ResearchPad - adrenal---cortisol-excess-and-deficiencies Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[MON-160 The Burdens of Adrenal Insufficiency: A Survey Study from Two Tertiary Care Centers in the United States]]> Background: Adrenal insufficiency (AI) is a chronic disorder necessitating life-long replacement. Patients’ quality of life and health outcomes depend on knowledge and comfort level with self-management.

Objective: To determine patients’ knowledge in regards to diagnosis and management, estimate burden of disease and to identify predictors of adverse outcomes in patients with AI

Methods: Survey study of patients with AI evaluated at two tertiary medical centers between 2015 and 2019. Collected variables included data on circumstances of AI diagnosis, symptoms, management, burden of disease, and overall well-being.

Results: Among 785 patients (mean age at diagnosis 44.2 ± 18.0, 64% women, and 92% Caucasian), 310 (40%) had primary AI (PAI), 255 (33%) had secondary AI (SAI) not related to glucocorticoid use, and 211 (27%) had steroid-induced AI (SIAI). Patients were diagnosed with AI after presenting with symptoms for a median of 1 year (0-6), 28% with symptoms lasting >2 years, 44% visiting emergency room (ER) at least once prior to diagnosis. A third of patients reported a discordant diagnosis from their medical record.

Baseline glucocorticoid replacement therapy included hydrocortisone (HC) in 447 (59%), median of 20 mg (IQR 15 - 25mg), prednisone in 190 (25%), median of 5 mg (IQR 4 - 7.5mg), other regimens in 38 (5%), and no steroids in the remainder (85, 11%); 197 (26%) patients reported daily equivalent HC dose of >25 mg. Overall, 549 (73%) of patients reported use of stress dose steroids at least once per year, higher in patients taking HC >25 mg/day (3.2 vs 2.7 times per year if HC<25mg/day, p=0.01). Improper use of stress steroids was reported in 193, 25% patients. Patients taking HC>25 mg /day reported a higher number of adrenal crises (1.6 vs 1.3 in patients on HC<25 mg/day, p=0.04). Among 314 (41%) patients who reported ER visits due to adrenal crisis, only a third received prompt glucocorticoids.

One third of patients described their general health as fair or poor. Predictors of negative perceptions of overall health included SIAI (OR 6.2 and 2.5, vs PAI and SAI respectively), poor understanding of diagnosis (OR 2.6), daily HC>25 mg (OR 2.1), and presence of at least one adrenal crisis (OR 2.3) (p<0.001 for all).

Conclusion: Patients with AI experience delay in diagnosis, and a third do not fully understand their diagnosis. In addition to patient education, interventions to improve general health and outcomes may include selecting a physiological glucocorticoid replacement therapy, prevention of adrenal crisis, and improving ER care.

<![CDATA[MON-179 Association Between Long-Term Prednisolone Induced Adrenal Insufficiency and Polymorphisms in the Glucocorticoid Receptor Gene]]> OBJECTIVE: Several biomarkers for glucocorticoid (GC) sensitivity have been proposed relevant for the inter-individual variation seen in treatment response and side effects to GC treatment. Four single nucleotide polymorphisms (SNPs) of the GC receptor (GR) gene have been associated with increased (Bcl1 and N363S) or decreased (9β and ER23/23EK) GC sensitivity. We investigated the influence of these proposed biomarkers for GC sensitivity on GC-induced adrenal insufficiency.

SUBJECTS AND METHODS: We included 239 patients receiving long-term prednisolone treatment for rheumatoid arthritis (RA), polymyalgia rheumatica (PMR) / giant cell arteritis (GCA), or after renal transplantation (RTx). Four GR gene SNPs (Bcl1 rs41423247; 9β rs6198; N363S rs56149945; ER22/23EK rs6189 + rs6190) were sequenced by Sanger sequencing. Adrenal function was evaluated by a 250 µg corticotropin stimulation test. To compare allele frequencies with background population, two control groups were generated from two regional whole-genome databases. We downscaled each genome dataset to 239 individuals/group to balance statistical analysis.

RESULTS: In total 239 patients were genotyped and 178 of these (RA n=103, PMR/GCA n=47, RTx n=28) treated with a median current dose of 5 mg prednisolone/day (interquartile range 5-7 mg) and a median treatment duration of 48 months (interquartile range 22-111 months) completed the corticotropin test. Seventy-three (41%, CI95%: 34-48%) patients had an insufficient response to the corticotropin test. Neither the risk of adrenal insufficiency, unstimulated nor stimulated P-cortisol levels were directly associated with any of the GR SNPs. However, for both insensitive SNPs 9β and ER23/23EK the effect of current prednisolone dose on stimulated P-cortisol was smaller (higher dose did not suppress the cortisol level as much) in carriers vs. non-carriers (p=0.035 and p=0.0075). The same sensitivity-associated tendency was seen for the N363S, but not the Bcl1 SNP. The Bcl1 SNP occurred more frequently in our cohort compared with control groups (63% vs. 40%, p<0.0001). The same trend was seen for the other sensitive but less frequent SNP N363S. The 9β SNP also occurred more frequently in our cohort (18% vs. 13%, p=0.029), but depending on regional sub cohorts in one control group.

CONCLUSION: The GR SNPs did not directly associate to the risk of adrenal insufficiency, unstimulated nor stimulated cortisol levels, respectively. However, the effect of prednisolone dose on stimulated cortisol depended on the GR SNPs: Cortisol was less suppressed with higher current prednisolone dose in patients carrying the insensitive SNPs. The substantially higher frequency of the Bcl1 SNP is remarkable even with modest n=239. It questions whether there is an association between carrying the sensitive GR SNPs and inability to taper GC treatment ending up in this cohort of long-term treated patients.

