Pregnant Women with Hypertension and Hypercortisolism May Have Cushing’s

Pregnant woman with hypertension and significant signs of hypercortisolism (high cortisol levels) may have Cushing’s disease, according to a new case report.

The report, titled “A Case of Cushing’s Syndrome in Pregnancy,” was published in the Iranian Journal of Medical Sciences.

While Cushing’s rarely occurs in women during pregnancy, high cortisol levels can lead to major complications for both the mother and the fetus, such as premature birth and high fetal mortality.

However, it can be difficult to diagnose pathological hypercortisolism in these women as the symptoms might resemble other diseases that commonly occur during pregnancy, such as preeclampsia (high blood pressure during pregnancy) and gestational diabetes.

Unfortunately, there are no effective long-term medical therapies for Cushing’s. The most definitive therapy is the surgical removal of the pituitary or adrenal adenoma, if that is the case of hypercortisolism.

The case report details that a 29-year old women in the 27th week of pregnancy presented to the Ghaem Hospital clinic in Mashhad, Iran, with edema, weakness, and hypertension. Her symptoms also included truncal obesity, moon face (her face had a rounded appearance), purple steria on her upper and lower limbs and abdomen, excessive edema, and wet skin.

At first, she was hospitalized for suspected preeclampsia, but the diagnosis was later excluded.

The patient’s hormonal profile showed high levels of 24-hour urine cortisol. There were also low levels of adrenocorticotropic hormone (ACTH), which results from a negative feedback due to excessive cortisol. However, plasma cortisol is generally elevated during pregnancy, and therefore may not be the best method for diagnosis.

An abdominal ultrasonography revealed a well-defined mass in the right adrenal gland.

While hospitalized, the patient experienced two crises of blood pressure, and while preeclampsia was ruled out, the physicians could find no more plausible explanation than eclampsia (the onset of seizures in a women with preeclampsia).

Since eclampsia was suspected, the physicians terminated the pregnancy at 28th week of gestation using misoprostol. The woman delivered a male infant weighing 1.94 pounds.

Two days after birth, the physicians conducted a computed tomography (CT) scan and again found a mass in the right adrenal gland.

As a result, the patient underwent a laparoscopic right adrenalectomy to remove the mass one week after giving birth. The patient’s blood pressure normalized and cortisol levels declined. Her condition remained stable after surgery.

“Cushing’s syndrome should be considered in hypertensive pregnant patients with remarkable signs of hypercortisolism,” the researchers concluded. “The best results would be achieved through a collaboration between obstetricians, endocrinologists, and surgeons.”

From https://cushingsdiseasenews.com/2017/12/19/pregnant-women-hypertension-hypercortisolism-may-have-cushings-disease/

Blood Sample from Tributary Adrenal Gland Veins May Help to Diagnose Subclinical Cushing’s Syndrome

Researchers report a new technique for collecting blood samples from tiny veins of the adrenal glands, called super-selective adrenal venous sampling (ssAVS). The technique can be used to help diagnose diseases marked by excessive release of adrenal hormones, such as subclinical Cushing’s syndrome (SCS) or primary aldesteronism (PA).

The study, titled “A Novel Method: Super-selective Adrenal Venous Sampling,” was published in JOVE, the Journal of Visualized Experiments. JOVE has also made a video that demonstrates the procedure.

The adrenal glands are a pair of glands found above the kidneys that produce a variety of hormones, including adrenaline and the steroids aldosterone and cortisol. Excessive production of cortisol in the adrenal glands is the cause SCS, and aldosterone of PA.

These glands have central veins running through them, and three tributary veins (veins that empty into a larger vein). Conventional AVS collects blood from the central veins, but these veins have blood from the adrenal glands as well as blood in wider circulation flowing through them.

ssAVS uses tiny catheters — very long, narrow tubes inserted into blood vessels, called microcatheters — to collect blood from the tributary veins in both adrenal glands. Only blood from the adrenal glands flows through the tributary veins, making analysis of hormone levels easier, and pinpointing the region, or segment, of the gland that is not working properly.

