Clues for early detection of autoimmune Addison's disease - myths and realities.

BACKGROUND: Early detection of autoimmune Addison's disease (AAD) is important as delay in diagnosis may result in a life-threatening adrenal crisis and death. The classical clinical picture of untreated AAD is well-described, but methodical investigations are scarce. OBJECTIVE: Perform a retrospective audit of patient records with the aim of identifying biochemical markers for early diagnosis of AAD. MATERIAL AND METHODS: A multicentre retrospective study including 272 patients diagnosed with AAD at hospitals in Norway and Sweden during 1978-2016. Scrutiny of medical records provided patient data and laboratory values. RESULTS: Low sodium occurred in 207 of 247 (84%), but only one-third had elevated potassium. Other common nonendocrine tests were largely normal. TSH was elevated in 79 of 153 patients, and hypoglycaemia was found in 10%. Thirty-three per cent were diagnosed subsequent to adrenal crisis, in whom electrolyte disturbances were significantly more pronounced (P < 0.001). Serum cortisol was consistently decreased (median 62 nmol L-1 [1-668]) and significantly lower in individuals with adrenal crisis (38 nmol L-1 [2-442]) than in those without (81 nmol L-1 [1-668], P < 0.001). CONCLUSION: The most consistent biochemical finding of untreated AAD was low sodium independent of the degree of glucocorticoid deficiency. Half of the patients had elevated TSH levels. Only a minority presented with marked hyperkalaemia or other nonhormonal abnormalities. Thus, unexplained low sodium and/or elevated TSH should prompt consideration of an undiagnosed AAD, and on clinical suspicion bring about assay of cortisol and ACTH. Presence of 21-hydroxylase autoantibodies confirms autoimmune aetiology. Anticipating additional abnormalities in routine blood tests may delay diagnosis.

Extended exome sequencing identifies BACH2 as a novel major risk locus for Addison's disease.

BACKGROUND: Autoimmune disease is one of the leading causes of morbidity and mortality worldwide. In Addison's disease, the adrenal glands are targeted by destructive autoimmunity. Despite being the most common cause of primary adrenal failure, little is known about its aetiology. METHODS: To understand the genetic background of Addison's disease, we utilized the extensively characterized patients of the Swedish Addison Registry. We developed an extended exome capture array comprising a selected set of 1853 genes and their potential regulatory elements, for the purpose of sequencing 479 patients with Addison's disease and 1394 controls. RESULTS: We identified BACH2 (rs62408233-A, OR = 2.01 (1.71-2.37), P = 1.66 × 10-15 , MAF 0.46/0.29 in cases/controls) as a novel gene associated with Addison's disease development. We also confirmed the previously known associations with the HLA complex. CONCLUSION: Whilst BACH2 has been previously reported to associate with organ-specific autoimmune diseases co-inherited with Addison's disease, we have identified BACH2 as a major risk locus in Addison's disease, independent of concomitant autoimmune diseases. Our results may enable future research towards preventive disease treatment.

Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency.

Primary adrenal insufficiency (PAI), or Addison's disease, is a rare, potentially deadly, but treatable disease. Most cases of PAI are caused by autoimmune destruction of the adrenal cortex. Consequently, patients with PAI are at higher risk of developing other autoimmune diseases. The diagnosis of PAI is often delayed by many months, and most patients present with symptoms of acute adrenal insufficiency. Because PAI is rare, even medical specialists in this therapeutic area rarely manage more than a few patients. Currently, the procedures for diagnosis, treatment and follow-up of this rare disease vary greatly within Europe. The common autoimmune form of PAI is characterized by the presence of 21-hydroxylase autoantibodies; other causes should be sought if no autoantibodies are detected. Acute adrenal crisis is a life-threatening condition that requires immediate treatment. Standard replacement therapy consists of multiple daily doses of hydrocortisone or cortisone acetate combined with fludrocortisone. Annual follow-up by an endocrinologist is recommended with the focus on optimization of replacement therapy and detection of new autoimmune diseases. Patient education to enable self-adjustment of dosages of replacement therapy and crisis prevention is particularly important in this disease. The authors of this document have collaborated within an EU project (Euadrenal) to study the pathogenesis, describe the natural course and improve the treatment for Addison's disease. Based on a synthesis of this research, the available literature, and the views and experiences of the consortium's investigators and key experts, we now attempt to provide a European Expert Consensus Statement for diagnosis, treatment and follow-up.

Intellectual profile and level of IQ among a clinical group of obese children and adolescents.