<![CDATA[MON-169 Diagnostic Utility of Free Cortisol in Dexamethasone Suppression Test. A Prospective Study in Healthy Subjects]]> OBJECTIVE: Low dose dexamethasone suppression testing (DST) is standard of care in patients with adrenal incidentalomas or suspected endogenous hypercortisolism. False positive total serum cortisol (TC) results occur due to poor absorption, rapid metabolism or estrogen use. Free serum cortisol (FC) measurement is an alternative, but optimal cut-offs are unknown. We aimed to establish the optimal serum dexamethasone concentrations (DEXA) to interpret TC and FC results and identify reasons for discrepancies between TC and FC values in healthy male and female (with and without oral contraceptive therapy, OCT) subjects. METHODS: Single center prospective study of healthy subjects >17 years old undergoing assessment with DST between 2016 and 2019. Measurement of FC and DEXA was performed by tandem mass spectrometry and TC by immune-enzymatic assay at 8 AM following overnight administration of 1 mg dexamethasone at 11pm. Subjects were excluded if they had a known adrenal adenoma, any form of endogenous cortisol excess, or exogenous steroid use. RESULTS: DST was performed in 165 healthy volunteers, median age of 29.5 (18-74) years; 53 men (32%) and 112 (67%) women, median BMI 25 (18-42) kg/m2, 47 (42%) of which were taking OCT (median daily ethinyl-estradiol dose of 30 (20-35) mcg). The median DEXA was 0.34 (0.09-1.12) mcg/dl, median TC was 0.8 (0.25-15.7) mcg/dl and median FC was 24 (4-714) ng/ml. TC and FC measurements were highly correlated (r2=0.89, p<0.0001). The median FC/TC was 3% (0.3-6.7), lowest in women on OCT (median 2.5% vs 3.3% in women not on OCT and men, p<0.0001). TC>1.8 mcg/dl was demonstrated in 18 (11%) healthy subjects (men: 3/53, 5.7% vs women not on OCT: 3/65, 4.6% and women on OCT: 12/47, 25.5%, p=0.0007). Excluding women on OCT, the proportion of subjects with TC>1.8 was higher when DEXA was <0.2mcg/dl (4/15, 27%) vs when DEXA was >0.2mcg/dl (2/101, 2%),(p<0.0001). After excluding 24 (14%) healthy subjects with DEXA <0.2 mcg/dl, in the remaining 142 subjects (51 (35%) men, 54 (38%) women not on OCT and 39 (27%) women on OCT), median TC was 0.75 (0.25-4.6) mcg/dl and median FC was 23 (4-103) ng/ml). Significant differences were noted in both TC and FC following DST within subgroups: men vs women not on OCT vs women on OCT, TC: 0.6 vs 0.7 vs 1.3 mcg/dl, (p<0.0001) and FC: median 20 vs 22 vs 31 ng/ml, (p<0.0001). All men and all women not on OCT demonstrated post-DST FC <50 ng/ml (97.5% cutoff of 47 and 37), while women on OCT demonstrated post-DST FC <50 in 80% and FC<75 in 95%. CONCLUSION: Post-DST TC>1.8 mcg/dl was demonstrated in 11% of all healthy subjects, of which 1 in 4 were women on OCT and 1 in 4 had DEXA<0.2 mcg/dl. Simultaneous measurement of serum DEXA during DST may be valuable when false positive results are suspected. Despite a lower FC/TC ratio in women on OCT, post-DST FC cutoffs were higher in women on OCT. Measurement of FC after DST may be helpful in some but not all women on OCT.

<![CDATA[MON-188 The Diagnostic Value of DHEAS in Subtyping Patients with Cushing Syndrome]]> Objective: Serum dehydroepiandrosterone sulfate (DHEAS) can be used to assess the integrity of the hypothalamic-pituitary-adrenal (HPA) axis. The aim of this study was to evaluate the clinical value of DHEAS in differentiating adrenal Cushing syndrome (ACS) from Cushing’ disease (CD). Methods: We recruited 100 patients with Cushing syndrome, 36 with CD and 64 with ACS. 72 sex-, age- and BMI-matched nonfunctional adrenal adenomas (NFAAs) were served as controls. Clinical and laboratory data were collected. DHEAS levels were measured and DHEAS ratio was calculated by dividing the measured DHEAS by the lower limit of the respective reference range (age- and sex-matched). Results: 1) No significant differences in age, sex, or BMI were detected among the NFAAs, ACS and CD groups. Compared to NFAAs group, ACS patients had lower plasma ACTH levels [1.11(1.11,1.74) vs 5.0 ± 2.9 pmol/L, P<0.01], lower DHEAS levels (24.00 ± 20.72 vs 189.05 ± 82.03 ug/dL, P < 0.01) and lower DHEAS ratio [0.58(0.27,0.98) vs 5.34 ± 3.0]; Plasma ACTH (22.12 ± 14.22 pmol/L), DHEAS (309.4 ± 201.1 ug/dL) and DHEAS ratio (10.51 ± 7.65) in CD patients were significantly higher compared to those in NFAAs and ACS patients (all P<0.01). 2) In ACS patients, there were 53 patients with suppressed ACTH level of <2.0 pmol/L, 11 patients without plasma ACTH suppression (≥2.0pmol/L). Compared to NFAAs, lower DHEAS and DHEAS ratio were detected in these two groups, and no significant differences were found in the DHEAS [15(15, 23.5) vs 23.8 ± 14.4 ug/dL, P=0.86] and DHEAS ratio [0.58(0.27, 0.80) vs 1.0(0.25,2.09) ug/dL, P=0.40] between the two groups. 3) ROC analysis showed that the area under the curve (AUC) of plasma ACTH, serum DHEAS and DHEAS ratio in diagnosing 0.954, 0.997 and 0.990 respectively. The optimal cut-off values for DHEAS and its ratio were 79.1ug/dL, and 2.09, respectively. The diagnostic sensitivity and specificity of plasma ACTH (<2.0pmol/L) were 84.1 and 100%, those of DHEAS were 97.5% and 100%, and those of DHEAS ratio were 95% and 100%, respectively. Conclusions: Patients with different subtype of Cushing syndrome showed distinctive DHEAS levels and DHEAS ratio. DHEAS and DHEAS ratio are useful in differential diagnosis of Cushing syndrome. Especially, when the plasma ACTH level is not conclusive. The measurement of DHEAS may offer a supplementary test to diagnosis ACS from CD.