A medical imaging technique, known as angiography, is used to track the positions of the microcatheters. Angiography is a procedure widely used to visualize the inside of blood vessels and organs, and takes roughly 90 minutes.

The paper reported on the use of ssAVS in three patients with adrenal gland disorders, and one (case #2) was diagnosed with SCS and PA. “Overall, in Cases #1 and #2, the ssAVS method clearly indicated segmental adrenal hormone production, not only for aldosterone, but for cortisol, and enabled these patients to be treated by surgery,”  the researchers reported.

Conventional AVS measures hormone levels in whole glands. It is useful for identifying which of the two glands is diseased, and the type of hormone that is overproduced. But sometimes both glands are affected, and only removal of the diseased parts in both glands is safe and effective.

That’s one of the reasons why ssAVS is so useful. By sampling the smaller, tributary veins in three different regions of each gland, the diseased parts can be identified. The diseased parts can then be removed from both glands, if medically advisable, leaving the healthy parts of the glands intact and functional.

ssAVS is also useful because it collects samples of blood coming directly from the adrenal glands, making analysis of hormone levels more reliable.

Researchers concluded that ssAVS is useful in both the diagnosis of adrenal gland disorders and for research that might lead to new therapies.

“Between October 2014 and September 2015, two angiographers … performed ssAVS on 125 cases … with a 100 % success rate and within a reasonable time (58 – 130 min) without adrenal rupture or thrombosis that required surgery,” they wrote. “The ssAVS method is not difficult for expert angiographers, and, thus, is recommended worldwide to treat PA cases for which cAVS does not represent a viable surgical treatment option.”

From https://cushingsdiseasenews.com/2017/10/17/subclinical-cushings-syndrome-may-be-diagnosed-via-blood-from-tributary-adrenal-gland-veins/

Adrenal Insufficiency: Primary and Secondary

By Dr Tomislav Meštrović, MD, PhD

Adrenal insufficiency is a condition that develops when most of the adrenal gland is not functioning normally. Primary adrenal insufficiency arises due to the damage of the glands or because of using drugs that halt synthesis of cortisol. On the other hand, secondary adrenal insufficiency stems from processes that inhibit the secretion of the adrenocorticotropic hormone (ACTH) by the hypophysis as a result of a hypothalamic or pituitary pathology. The former is sometimes also referred to as tertiary adrenal insufficiency.

Adrenal insufficiency is still a significant challenge for both patients and their physicians, but also scientists and researchers. In the past decade, long-term studies with adequate follow-up have shown a surge in mortality and morbidity, as well as impaired quality of life in individuals with this condition.

Primary Adrenal Insufficiency

In developed countries, the most common cause of primary adrenal insufficiency is autoimmune adrenalitis, whereas in the developing world tuberculosis is still considered a primary causative factor. Moreover, in young males, an X-linked adrenoleukodystrophy (also known as the less severe form of adrenomyeloneuropathy) must also be considered.

Histopathologically, in autoimmune primary adrenal insufficiency, there is a diffuse mononuclear cell infiltrate that can gradually progress to atrophy. Primary adrenal insufficiency is linked to both cortisol and mineralocorticoid deficiency.

Recent research drew attention to drug-related and infectious causes of adrenal insufficiency. Antifungal agents are known to substantially reduce cortisol synthesis, while imunosuppression associated with human immunodeficiency virus (HIV) has resulted in a resurgence of infectious causes, most notably tuberculous and CMV adrenalitis.

Secondary Adrenal Insufficiency

Secondary adrenal insufficiency has three principal causes: adrenal suppression after exogenous glucocorticoid or ACTH administration, abnormalities of the hypothalamus or pituitary gland that lead to ACTH deficiency, as well as adrenal suppression upon the correction of endogenous glucocorticoid hypersecretion.

Any lesion of the hypophysis or hypothalamus can result in secondary adrenal insufficiency; some of the examples are space-occupying lesions such as adenomas, craniopharyngiomas, sarcoidosis, fungal infections, trauma, and also metastases from distant malignant processes.