This study explored intellectual profile of children attending a clinic for obesity and to what extent their characteristics predicted full scale IQ. Totally, 60 patients aged 8-16 years were recruited consecutively from the National Childhood Obesity Centre at Karolinska University Hospital in Sweden. These patients were tested using the Wechsler Intelligence Scale for Children (WISC). Of these 60 patients, 51 (85%) parents gave informed consent for their children's results to be included in this study (mean age 12.94, standard deviation, SD 2.42). The children's mean full scale IQ was 85.39. Parental education was strongly associated with child IQ. After adjustment for parental education, female gender and a higher level of obesity were associated with lower IQ. Obese children are at increased risk of having below average IQ and strategies to tackle associated problems should be developed in paediatric obesity clinics.

Family stress and BMI in young children.

AIM: The aim of this study was to investigate if family stress and parental attachment style are associated with body mass index (BMI) in young children, and identify possible explanations. METHODS: A cross-sectional survey with a two-stage design was used. Parents of 873 children participated. They completed a demographic questionnaire, the Swedish Parenthood Stress Questionnaire (SPSQ), the Relationship Questionnaire (RQ) and reported their children's television-viewing habits (as a marker of physical activity). Children's height, weight and BMI were obtained from a general population-based register, BASTA. Associations with over- and underweight in children were assessed using multiple logistic regression analysis. RESULTS: Family stress indicated by SPSQ-score was associated with suboptimal BMI. Maternal, but not paternal, SPSQ-stress score was statistically significantly associated with overweight and underweight, with adjusted odds ratios (and 95% confidence interval) of 4.61 (3.11-6.84; p < 0.001) and 3.08 (1.64-5.81; p < 0.001) respectively. Associations between childhood BMI and parental attachment style were identified, but were not independent of maternal SPSQ-score. CONCLUSION: Our findings support a role for family stress in development of both overweight and underweight among young children. This is likely to be attributed to behavioural mechanisms but a more direct metabolic influence of stress could also be involved.

Inverse association of high-fat diet preference and anxiety-like behavior: a putative role for urocortin 2.

The aim of this study was to investigate whether the preference for a palatable high-fat diet (HFD) is associated with response to novelty and with anxiety-like behavior in rats and whether such fat preference correlates with gene expression of hypothalamic neuropeptides related to feeding. We subjected male rats to two tests of exploration of novel environments: the multivariate concentric square field (MCSF) and the elevated plus maze (EPM). The rats were then exposed to a 5-day test of preference for a palatable HFD versus reference diets. Messenger RNA (mRNA) levels of 21 neuropeptides were investigated by quantitative polymerase chain reaction. We found a strong positive correlation of HFD preference and open-arm activity in the EPM (% open-arm time, r(s) = 0.629, df = 26, P < 0.001). Thus, HFD preference was inversely associated with anxiety-like behavior. The same association was found for HFD preference and behavior in the MCSF (bridge entries, r(s) = 0.399, df = 23, P = 0.048). In addition, the HFD preference was positively correlated (r(s) = 0.433, df = 25, P = 0.021) with hypothalamic mRNA levels of urocortin 2 (Ucn 2). Moreover, behavior in the EPM was significantly correlated with expression levels of the receptor for Ucn 2, the corticotropin-releasing factor receptor 2, in the hypothalamus (r(s) = 0.382, df = 33, P = 0.022, pituitary (r(s) = 0.494, df = 31, P = 0.004) and amygdala (r(s) = 0.381, df = 30, P = 0.032). We conclude that preference for palatable HFD is inversely associated with anxiety and propose that Ucn 2 signaling may play a role in this association.

Contribution of gluconeogenesis and glycogenolysis to hepatic glucose production in acromegaly before and after pituitary microsurgery.

The diabetogenic effect of excess growth hormone (GH) such as that in acromegaly is well known. However, the contribution of the various components to hepatic glucose production (HGP) is not completely understood. In this study we evaluated insulin resistance, HGP, gluconeogenesis (GNG), and glycogenolysis (GLY) in five patients with acromegaly before and after pituitary microsurgery. Insulin resistance was estimated by the HOMA index. HGP was measured using a primed continuous (6,6- 2H2) glucose infusion, and GNG was measured from 2 H enrichment at carbons 2 and 5 of blood glucose on ingestion of 2H2O. The ratio of these enrichments equals the fractional contribution of GNG to HGP, and GLY was calculated as the difference between HGP and GNG. All measurements were performed after 12 hours of fasting. Levels of GH and IGF-I decreased, as did the HOMA index (p<0.05). HGP was reduced from 11.4 micromol/kg/min to 9.7 micromol/kg/min (p=0.032). GNG contributed most to HGP. GNG was unchanged, whereas GLY's fraction decreased 29% (p=0.056) postoperatively. This pilot study indicates that GNG is the main contributor to HGP and that GLY is more sensitive than is GNG to the insulin resistance existing in acromegaly.

Plasma galanin, vasopressin, and oxytocin in patients with Addison's disease.