Keywords: Adrenal Cushing syndrome; Cushing disease; Adrenocorticotropic hormone; Dehydroepiandrosterone sulfate

<![CDATA[MON-177 CAH-X Syndrome in a German Cohort of Patients with Congenital Adrenal Hyperplasia]]> Congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) is encoded by the CYP21A2 gene. The CYP21A2 gene is flanked and partially overlapped by the TNXB gene encoding an extracellular matrix protein called Tenascin-X. Deficiency of Tenascin X can cause the Ehlers-Danlos Syndrome (EDS). Deletions of CYP21A2 extending into TNXB rarely cause CAH combined with EDS. Heterozygosity of TNXB mutations causing haploinsufficiency of TNX, however, have been described in about 5-7% in a patient cohort from the US and has been named CAH-X syndrome, CAH associated with mild hypermobility form of EDS.

We genetically investigated a cohort of 81 adult patients (31 males, mean age 37,8 years +/- 9,8) with classic CAH for CAH-X. Patients genetically positive for CAH-X and unaffected CAH control patients matched for sex, age and BMI underwent a thorough clinical investigation including joint examination by Beighton 9-point scale, skin and neurological examination, by a standardised protocol of thransthoracic echocardiography and muscle ultrasound. In addition serum tenascin-X has been measured.

In our cohort we identified one patient with CAH and EDS and 4 patients with CAH-X syndrome. All CAH-X patients had serum concentrations of tenascin-X below the normal range, however, not different from 35 unaffected CAH patients with regard to serum concentration. All 4 patients with CAH-X syndrome showed some associated clinical symptoms. Two had joint hypermobility detected by Beighton 9-point score. Two of four CAH-X patients showed cardiac abnormalities (mild mitral regurgitation in one patient and a surgically corrected common arterial trunk type I A in the other patient). The patient with CAH and EDS showed cardiac abnormalities in addition to typical EDS symptomatology. All 5 affected patients complained about back pain and showed foot malposition. Profound changes in muscle ultrasound were found in 60 % of patients with CAH-X syndrome (3/5) and in none of the controls (0/5).

In conclusion, our data confirm the previously described prevalence of CAH-X. Beighton-score seems to be a quick and cheap screening instrument for CAH-X and should be performed in all patients with classic CAH, since protein level in serum cannot be used for screening for CAH-X-Syndrome. A stronger focus needs to be made on back pain and foot malposition as symptoms of CAH-X and echocardiography should be performed in all CAH-X patients. Therapy should depend on clinical symptoms in patients.

<![CDATA[MON-175 Structural Instability as an Underlying Pathomechanism in Congenital Adrenal Hyperplasia]]> Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting key enzymes of cortisol biosynthesis. In the majority of cases the underlying cause are detrimental mutations in the steroidogenic cytochrome P450 enzyme 21-hydroxylase (CYP21A2). Early diagnosis via newborn screening programs in most Western countries and lifelong oral cortisol replacement therapy enable survival, however quality of life often is reduced and co-morbidities are substantially increased. Treatment is a major challenge as disease control can only be achieved with supraphysiological glucocorticoid doses. In addition, the currently available drugs cannot ideally mimic the circadian rhythm and stress adaption of cortisol secretion. Currently, disease severity is classified by residual enzyme activity. The goal of our research is to better understand the specific biophysico-chemical pathomechanism of 21-hydroxylase deficiency in order to enable causative therapeutic approaches. To this end, we investigated the structural and stability properties of six clinically relevant mutant variants of CYP21A2 (V282G/L, P31L, D323G, R484Q/W). Difficulty in purification of these CYP21A2 variants and various biophysical studies suggest that the proteins were less stable than wild-type (WT). Structural and thermal stability assessment by circular dichroism (CD) spectroscopy of recombinant, purified CYP21A2 mutant variants revealed high α-helical content for the WT (65% α-helix) and the mutants at the position 282 (V282G: 60.6 %, V282L: 57.6%). Other mutations (P31L, D323G, R484Q/W) disrupt the α-helical organization of CYP21A2 in exchange for a slight increase in ß-sheet content but mainly for random coil. Temperature dependent CD spectroscopy showed that all mutant variants have reduced thermal stability (Tm: 41.3 - 45,6°C) compared to the WT (Tm: 47.1°C). Tryptophane fluorescence showed that mutant variants of the protein were more prone to local unfolding at the hydrophobic core compared to WT using urea as denaturant. Furthermore, in UV/Vis spectroscopy at 280 nm and 418 nm we could demonstrate that all mutant variants had a reduced heme incorporation (A418/A280: 0.20 - 0.63) compared to WT (A418/A280: 0.88). Our results show that correct structural folding and stability pose a major problem in specific mutations involved in CAH. Therefore we propose that structural protein instability, play a key role in the pathophysiology of CAH and thus might constitute a novel tailored therapeutic target for the treatment of affected patients.

<![CDATA[MON-158 Rates of Illnesses in Patients with Congenital Adrenal Hyperplasia]]> Background: Classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is the most common cause of primary adrenal insufficiency during childhood and patients are at risk for life-threatening adrenal crisis. In a recent study from our group, we reported gastrointestinal and upper respiratory tract infections as the two most common precipitating events for adrenal crises and hospitalizations across all ages. We also reported 11 incidents of life-threatening hypoglycemic events in children, sometimes accompanied by seizures.

Objective: To evaluate the annual rates of illnesses in patients with CAH.

Methods: We retrospectively reviewed longitudinally collected data over 23 years from 156 CAH patients enrolled in our CAH natural history study ( #NCT00250159). Incidence of illnesses and occurrence of stress-dose days were computed per person-years. Incidence rate ratio (IRR) with 95% confidence intervals (CI) were calculated for comparisons.

Results: A total of 2298 visits (1909 for children and 389 for adults) were available for evaluation among the 156 patients (21-OHD: 97.4%). A total of 1870 illness events (1664 in children) were observed in 143 patients (121 children) and 2710 stress-dose days (2460 in children) were observed in 141 patients (120 children) during the study period. The incidence rate of illnesses was higher in children than adults (1.5 vs. 0.5 illnesses/person-years, IRR = 3.1, 95% CI 2.7 - 3.6; P<.0001) with incidence highest in young patients: 2.5 illnesses/person-years in <3 year olds. Similarly, the stress-dose days were higher in children than adults (2.2 vs. 0.6 days/person-years, IRR = 3.8, 95% CI 3.3 - 4.3; P<.0001).