The histologic appearance of the adrenal glands in secondary adrenal insufficiency can range from normal to complete atrophy of the cortex (with preserved medulla). In contrast to primary adrenal insufficiency, secondary types are associated with the lack of cortisol, but not mineralocorticoid deficiency.

Clinical Features of Adrenal Insufficiency

The clinical presentation of adrenal insufficiency is related to the rate of onset and severity of adrenal deficiency. In a large number of cases, the disease has a gradual onset, thus the diagnosis can be made only when the affected individual presents with an acute crisis due to an inadequate rise in cortisol secretion during a physiologic stress. Such acute adrenal insufficiency (also known as the Addisonian crisis) is a medical emergency.

On the other hand, the course of chronic adrenal insufficiency is more subtle and insidious, with the predomination of symptoms such as fatigue, weakness, weight loss, diarrhea or constipation, muscle cramps, pain in joints and postural hypotension (low blood pressure). Salt craving and low-grade fever may also be present.

The classic physical finding that can help in differentiating primary from secondary adrenal failure is hyperpigmentation of the skin or the “suntan that does not fade”. Furthermore, patients with secondary adrenal insufficiency may present with additional symptoms related to pituitary disease (e.g., menstrual disturbances, loss of libido, galactorrhea, or hypothyroidism).

Laboratory Findings and Management

In cases of adrenal insufficiency, the complete blood count usually reveals anemia, neutropenia, eosinophilia, and relative lymphocytosis. Common chemical abnormalities include metabolic acidosis and prerenal azotemia, while hyponatremia, hypoglycemia, and hyperkalemia may also be present.

A cosyntropin stimulation test (also known as ACTH or Synacthen test) is required to establish the diagnosis of adrenal insufficiency. Magnetic resonance imaging (MRI) of the hypophysis in secondary adrenal insufficiency and computed tomography (CT) of the adrenal glands in primary adrenal insufficiency can aid in establishing a diagnosis. The adrenal glands appear normal in cases of autoimmune disorder.

Glucocorticoid replacement in patients with adrenal insufficiency can be lifesaving. Nevertheless, renal crisis is still a threat to patients’ lives, which is why awareness and adequate preventative measures receive increasing attention in the recent years.

Reviewed by Susha Cheriyedath, MSc

From http://www.news-medical.net/health/Adrenal-Insufficiency-Primary-and-Secondary.aspx

Cushing’s disease best treated by endocrinologist

Dear Dr. Roach: I was told that I have Cushing’s disease, which has caused diabetes, high blood pressure, hunger, weight gain and muscle loss. I was never sick before this, and I did not have any of those things. I am told I have a tumor on my right adrenal gland. I have been to numerous doctors, but most have not been too helpful. They seem to try to treat the diabetes or blood pressure, but nothing else. They seem not to be familiar with Cushing’s. I tell them which medication works, but they still give me new medication. I have an endocrinologist and am scheduled to meet a urologist.

I have managed to go to physical therapy, exercise every day and lose over 50 pounds. I am not happy with the advice I’m getting. I was told that surgery to remove the tumor will fix everything, but that I would need to take steroids for either a short term or for life. My body is already making too much cortisol. I have 50 more pounds to lose. I work hard to keep the weight down. I feel like a science experiment. Within a week, I have had three different medications. I could not tell which was causing the side effects and making me dehydrated. I am not sure surgery is right for me, because they said it can be done laparoscopically, but if they can’t do it that way, they will have to cut me all the way across, which may take a long time to heal and may get infected.

Do you know what tests will confirm the diagnosis? Would surgery fix all these problems? I had the 24-hour urine test, the saliva test and blood tests. I want to know if it may be something else instead of Cushing’s. I’m not on anything for the high cortisol levels.

– A.L.