Galanin is colocalized with adrenocorticotrophin (ACTH) in the human pituitary and with corticotrophin releasing hormone, arginine, vasopressin, and oxytocin in the hypothalamus. Galanin, vasopressin, and oxytocin influence the secretion of pituitary ACTH. The aim of this study was to investigate if the endogenous stimulation of ACTH release in Addison's disease was reflected in plasma galanin, vasopressin, and oxytocin. ACTH, galanin, vasopressin, and oxytocin were measured in plasma from 14 patients with Addison's disease, one patient with Nelson's syndrome, and 14 healthy controls. Eight patients had elevated plasma ACTH whereas six patients and all controls had ACTH levels within the reference-range. There was no difference in galanin or vasopressin between patients and controls or between samples with low or high ACTH concentrations. In contrast, oxytocin was higher in patients with elevated plasma ACTH compared to patients and controls with normal or low ACTH. No relation was found between galanin or oxytocin and age or sex. A tendency towards lower vasopressin with increasing age was found among the men (p=0.057). The highest ACTH and galanin levels were found in the patient with Nelson's syndrome. In conclusion, increased plasma ACTH was not reflected in elevated plasma galanin or vasopressin. In contrast, elevated ACTH levels were accompanied by higher oxytocin levels.

Lymphocytic hypophysitis: report of two biopsy-proven cases and one suspected case with pituitary autoantibodies.

Lymphocytic hypophysitis (LyH) is a rare inflammatory disease, considered to be autoimmune. LyH has mainly been reported in females and in relation to pregnancy or the post-partum period. We describe a 73-yr-old woman and a 63-yr-old male who were evaluated at our clinic because of pituitary hormone deficits. Both patients had pituitary masses suggestive of a pituitary adenoma on magnetic resonance imaging (MRI). Transsphenoidal pituitary surgery was performed and histopathological examinations revealed LyH in both cases. Clinical, laboratory, radiological and the histopathological findings in these two patients are discussed in detail. In addition, we report on a 79-yr-old man with partial hypopituitarism and empty sella. Screening of a human pituitary cDNA library with his serum revealed autoantibodies against secretogranin II. This is a protein commonly present in human gonadotrophs, thyreotrophs and corticotrophs. Since the patient selectively showed the corresponding pituitary insufficiencies, we speculate on an autoimmune background. Further studies may ascertain the importance of secretogranin II autoantibodies as markers for LyH.

Heterogeneous forms of immunoreactive galanin in human plasma; higher levels in men than in women.

Galanin, a neuropeptide, has important effects on hormone secretion from the hypothalamus and pituitary, and may also be involved in important biological processes such as pain, memory, and food intake. Yet, there is limited knowledge about how these processes are reflected by circulating galanin. To study the levels and molecular forms of galanin in the human circulation, plasma was analysed from 27 healthy subjects, 14 women and 13 men, using two extraction methods and a specific radioimmunoassay for human galanin. After extraction on Sep Pak C-18 columns, plasma galanin-like immunoreactivity (galanin-LI) in the healthy men was 6.3 +/- 2.5 pmol/l (mean +/- SD, n = 12), which was higher than in the women, 4.1 +/- 1.5 pmol/l (n = 14, p = 0.010). A small increase in galanin-LI was seen with age in the women (r = 0.54, p < 0.05) but there was no significant difference between pre- and postmenopausal women. Galanin immunoreactivity after Sep Pak and immunoextraction correlated (r = 0.74, p < 0.001) the levels being higher after immunoextraction (p < 0.001). Gel chromatography disclosed heterogeneity of circulating galanin-LI with the majority eluting as homologs with a molecular weight higher than synthetic human galanin. Homologs smaller than galanin were also found. Sep Pak C-18 extraction eliminated the majority of the higher molecular forms. In conclusion, circulating galanin-LI was found to be higher in men and to be present mainly as molecular forms larger than synthetic galanin.

Galanin in human plasma.

The neuropeptide galanin has important effects on hormone secretion from the hypothalamus and pituitary, and it may also be involved in central biological processes such as pain, memory, and food intake. Yet, there is limited knowledge about how these processes are reflected by circulating galanin. To study the levels and molecular forms of galanin in the human circulation, plasma was analysed from 26 healthy subjects, 14 women and 12 men, using two extraction methods and a specific radioimmunoassay for human galanin. Galanin-LI levels in unextracted plasma were higher (141-191 pmol/L) than after immunoextraction (3.4-30.7 pmol/L) and Sep Pak extraction (2.2-12.6 pmol/L). Galanin immunoreactivity after Sep Pak and immunoextraction correlated (r = 0.74, p<0.001). Galanin-LI levels were significantly higher in the men than in the women (p = 0.01) after Sep Pak extraction. A small increase in galanin-LI was seen with age in the women (r = 0.54, p < 0.05). The proportion of Sep Pak extracted galanin-LI increased with age in the women (r = 0.73, p < 0.05)) but not in the men.