Conclusions: Patients with CAH do not appear to have higher rates of infectious illnesses than expected, but remain at risk for life-threatening adrenal crises. As expected, illness rates are higher during childhood than adulthood. Prevention of adrenal crisis is crucial and is best accomplished through repeated age-specific education of patients and caregivers.

Acknowledgement: This research was supported by the Intramural Research Program at the National Institutes of Health (NIH), Bethesda, Maryland.

<![CDATA[MON-162 Utility of 24-Hour Urine Cortisone for the Diagnosis of Cushing’s Syndrome]]> Background: Obesity, diabetes and hypertension are common in the general population, and do not discriminate between patients (pts) with or without Cushing’s syndrome (CS). Thus, Endocrine Society guidelines recommend biochemical testing in pts with multiple features compatible with the diagnosis (1). A 24-hour (d) urine cortisol (UF) is one of the recommended screening tests. However, tandem mass spectrometry (MS/MS) measurement of UF may be less sensitive than immunoassay because of antibody cross-reactivity with cortisol-like compounds. Cortisone (E), the product of 11β‐hydroxysteroid dehydrogenase type 2 (11βHSD2) inactivation of cortisol, can be measured in the urine (UE) by MS/MS and might improve the sensitivity of UF alone. The goal of this study was to compare the diagnostic utility of UE, UF, their sum (UF+UE) and their ratio (rUF/UE) for the detection of CS.

Methods: We retrospectively reviewed 35 pts evaluated for CS from 1/2017 to 9/2019. UF (reference range (RR), 3.5-45 ug/d) and UE (RR 17-129 ug/d) were measured by MS/MS. CS etiology was later confirmed in 24 pts by pathology and/or tumor localization [14 female; 14 Cushing’s disease, 7 ectopic ACTH secretion (EAS), 3 presumed EAS awaiting surgery; 46 UF and UEs], and was excluded (noCS) in 11 pts followed over time [8 female; 65 UF and UEs with salivary cortisol and/or dexamethasone suppression]. For CS patients with multiple results, the sample with the lowest UF was compared with all available samples from the NoCS group.

Results: Using a single result for each CS pt, the median (range) for UF, UE, UF+UE and rUF/UE were 281 ug/d (34 - 32,444), 358 ug/d (171 - 802), 642 ug/d (232 - 33246) and 0.78 (0.13 - 40.5). By contrast, using all observations in noCS pts, median (range) for UF, UE, UF+UE and rUF/UE were 13.6 ug/d (2.2 - 88.8), 79.5 ug/d (4.9 - 253), 98.2 ug/d (7.1 - 342) and 0.2 (0.05-0.67).

Using the upper RR (or their sum) as a criterion for abnormality, all CS pts had abnormal UE and UF+UE; 45/46 had abnormal UF. In noCS samples, abnormal values were seen in 12/65 UF (3 pts), 14/65 UE (4 pts), and 13/65 UF+UE (3 pts).

The rUF/UE was < 0.70 in all noCS pts and in 9/24 CS patients. Within this group, the UF+UE was > 230 ug/d in two noCS patients (2/3 and 2/7 samples/pt), and in all 9 CS patients, including two with normal UF and two with UF <50% above the RR. Alternatively, a UE > 170 ug/d identified the same noCS and CS patients.

Conclusion: UF remains an important tool for screening of CS. The addition of UE and UF+UE may provide additional information to discriminate CS from noCS in patients with rUF/UE < 0.70. In contrast to CS pts, noCS pt consistently had UF+UE > 230 ug/d or UE > 170/d, underscoring the importance of multiple samples. Additional study, especially of pts with mild hypercortisolism, is needed to determine optimal diagnostic criteria.

1.Nieman L et al. J Clin Endocrinol Metab 93:1526, 2008

<![CDATA[MON-168 Peri-Operative Glucocorticoids in Patients Having Total Joint Replacements: Help or Harm?]]> Introduction: There is limited evidence to guide peri-operative steroid regimen in patients receiving chronic glucocorticoid (GC) therapy. Many patients who undergo minor surgical procedures receive stress-dose steroids. While hemodynamic instability and hypotension are well-recognized risks of inadequate peri-operative GCs, there may be harms associated with using doses higher than necessary. Whether surgical outcomes differ according to peri-operative steroid dose is not known. We hypothesized that patients who had greater GC exposure have less hypotension, but higher rates of hyperglycemia and post-operative complications.

Methods: This retrospective study investigated the relationships between peri-operative GC use and post-operative complications following total hip/knee joint replacement (arthroplasty) in patients with rheumatoid arthritis (RA). All GCs were converted to prednisone equivalents; GC exposure was assessed by number of doses and total cumulative dose during the hospitalization. Complications (infection, thromboembolism and cardiovascular events) were determined by chart review.

Results: Of 432 patients with RA included, half (54%) underwent knee arthroplasty. Mean age was 64±12 years, 78% were women. Thirty percent of patients were on home GCs (mean dose 7±4mg/day). Median cumulative GC dose during hospitalization was 37mg [IQR 27, 57]. Compared to patients who only received one peri-operative dose of steroids, those who received multiple doses had a greater risk of post-operative complications (OR 3.319 (95% CI 1.03, 12.62; p<0.05] and hyperglycemia, glucose >180 mg/dl, [OR 1.812(0.99, 3.32; p<0.05]. They did not have an increase in hypotension or need for pressors. Among patients who received steroids while in the hospital (90%), there was a small but significant dose response relationship with hyperglycemia (r=0.16; p<0.01). Higher cumulative dose was also associated with higher risk of complications; for every 10 mg increase in cumulative dose, the risk of complications increased by 15% (p<0.01).

