin sensitivity, but also directly by organ specific hormonal effects on energy metabolism. In this review, we aim to I) provide information about the impact of pituitary disorders on ectopic fat stores, II) and to present up-to-date knowledge on potential pathophysiological mechanisms of hormone action in ectopic lipid metabolism.

Phenotypic and genotypic landscape of PROKR2 in neuroendocrine disorders.

Prokineticin receptor 2 (PROKR2) encodes for a G-protein-coupled receptor that can bind PROK1 and PROK2. Mice lacking Prokr2 have been shown to present abnormal olfactory bulb formation as well as defects in GnRH neuron migration. Patients carrying mutations in PROKR2 typically present hypogonadotropic hypogonadism, anosmia/hyposmia or Kallmann Syndrome. More recently variants in PROKR2 have been linked to several other endocrine disorders. In particular, several patients with pituitary disorders have been reported, ranging from mild phenotypes, such as isolated growth hormone deficiency, to more severe ones, such as septo-optic dysplasia. Here we summarize the changing landscape of PROKR2-related disease, the variants reported to date, and discuss their origin, classification and functional assessment.

Mapping of the current transition of care practice for patients with pituitary disease at Endo-ERN reference centers.

Rare endocrine conditions present specific diagnostic and management challenges for healthcare providers, one of which is the understudied transition of care. Despite the need for guidance regarding transition, consensus on structured and protocolled approaches is lacking. Therefore, we aimed to map the current clinical practice and identify unmet needs regarding transition of care for patients with pituitary disease in the reference centers (RCs) of the European Reference Network on Rare Endocrine Conditions (Endo-ERN). A survey-based, cross-sectional study using the EU Survey tool was performed and completed by 46 physicians (n) from 30 RCs (N). Transition is a common practice among RCs (n = 44/46), usually accomplished by a multidisciplinary team meeting (N = 20/30). Criteria for start and end of transition were defined in half of the RCs, with 16.7% of centers providing dissimilar answers. Transition readiness was assessed by >75% of the RCs, mostly by unvalidated means (e.g. subjective opinions, informal consultations). Pituitary-specific transition assessment tool was applied in one RC only. Transition protocols were present in only 9% of RCs, while in many RCs, transition decisions were taken in combined adult-pediatric meetings or based on clinicians' personal judgment. A minority of physicians evaluated the effectiveness of transition-related interventions (n = 11/46) or medical outcomes (n = 8/46). Patient-reported outcome measures were infrequently used (n = 4/46). Identified unmet needs included the development of guidelines (n = 5/46) and EU-wide approach (n = 2/46). This study exemplifies the unmet needs for a structural definition of the transition period and transition management for patients with rare hypothalamic and pituitary conditions from healthcare providers' perspective.

Sustained hypercortisolemia after bilateral adrenalectomy in Cushing's disease

Abstract Introduction Cushing's disease caused by pituitary corticotropin (ACTH)-secreting tumors. These tumors are almost always benign and are usually microadenomas. In 30 to 40 percent, the microadenoma is so small that it is not detectable by magnetic resonance imaging (MRI). Primary therapy consists of transsphenoidal surgery or pituitary irradiation. Patients who fail this first approach can be treated either by repeat transsphenoidal surgery, medical therapy, radiotherapy, or, as a final resort, surgical or medical adrenalectomy. Clinical Case A 38-year-old male patient presented with headache and fatigue. The laboratory examinations reviewed ACTH depending Cushing's syndrome. A suspicious lesion in the pituitary with no contrast enhancement was observed in Sella MRI. Cavernous sinus sampling consistent with central sources. He was operated in 2018 for pituitary Cushing's disease. Reticulin framework disrupted compatible with adenoma but, ACTH could not be stained in immunohistochemical staining for technical reasons. Due to the high cortisol levels of the patient in the postoperative follow-up, the patient underwent bilateral adrenalectomy in 2019. Because of active Cushing's disease, patient was re-evaluated in 2022. In laboratory examinations, HGB 16.6 g/dL, WBC 6400 /uL, NEU 3200 /uL, PLT 228000 uL, cre 0.76 mg/dL, TSH 1.5 mIU/L, FT4 1.2 ng/dl, FSH 4.6 U/L, LH 7.98 U/L, PTH 23.7 ng/L, PRL 17 µg/L, Total Testosterone 571 ng/dl, Progesterone 0.06 µg/L, GH 0.04 ug/L, IGF1 83 µg/L were detected. Basal cortisol was 35 ug/dl and ACTH 67 ng/L. Cortisol with 1 mg of DST resulted in 28 ug/dl. 2 mg DST resulted in cortisol 38 ng/L. Free cortisol in the urine was found to be 281 mg/day (n&amp;lt;130 mg/day). Empty sella was observed in sella MR. No prominent contoured lesion was observed in the pituitary gland. Adrenal gland was not observed in the Abdominal MRI. No tumor was detected in Thorax CT. The patient's pasireotide 0.3 mg 1×1 treatment was continued. Metyropane 250 mg 2×1 was added to the treatment. Conclusion In Cushing's disease, the ACTH-secreting adenoma may be too small to be detected.

Endocrine Hypertension: The Urgent Need for Greater Global Awareness.

Hypertension affects about 1.28 billion adults globally, and significantly increases the risk of chronic morbidity and mortality among sufferers. About 15% of these individuals have secondary hypertension, the majority of whom have dysfunction of one or more endocrine systems as the cause of hypertension. Although adrenal disorders are often identified as the cause of endocrine hypertension, extra-adrenal disease and pituitary disorders also can cause the disease. Timely diagnosis is of paramount importance, because of the potential for a surgical cure or optimal disease control with pharmacotherapy to prevent hypertensive complications. Even with its relatively high prevalence compared with many other chronic illnesses, the diagnosis of endocrine hypertension is often delayed or never made because of poor awareness about the disease among physicians. This review attempts to provide an overview of the disease, with some practical aspects of diagnosis and management of a few of the important disorders causing endocrine hypertension.

Association of serum level of interleukin-33 and insulin resistance in overt and subclinical hypothyroidism patients

Hypothyroidism is a condition that occurs when the thyroid gland fails to produce an adequate amount of the hormone thyroid, as a result of factors for example hypothalamic or pituitary gland disease, common tissue resistance to thyroid hormones, and thyroid gland diseases. It’s the most prevalent thyroid disorder. Interleukin-33 (IL-33) is a nuclear cytokine of the IL-1 family members that is abundantly expressed during homeostasis and inflammation in endothelial, epithelial, and fibroblast-like cells. It is worth noting that higher IL33 levels have been associated with insulin resistance. Aims the study: Its purpose was to examine the correlation between insulin resistance and IL33 in patients with hypothyroidism by measuring their IL33 levels. In a case-control study, 180 people were recruited and split into three categories: those with overt hypothyroidism (60), those with subclinical hypothyroidism (60), and those who were otherwise healthy (60). were of a similar age range to the patient (between 20 and 55), with 55.5% female participants and 44.5% male participants.