A: It sounds very much like you have Cushing’s syndrome, which is caused by excess cortisone, a hormone that has many effects. It is called Cushing’s disease when the underlying cause is a pituitary tumor that causes the adrenal gland to make excess cortisone. (Cortisone and cortisol are different names for the same chemical, also called a glucocorticoid.) Cushing’s syndrome also may be caused by an adenoma (benign tumor) of the adrenal gland, which sounds like the case in you.

The high amounts of cortisone produced by the adrenal tumor cause high blood pressure, glucose intolerance or frank diabetes, increased hunger, obesity (especially of the abdomen – large bellies and skinny limbs are classic), dark-colored striae (stretch marks), easy bruising, a reddish face and often weakness of arm and leg muscles. When full-blown, the syndrome is easy to spot, but many people don’t have all the characteristics, especially early in the course of the disease.

Your endocrinologist is the expert in diagnosis and management, and has done most of the tests. I am somewhat surprised that you haven’t yet seen a surgeon to have the tumor removed. Once it is removed, the body quickly starts to return to normal, although losing the weight can be a problem for many.

I have seen cases in my training where, despite many tests, the diagnosis was still uncertain. The endocrinologist orders a test where the blood is sampled from both adrenal veins (which contain the blood that leaves the adrenal glands on top of the kidneys). If the adrenal vein on the side of the tumor has much more cortisone than the opposite side, the diagnosis is certain.

By DR. KEITH ROACH For the Herald & Review at http://herald-review.com/news/opinion/editorial/columnists/roach/dr-roach-cushing-s-disease-best-treated-by-endocrinologist/article_38e71835-464d-5946-aa9c-4cb1366bcee3.html

Resolution of the physical features of Cushing’s syndrome in a patient with a cortisol secreting adrenocortical adenoma after unilateral adrenalectomy

A 37-year-old woman developed clinical manifestations of Cushing’s syndrome over a span of 2 years. Physical examination revealed features that best describe Cushing’s syndrome, such as wide purple striae (>1 cm) over the abdomen, facial plethora and easy bruisability.1  Other features observed were hypertension, moon facies, acne, a dorsocervical fat pad, central obesity and dyslipidaemia.

The diagnosis of hypercortisolism was confirmed using a 1 mg overnight dexamethasone suppression test (19.7 ng/dL, N: <1.8) and 24 h urine free cortisol (185.9 μg/24 h, N: 3.5–45). A suppressed adrenocorticotropic hormone (ACTH) level (4 pg/mL, N: 5–20) and a lack of hyperpigmentation suggested ACTH-independent Cushing’s syndrome. Further work up using CT with contrast of the adrenals showed a 2.4×2.3×2.4 cm right adrenal mass. The patient then underwent laparoscopic adrenalectomy of the right adrenal gland. Steroids was started postoperatively and tapered over time. Histopathology results were consistent with an adrenocortical adenoma (2.5 cm widest dimension). Six months after surgery, there was resolution of the physical features, weight loss and improvement in blood pressure.

Figure 1 is a serial photograph of the physical features seen in Cushing’s syndrome, such as moon facies, a dorsocervical fat pad and wide purple striae, taken preoperatively, and at 3 and 6 months after surgery. With treatment, physical and biochemical changes of Cushing’s syndrome both resolve through time.2 The time course of the resolution of these changes, however, is varied.2 ,3 We observed that the physical features were ameliorated at 3 months and resolved at 6 months.

Learning points

  • Physicians as well as patients should be aware that improvement of the features of Cushing’s syndrome after treatment does not occur immediately.

  • Dramatic resolution of the physical features of Cushing’s syndrome, however, can be observed as early as 6 months after surgery.

Figure 1

Physical features of Cushing’s syndrome (top to bottom: moon facies, a dorsocervical fat pad and wide purple striae (>1 cm) over the abdomen) documented before surgery, and at 3 and 6 months after surgery.

Footnotes

  • Twitter Follow John Paul Quisumbing at @jpquisumbingmd

  • Contributors JPMQ worked up the case and wrote the case report. MASS reviewed the case report and critically appraised it. JPMQ incorporated his suggestions.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

References

From http://casereports.bmj.com/content/2016/bcr-2016-215693.short?rss=1

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