Conclusions: Among RA patients undergoing arthroplasty, we did not find that lower doses of GCs were related to more hypotension. However, patients with higher GC exposure were more likely to have hyperglycemia and post-operative complications. Our results suggest that use of peri-operative GC is not without risk, and the lowest doses possible should be considered. Further studies are needed to confirm these findings and to define the optimal dosing strategies for patients receiving peri-operative GCs.

<![CDATA[MON-178 Cyclical Cushing’s Syndrome in 12 Patients with Ectopic ACTH Secretion]]> Background: Cyclical Cushing’s syndrome (CCS) is characterized by alternating periods of endogenous hypercortisolism and eucortisolism. A literature survey of 60 adult patients with CCS found 15 to have ectopic ACTH secretion (EAS) (1). The duration and frequency of hypercortisolemia are unpredictable, creating a diagnostic challenge.

Objective: Describe biochemical and clinical characteristics of patients with CCS due to occult or histologically proven ectopic ACTH-secreting neuroendocrine tumor (NET).

Methods: We conducted a retrospective medical record review of 12 adults with EAS admitted to our institution. Inclusion required 1) evidence of ectopic ACTH tumor from biochemical testing (CRH stimulation, 8 mg dexamethasone suppression [DST], and/or inferior petrosal sinus sampling [IPSS]) or pathology results and 2) cycles of hypercortisolism (Hi-F) to eucortisolism (Eu-F) off medical treatment.

Results: Average age on admission was 61 (46-79) years; 58% were women. All 12 had biochemical evidence of ACTH-dependent Hi-F. IPSS results suggested EAS in 9 patients, 8 of whom had Hi-F for more than two months, and 1 whose cycles occurred every 5 - 7 days. IPSS was consistent with Cushing’s disease (CD) in 2 patients after Hi-F of only 6 -7 weeks and one with Eu-F on admission, estimated duration < 4 weeks. DST suggested EAS in 9 patients, and CD in the one with recent Eu-F. CRH was consistent with EAS in 10 patients, but suggested CD in 2 with marginal increases in ACTH (34.5%, 38%) but not cortisol. 7 patients had ACTH-secreting tumor on pathology (5 pulmonary, 1 pancreas, 1 appendix NET), and 5 had occult presumed EAS. Time from one Hi-F episode to the next ranged from 1 week to 6 years with Hi-F duration of 3 days to 5 years. 24-hour urine free cortisol (UFC) levels were 17 - 301 times the upper reference range (RR) during Hi-F periods. During Eu-F, lowest UFCs were within RR in 9 patients and subnormal in 3. Hypokalemia occurred in 11 patients with Hi-F; increasing values paralleled movement to Eu-F.

Conclusion: Patients with possible ectopic ACTH-secretion and CCS may pose a diagnostic challenge: clinical and biochemical evidence of hypercortisolemia may not be present, depending on the timing and/or duration of hypercortisolism. Furthermore, test results may inappropriately suggest Cushing’s disease if performed after less than 8 weeks of hypercortisolism, or with recent eucortisolism. Thus, weekly UFC measurement may facilitate diagnosis of cyclical Cushing’s syndrome and determine appropriate timing of dynamic testing such as inferior petrosal sinus sampling. Potassium may be a useful marker to determine when medical treatment can be tapered or stopped.

1. Meinardi JR, et al. Eur J Endocrinol. 157:245, 2007.

<![CDATA[MON-156 Efficacy and Safety of Prenatal Dexamethasone Treatment in Offspring at Risk for Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency]]> Objective: To assess the efficacy and safety of prenatal dexamethasone treatment in offspring at risk for congenital adrenal hyperplasia. Methods: MEDLINE, EMBASE, the Cochrane Library, the website databases was systematically searched from inception through March 2019. WMD and SMD with 95%CIs were calculated using random or fixed effects models. Results: There was a significant reduction of virilizationin the DEX-treated group (WMD: -2.39, 95%CI: -3.31,-1.47). No significant differences were found in newborn physical outcomes for birth weight (WMD: 0.09, 95%CI: -0.09, 0.27) and birth length (WMD= 0.27, 95%CI: -0.68, 1.21). Concerning cognitive functions, no significant differences in the domains of psychometric intelligence (SMD: 0.05, 95%CI: -0.74, 0.83), verbal memory (SMD: -0.17, 95%CI: -0.58, 0.23), visual memory (SMD: 0.10, 95%CI: -0.14, 0.34), learning (SMD: -0.02, 95%CI: -0.27, 0.22), verbal processing (SMD: -0.38, 95%CI: -0.93, 0.17). Regarding behavioral problems, no significant differences in the domains of internalizing problems (SMD: 0.16, 95%CI: -0.49, 0.81), externalizing problems (SMD: 0.07, 95%CI: -0.30, 0.43), total problems (SMD: 0.14, 95%CI: -0.23, 0.51). With respect to temperament, no significant differences in the domains of emotionality (SMD: 0.13, 95%CI: -0.79, 1.05), activity (SMD: 0.04, 95%CI: -0.32, 0.39), shyness (SMD: 0.25, 95%CI: -0.70, 1.20), sociability (SMD: -0.23, 95%CI: -0.90, 0.44). Conclusions: Prenatal DEX treatment reduced virilization with no significant differences in newborn physical outcomes, cognitive functions, behavioral problems, temperament. The results need to be interpreted cautiously due to the existence of limitations.

<![CDATA[MON-190 Telomere Length as a Novel Prognostic Marker of Cushing Complications]]> Telomeres are small sequences at the end of chromosomes, protecting them from abnormal degradation. Certain conditions, like cancer, have been associated with changes in telomere length (TL), which, in turn, may predict outcomes of the disease. Studies on the effect of cortisol on TL have not led to conclusive results or are limited in stress induced hypercortisolemia. Moreover, no study has focused on effects of persistent endogenous hypercortisolemia during childhood, a known important period for telomere modifications.

We hypothesized that TL is affected in pediatric patients with endogenous Cushing syndrome (CS) and it correlates with markers and complications of hypercortisolemia.