Autoantibodies against pituitary proteins in patients with adrenocorticotropin-deficiency.

BACKGROUND: An autoimmune cause of adrenocorticotropin (ACTH)-deficiency is presented, as it is known to be a characteristic feature of lymphocytic hypophysitis, a disease of the pituitary gland considered to be autoimmune. MATERIALS AND METHODS: The aim of this study was twofold: (1) to evaluate the occurrence of pituitary autoantibodies and (2) to correlate it to clinical and immunological features in a large group of patients with ACTH-deficiency of possible autoimmune aetiology. Sixty-five patients with ACTH-deficiency and 57 healthy subjects participated in the study. Pituitary autoantibodies were measured by an immunoblotting assay with human pituitary cytosol as antigen. RESULTS: Autoantibodies to a novel 36-kDa pituitary autoantigen were seen in sera from 18.5% (12/65) patients and only 3.5% (2/57) of control subjects (P = 0.0214). When taking only those subjects with strong immunoreactivity into account, the significance was lost; P = 0.3642. Immunoreactivity to a 49-kDa pituitary autoantigen was observed in 21.5% (14/65) of ACTH-deficient patients compared with 8.8% (5/57) of control subjects (P = 0.0910). This 49-kDa pituitary autoantigen has recently been identified as neurone-specific enolase and a candidate marker for neuroendocrine autoimmunity. Clinical parameters in patients with positive versus those with negative pituitary immunoreactivity did not differ. However, autoantibodies to thyroglobulin were positively correlated to immunoreactivity against the 36-kDa pituitary autoantigen (P = 0.014). CONCLUSIONS: Our findings of pituitary autoantibodies in patients' sera support the theory that an autoimmune destruction of corticotrophs may be the underlying cause of hormonal deficit in some patients with ACTH-deficiency.

Guidelines for prevention and treatment of adverse effects of antipsychotic drugs on glucose-insulin homeostasis and lipid metabolism.

RATIONALE: With the antipsychotic drugs available today, especially with some of the newer, atypical antipsychotics, metabolic side effects, such as weight gain, diabetes mellitus and lipid abnormalities, have become a complication to the drug therapy that have to be recognized and treated. OBJECTIVE: The aim of this article is to suggest guidelines for prevention and treatment of adverse effects of antipsychotics on glucose-insulin homeostasis and lipid metabolism, whereas strategies for management of antipsychotic-induced weight gain are summarized elsewhere. METHOD: The guidelines are based on results of experimental and clinical studies presented in the article, as well as on a recently published review of 180 articles in the field. RESULTS: Both conventional and atypical antipsychotics can indirectly, by causing obesity, promote development of insulin resistance and type-2 diabetes. In addition, some atypical agents probably directly induce hyperinsulinemia, followed by weight gain, insulin resistance and drug-induced, sometimes insulin-dependent, diabetes. CONCLUSION: In this article, guidelines for the management of adverse metabolic effects of antipsychotics are described.

No evidence for autoimmunity as a major cause of the empty sella syndrome.

OBJECTIVE: The cause of empty sella syndrome (ESS) remains largely unknown. We measured eleven organ-specific autoantibodies in serum in order to evaluate possible autoimmune components in ESS. PATIENTS: Thirty patients with ESS and 50 healthy blood donors participated in the study. MEASUREMENTS: Detection of pituitary autoantibodies was performed by immunoblotting with human pituitary cytosol as antigen. Thyroid peroxidase (TPO) and TSH receptor (TRAK) autoantibodies were analysed by radioimmunoassay. The remaining eight autoantibodies were detected by in vitro transcription and translation of the autoantigens and immunoprecipitation. RESULTS: The majority of the ESS patients (18/30) exhibited no immunoreactivity at all. None of the remaining 12 ESS patients reacted against more than one autoantigen. No immunoreactivity was found more frequently among ESS patients than healthy blood donors. Pituitary autoantibodies were not correlated to the ESS patients' pituitary function or sellar size, although the results indicated a tendency of increased autoimmunity in patients with hypopituitarism and normal sella size respectively. CONCLUSION: Detection of autoantibodies is a valuable tool in the diagnostic work-up of autoimmune diseases. By analysing a large number of organ-specific autoantibodies we found no evidence of ESS being associated with any specific autoimmune disease. The pathogenesis of ESS is believed to be heterogeneous and our findings suggest autoimmune components to be of minor importance. In some selective cases, ESS in combination with hypopituitarism may be the result of an autoimmune disease in the pituitary gland but this needs further investigation.