I am a huge fan of Coursera. This lecture is on the HPA Axis.
You may have to sign up/log in to view this video but Coursera is free – and you might find other courses of interest!
https://www.coursera.org/learn/physiology/lecture/DceZ9/hypothalamus-pituitary-adrenal-axis
Filed under: adrenal, Cushing's, pituitary, Video | Tagged: adrenal, Coursera, HPA axis, hypothalamus, pituitary, video | Leave a comment »
A woman experienced red, irritated and bulging eyes. She saw an ophthalmologist who strongly suspected Graves’ ophthalmopathy. However, the patient did not have and never had hyperthyroidism.
Indeed, she had primary hypothyroidism optimally treated with levothyroxine. Her thyroid stimulating hormone level was 1.197 uIU/mL.
An MRI of the orbits showed normal extraocular muscles without thickening, but there was mild proptosis and somewhat increased intraorbital fat content. Both thyroid-stimulating immunoglobulins as well as thyrotropin receptor antibodies were negative.
The patient presented to her primary care physician a few months later. She had experienced a 40-lb weight gain over only a few months and also had difficult-to-control blood pressure.
After failing to respond to several antihypertensive medications, her primary care physician astutely decided to evaluate for secondary causes of hypertension. A renal ultrasound was ordered to evaluate for renal artery stenosis, and the imaging identified an incidental right-sided adrenal mass. A CT confirmed a 3.4-cm right-sided adrenal mass. Her morning cortisol was slightly high at 24.7 ug/dL (4.3 – 22.4) and her adrenocorticotropic hormone was slightly low at 5 pg/mL (10-60).
At this point I saw the patient in consultation. She definitely had many of the expected clinical exam findings of Cushing’s syndrome, including increased fat deposition to her abdomen, neck, and supraclavicular areas, as well as striae. Her 24-hour urine cortisol was markedly elevated at 358 mcg/24hrs (< 45) confirming our suspicions.
She asked me, “Do you think that my eye problem could be related to this?”
“I’ve not heard of it before,” I replied, “but that doesn’t mean there can’t be a connection. Wouldn’t it be wonderful if your eyes got better after surgery?”
The patient underwent surgery to remove what fortunately turned out to be a benign adrenal adenoma.
When we saw her in follow-up 2 weeks later, her blood pressures were normal off medication and her eye symptoms had improved. I had a medical student rotating with me, so I suggested that we do a PubMed literature search.
The first article to come up was a case report titled “Exophthalmos: A Forgotten Clinical Sign of Cushing’s Syndrome.” Indeed, not only did Harvey Cushing describe this clinical finding in his original case series in 1932, but others have reported that up to 45% of patients with active Cushing’s syndrome have exophthalmos.
The cause is uncertain but is theorized to be due to increased intraorbital fat deposition. Unlike exophthalmos due to thyroid disease, the orbital muscles are relatively normal — just as they were with our patient.
Some of you may have seen exophthalmos in your Cushing’s patients; however, this was the first time I had seen it. Just because one has not heard of something, does not mean it could never happen; no one knows everything. “When in doubt, look it up” is a good habit for both attending physicians and their students.
For more information:
Giugni AS, et al. Case Rep Endocrinol. 2013; 2013: 205208.
Filed under: adrenal, Cushing's, Rare Diseases, Treatments | Tagged: 24-hour urinary free cortisol, 24-hour urine free cortisol test, adrenal, adrenal adenoma, adrenal surgery, Adrenocorticotropic hormone, blood pressure, cortisol, Cushing's Syndrome, Dr. Harvey Cushing, exophthalmos, Graves', hyperthryoidism, levothyroxine, MRI, ophthalmologist, renal artery stenosis, surgery, thyroid, TSH, weight | Leave a comment »
2014 has seen advances in our understanding of benign and malignant tumours of the adrenal cortex, particularly in Cushing syndrome. Modern genetics has generated a flurry of data. The challenge is to give sense to them; however, the difficulties of collecting the clinical data must not be underestimated.
Download this information at http://www.nature.com/nrendo/journal/vaop/ncurrent/full/nrendo.2014.215.html
Filed under: adrenal, Cushing's, pituitary | Tagged: adrenal, Adrenal cortex, aldosterone, Cushing's, genetics, PRKACA, tumors | Leave a comment »
Myth: “All types of Cushing’s are the same”
Fact: In the words of our dear friend and advocate, Robin Ess, “There are many genetic varieties with quite a few discovered in the past couple of years. Plus, there are several types such as adrenal, ectopic, and pituitary. And so on”….Amazingly, some doctors do not realize that there are different varieties of Cushing’s and that the symptoms can come from a different source.
For instance, a doctor might rule out a pituitary tumor and completely dismiss the patient, even with biochemical evidence of Cushing’s. That doctor, instead of dismissing the patient, should thoroughly look for other potential sources, such as an adrenal tumor, or yet another source. Did you know that tumors on one’s lungs can even cause Cushing’s? Most people don’t know that.
For more information about the different types of Cushing’s, please read: http://www.mayoclinic.org/diseases-conditions/cushing-syndrome/basics/causes/con-20032115
Another great article regarding ectopic Cushing’s can be found here: http://www.nejm.org/doi/full/10.1056/NEJM199809243391304#.VH-80v5f2s8.facebook
MaryONote: Folks might be interested in listening to this podcast episode with Jayne, a Cushing’s patient who had pituitary surgeries and a bilateral adrenalectomy before finding the true source of her ectopic Cushing’s – lung tumors.
Filed under: adrenal, Cushing's, Myths and Facts, pituitary, podcast, Rare Diseases | Tagged: adrenal, adrenalectomy, bilateral laparoscopic adrenalectomy, BLA, Cushing's, ectopic, lung, MaryO, Myths and Facts, pituitary, podcast, surgery, tumor | Leave a comment »
Myth: Cushing’s Syndrome/Disease can be healed or cured through change in diet or exercise.
Fact: NO! Caloric intake or lack of exercise has NO impact on weight gain and/ or loss in persons with Cushing’s.
Saying that someone “cheated” on their diet may seem reasonable to some as a reason for weight gain but I assure you that a candy bar or a piece of pie does not make a person with Cushing’s gain weight or get sick. Excess cortisol is the reason for Cushing’s symptoms. Treating the disease is the only way to alleviate symptoms.
The first line of treatment with the highest rate of remission is currently surgery to remove the tumor (s) from the pituitary, adrenal gland, or ectopic source.
Filed under: adrenal, Cushing's, Myths and Facts, pituitary | Tagged: adrenal, Cure, Cushing's, diet, ectopic, exercise, pituitary, remission, surgery, symptoms, tumor, weight | 1 Comment »
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