We studied 10 pediatric patients (mean age: 13.3 years, 7 females), diagnosed and treated successfully for Cushing disease. TL of total lymphocytes and their subtypes (Naïve T-cells, Memory T-cells, B-cells and NK-cells) were measured before and 1 year after treatment. TL was compared to age-matched control samples (6-8 per age group) and was correlated with clinical and biochemical characteristics. Paired or two-sample parametric or non-parametric statistical tests were performed, as appropriate.

Lymphocyte TL of patients with active CS did not differ from controls (p=.43). B-cell and NK-cell TLs were shorter after cure compared to active CS [mean B-cell TL difference: -1.44 Kb (-15%), p=.001; mean NK-cell difference: -0.51 Kb (-7%), p=.10] and controls [mean B-cell TL difference: -0.98 (-11%), p=.039; mean NK-cell difference: -1.3 Kb (-16%), p=.005]. Lymphocyte TL in active CS and the change of TL before and after cure did not correlate with measured markers of hypercortisolemia (morning and midnight cortisol, urinary free cortisol or ACTH levels). However, there was a strong inverse correlation between the difference of TL in active disease compared to controls and triglyceride level for all lymphocyte subtypes (range r= -0.74 to -0.86, range p= .003 to p=.022), suggesting that the higher the triglyceride levels, the shorter the TL in patients with CS. Additionally, inverse correlation was observed for weight and BMI SDS and B-cell TL, specifically (r= -0.76, p= .019 and r= -0.76, p= .018, respectively). Furthermore, there appeared to be an implication for shorter TL in CS patients with dyslipidemia compared to those without (mean TL difference from controls: -1.1 Kb in patients with dyslipidemia vs 0.53 Kb in those without, p= .067).

We conclude that although TL in active CS does not seem to differ from controls, B-cell and NK-cell TLs are affected after cure, and this may be related to acute changes that occur in the immune system peri- and post-operatively. Interestingly, the level of TL shortening correlates strongly with several complications of CS, including weight, BMI and dyslipidemia. This suggests that TL may be used as a surrogate prognostic marker of hypercortisolemia-related complications.

<![CDATA[MON-171 Characterization of the Adrenal Gland and Adrenal Rest Tissues in Congenital Adrenal Hyperplasia]]> Background: Adrenonodular hyperplasia and tumor formation are common long-term complications of congenital adrenal hyperplasia (CAH) driven by chronic ACTH elevation. Clinical studies indicate that the majority of males with classic CAH have testicular adrenal rest tumors (TART). Ovarian adrenal rest tumors (OART) are less commonly observed. Little is known about the pathophysiology of adrenal rest, however both adrenal cortex and Leydig cell markers have been described in TART, suggesting a pluripotent embryological cell origin.

Objective: To characterize adrenals and adrenal rest tissues of patients with CAH in comparison with normal tissues.

Materials and Methods: Using immunohistochemistry (IHC) and, real-time qRT-PCR we investigated CAH-affected adrenals (n=5), adrenal rest tissues (n=2; 1 testicular, 1 ovarian), controls [normal adrenal (n=2), testis (n=1), and ovary (n=1)]. Tissue sections prepared from paraffin embedded tissue blocks were immunostained with adrenal [melanocortin 2 receptor (MC2R), delta-like homolog 1 (DLK-1), steroidogenic factor 1 (SF-1), steroidogenic acute regulatory protein (StAR) and other cytochrome P450 genes], inflammatory [interleukin 2 receptor (IL-2R), B-lymphocyte antigen (CD20), cluster of differentiation 3 (CD3), tumor necrosis factor alpha (TNFα), interleukin 6 (IL6)], and gonadal markers [progesterone receptor (PR), androgen receptor (AR), insulin-like 3 (INSL3)]. RNA was isolated and gene expression studies were performed. High-throughput RNA sequencing technology was used to analyze the differential transcriptome profiles between the CAH adrenals, adrenal rest and normal tissues.


In contrast to the controls, CAH adrenals and adrenal rest tissues showed the following:

(i) IHC studies revealed 95% of tissue positive for adrenal zona-reticularis; (ii) significant nodular lymphocytic infiltration with a predominance of B and T lymphocytes and overexpression of lymphocyte markers IL-2R, CD20, CD3, and inflammatory cytokines TNFα and IL6; (iii) increased expression of adrenocortical specific genes MC2R, DLK1.

Conclusion: CAH-affected adrenals and adrenal rest tissue have similar predominance of zona reticularis and demonstrate lymphocytic infiltration. Active inflammation may play a role in the abnormal development of adrenal and adrenal rest tissue in CAH patients.

<![CDATA[MON-182 Increased Risk of Bleeding and Excessive Anticoagulation Using Standard Dose Low Molecular Weight Heparin (LMWH) in Cushing’s Syndrome]]> Background: Cushing’s Syndrome (CS) is a hypercoagulable state with increased risk of venous thrombosis events (VTE) including pulmonary embolism (PE) and deep venous thrombosis (DVT). In the absence of clear recommendations (1), a standard dose of low molecular weight heparin (LMWH) is given: 1 mg/kg q12h (with dose reduction for CrCl < 30ml/min and low BMI). Here we report an excessive level of anticoagulation (based on standard LMWH anti-Xa levels) using standard dosing requirements in 8 of 11 patients with CS complicated by VTE who received treatment with Enoxaparin.

Methods: We retrospectively studied 6 women and 5 men with active hypercortisolism and VTE (6 PE and 5 DVT) treated with Enoxaparin given at doses below every 12 hours. Self-declared race/ethnicity were 7 white (one Hispanic), 2 unknown, 1 Asian, and 1 African. Anticoagulation therapy was monitored 4 hours after administration with measurement of LMWH anti-Xa (therapeutic range: 0.5-1.2 IU/mL).

Results: The (subsequent) etiology of CS was ectopic ACTH secretion in 6 patients (3 pulmonary NET, 3 occult) and Cushing’s disease in 5. Median age was 53 years (range 24 - 74); median BMI 34.7 kg/M2 (range 24.9 - 52.9). Median urine cortisol was 659 mcg/24h (range 122 - 32,444; nl reference range 3.5 - 45). All had CrCl > 60 ml/min. 6 patients were taking a CYP3A4 inhibitor (Ketoconazole: n=5 or Mifepristone: n=1). 6/7 patients who received an initial dose of 1 mg/kg had supratherapeutic anti-Xa levels, from 1.4 - 2 IU/ml; five were on a CYP3A4 inhibitor. One died from a massive retroperitoneal bleed leading to organ failure. The other five required dose reduction; the median dose at which anti-Xa levels were at goal was 0.56 mg/kg (range 0.36 - 0.87 mg/kg). The sixth patient had an initial anti-Xa level of 0.2 IU/ml, which normalized on a dose of 1.1 mg/kg.

One patient started at 1.3 mg/kg exhibited an anti-Xa level of 1.7 IU/ml, with appropriate anti-Xa levels at a dose of 0.6 mg/kg. 3 patients started at reduced treatment doses (0.68, 0.78 and 0.87 mg/kg) exhibited therapeutic anti-Xa levels. In summary, therapeutic anti-Xa levels were achieved at a dose of approximately 1 mg/kg in only three patients (0.87, 0.96, 1.12 mg/kg); others required reduction of the usual recommended dose to between 0.36 and 0.78 mg/kg. CYP3A4 inhibitors were used in 5/8 patients with elevated anti-Xa levels.

Conclusions: Patients with Cushing’s syndrome appear to require lower than standard dose of enoxaparin; which may be only partly explained by concomitant CYP3A4 inhibitors. We suggest that anti-Xa levels be more closely monitored in CS patients to avoid morbidity and mortality caused by PE or bleeding. Further studies are needed to determine if this risk is present in patients receiving supraphysiologic doses of exogenous glucocorticoids.

1. Wagner J et al. Front Endocrinol (Lausanne). 9: 805, 2018

<![CDATA[MON-170 Real World Estimates of Adrenal Insufficiency Related Adverse Events in Children with Congenital Adrenal Hyperplasia: On Behalf of the I-CAH Consortium]]> Background Although congenital adrenal hyperplasia (CAH) is a rare condition, it is the commonest cause of early-onset primary adrenal insufficiency and places the patient at a life-long risk of sick day episodes (SDE) and adrenal crises (AC). Objective To investigate the epidemiology of SDE and AC in an international cohort of patients <18 yrs old with 21-OH deficiency CAH. Methods Multi-level logistic model analysis of data in the International CAH (I-CAH) registry ( to examine the clinical associations of SDE, AC, stress-dose days and hospitalisations. Results 518 patients (F, 53%) from 34 centres in 18 countries with a median number of cases per centre of 12 (IQR 1-26), had a total of 5388 reported visits with a median duration of follow-up per patient of 3.1 yrs (IQR 2.5-5.8). Of the 518 patients, 334 (64%) had ≥1 SDE; the median number of SDE per patient year per centre was 1.0 (IQR 0.4-2.2) and the median duration of SDE was 3.0 days (IQR 2.0-5.0). Children between 1-4 yrs and adolescents (15-18 yrs) had a greater risk of SDE [OR 2.02 (95%CI:1.60,2.56) and OR 1.64 (95%CI:1.34,2.02), respectively] and stress-dosing [OR 2.03 (95%CI:1.56,2.60) and OR 1.63 (95%CI:1.32,2.02), respectively] compared to children <1 yr old. Males were more likely to have a SDE [OR 1.40 (95%CI:1.13,1.73) and stress-dosing [OR 1.40 (95%CI:1.12,1.76) than females. An AC was reported in 4% of SDE (62/1544) with 92% of visits associated with hospital admission. Infectious illness was the most frequent associated event and was reported in 72% (1105/1544) of SDE and 47% (29/62) of AC. Males had a higher risk of AC compared to females [OR 1.03 (95%CI:1.03,1.03). Children with salt-wasting CAH were more likely to be hospitalised during a SDE, compared with those with simple-virilising CAH [OR 2.08 (95%CI:0.99,7.91)]. Children receiving glucocorticoid (GC) doses within the hydrocortisone (HC) equivalent dose (ED) of 10-15mg/m2/d were more likely to have SDE [OR 1.66 (95%CI:1.31,2.10), stress-dosing [OR 1.85 (95%CI:1.44,2.37) and AC [OR 1.08 (95%CI:1.08,1.08), p<0.001] than children on HC ED >15mg/m2/day. Similarly, children on HC ED <10mg/m2/d were more likely to have SDE [OR 2.20 (95%CI:1.66,2.90)], stress-dosing [OR 2.37 (95%CI:1.77,3.19)] and AC [OR 8.34 (95%CI:8.33,8.35), p<0.001] than those on higher doses. Children on FC doses between 50-200mcg/day and lower than 50 mcg were less likely to have AC [OR 4.54 (95%CI:4.54,4.55) and OR 8.58 (95%CI:8.57,8.59), respectively] than those on higher doses (>200mcg/day). Oral GC were increased in 74% (1147/1544) of SDE whilst HC injection was administered in 11% (176/1544) of SDE. Conclusions The real-world data within the I-CAH registry are a valuable resource for identifying factors that place a child with CAH at a higher risk of adverse events and can be used in prediction models for calculating individual risk.

<![CDATA[MON-161 Body Weight Reduction Not Always Reduced Adrenal Gland Volume in Obese Patients]]> Recent studies have shown that obesity is a major risk factor for idiopathic hyperaldosteronism (IHA). IHA patients have greater AGV than normal controls. However, it is unclear whether such changes are caused by obesity and whether losing weight could reverse the morphological and functional abnormalities of the adrenal gland. This study was to investigate the association of obesity with adrenal gland volume (AGV) and the effects of weight loss on AGV. This study recruited obese patients (N=25) who underwent sleeve gastrectomy and age- and sex-matched normal-weight (N=25) and overweight healthy volunteers (HV) (N=21). Thin-slice computed tomography was used to evaluate adrenal morphological changes. AGV was measured semiautomatically based on the digital imaging and communications in medicine (DICOM) image. The effects of weight loss on AGV were evaluated in patients for one year or more after sleeve gastrectomy. The results showed that left, right and total AGV were larger in obese patients than those in overweight and normal- weight HVs (6.77±0.36, 5.76±0.31, and 12.53±0.64 cm3 vs. 3.88±0.14, 3.09± 0.13 and 6.97± 0.24 cm3 vs. 3.38±0.23, 2.67±0.15 and 6.04±0.36 cm3). No statistically significant difference was identified between overweight and normal-weight HVs. Sleeve gastrectomy significantly reduced body weight (-27.1±2.5 kg), left AGV (-0.80±0.26 cm3), and right AGV (-0.88±0.20 cm2). However, the adrenal volume in five patients was not reduced, despite significant weight loss postsurgery. In brief, obesity leads to increased AGV, and in some cases, this effect seems to be irreversible. We speculate that obesity causes permanently adrenal morphological changes (increased volume or hyperplasia), and under certain circumstances, it results in excessive aldosterone secretion via altered adipokines (leptin, CTRP1, etc.).

<![CDATA[MON-184 Disrupted ACTH-Cortisol Temporal Coupling in Healthy Men After an Overnight Fast, and the Modulatory Role of Orally Ingested Macronutrients]]> AbstractWhile long term fasting is reported to augment the corticotropic function, effect of short term (overnight) fasting on ACTH-cortisol coordinated release pattern and potential effect(s) of nutrient intake is not fully defined. Eleven healthy men (age: 33-70 yrs, BMI 20.4-31.5 kg-m2) were studied after overnight fast on 4 separate days, involving oral ingestion of 300 ml of either water, dextrose, protein, or lipid solutions. Test meals were isocaloric (400 kcal). Sessions were 6.5 h long, starting at 0800-0900 hrs. Blood was collected at 10-min intervals for ACTH (pg per mL), and cortisol (µg per dL) measurements. Linear regression, cross-correlation, deconvolution, and ApEn were used for data analyses. ACTH and cortisol concentration time series during short-term fast (water day) were found not to be chronologically coupled per linear regression (r2= 0.0014, P=0.82), and cross-correlation (r= - 0.156, lag=150 min) statistics. Oral intake of the 3 macronutrients improved the temporal relationship between ACTH and cortisol concentrations, verified by linear regression (r2:P- dextrose 0.54:0.0001, protein 0.65: 0.0001, lipid 0.42:0.0001), and cross-correlation (r:lag in min- dextrose 0.8:10, protein 0.77:10, lipid 0.78:20). Oral ingestion of either macronutrient did not significantly alter mean ACTH and cortisol concentrations and their respective secretion pattern (total, pulsatile, basal) over the period of 6.5 hr. However compared to the control (water) session, dextrose ingestion evoked less frequent and larger ACTH secretory bursts, and more regular ACTH and cortisol secretory patterns. In this study, we have observed lack of concordance between ACTH and cortisol after overnight fasting, which is restored with oral intake of macronutrients. This effect appears to be uniform among the 3 macronutrients, except for less frequent and lager ACTH bursts and more regular ACTH and cortisol release events after dextrose intake. These findings and the specific role of nutrients being direct or via physiologic nutrient-induced hormonal adaptation warrants future investigation. ]]> <![CDATA[MON-187 Prevalence and Assessment of Overnight Dexamethasone Suppression Tests for Screening Endogenous Hypercortisolism When Serum Dexamethasone Is Below Threshold]]> 1.8 μg/dL usually defines autonomy. Aim: 1) determine the prevalence of invalid tests in a large series of DST used to investigate hypercortisolism during a 12y period in a single institution; 2) assess the percentage of negative tests (normal F suppression) among the subpopulation of invalid DST; 3) examine for interfering substances and clinical conditions that may justify and low DXA levels. Methods: DXA-controlled 1mg-DST was carried out in 162 control subjects (Cont; 107F/55M; 20-75y [median 50y]), to determine a valid threshold for serum DXA, and in 768 patients (80% female; 11-91y [median 53y]), investigated from 2007-19, for F autonomy (a total of 1,300 tests, with 41% repetitions). F and DXA were determined by specific RIA. We search our laboratory data bank for “invalid” DST, tests in which post-DST serum DXA values were below the cutoff established from the control subjects. Results: we set a cutoff for post-DST serum DXA at 140 ng/dL, the lowest value obtained from controls in whom post-DST serum F levels were < 2.5 µg/dL. From the 1,300 DST examined, 146 (11.2%) were considered invalid (DXA <140 ng/dL), and in 36 of them (25%), DXA was undetectable. Also, 35 DST (25%) gave F results below 1.8 µg/dL. Of all 146 invalid DST, 8 (6%) did not take DXA the night before as directed and 14 (10%) admitted being on glucocorticoids (GC), most of them from the undetectable DXA subgroup. Also, 21 patients (14%) were on anticonvulsants, another 21 (14%) were using other moderate or potent CPY3A4 inducers (phenytoin, rifampicin, efavirenz), and 15 (10%) subjects had gastrointestinal abnormalities (colectomy, colostomy, erosive gastritis and disabsorptive syndromes). Conclusions: Test accuracy depends on the serum levels reached by DXA, after adequate ingestion and absorption. Inappropriately low values may result in false-positive test results. One-fourth of “invalid” tests, presented DXA levels below the assay limit of sensitivity, suggesting patient noncompliance. Adherence to verbal and written recommendations and use of medication are essential to interpret the test. Conditions that alter gastric pH, as well as surgical procedures in the GI tract may reduce absorption or accelerate GI transit affecting DXA absorption. DXA metabolism by cytochrome p450 enzymes, mainly CYP3A4, can be enhanced by inducing drugs, making mandatory DXA dosage to validate the test. The wide individual variability in DXA metabolism may be associated not only with environmental and health factors, but also with CYP gene polymorphisms, which can modify drug clearance. ]]> <![CDATA[MON-172 Comparison of a Late-night Salivary Cortisol Immunoassay and a Cortisol and Cortisone LCMS Assay in Patients with Cushing’s Disease]]> <![CDATA[MON-174 Circadian Misalignment of the 24-H Profiles of Melatonin and Cortisol in Adrenal Insufficiency]]>