Cohort study of patients with adrenal lesions discovered incidentally.

BACKGROUND: This prospective cohort study investigated the incidence, clinical features and natural history of incidentally discovered adrenal mass lesions (adrenal incidentaloma, AI) in an unselected population undergoing radiological examination. METHODS: During an 18-month period, all patients with AI were reported prospectively from all 19 radiology departments in western Sweden. Inclusion criteria were: incidentally discovered adrenal enlargement or mass lesion in patients without extra-adrenal malignancy on detection. Clinical and biochemical evaluation was performed on inclusion and after 24 months. Computed tomography (CT) of the adrenals was scheduled at 4, 12 and 24 months. Magnetic resonance imaging was performed for lesions larger than 20 mm. The indications for surgical excision were: hormone activity, lesion diameter more than 30 mm, lesion growth or other radiological features suspicious of malignancy. RESULTS: Of 534 patients assessed for eligibility, 226 (mean age 67 years, 62·4 per cent women; mean lesion diameter 23·9 mm, 22·6 per cent bilateral) fulfilled the inclusion criteria. Mean follow-up was 19·0 months. After baseline evaluation, 14 patients had surgery owing to primary hyperaldosteronism (3), catecholamine-producing tumour (1), tumour size (6), size and indication of subclinical hypercortisolism (3) and metastasis (1). No hypersecreting lesions were confirmed during follow-up; one patient underwent adrenalectomy for a suspected phaeochromocytoma (adrenocortical adenoma at histopathology). No primary adrenal malignancy was found. CONCLUSION: In this prospective cohort study 6·6 per cent of patients with an AI had surgery and benign hormone-producing tumours were verified in 3·1 per cent. Repeat CT and hormone evaluation after 2 years did not increase the sensitivity for diagnosis of malignant or hormone-producing tumours.

Subjects with essential hypertension are more sensitive to the inhibition of 11 beta-HSD by liquorice.

In this intervention study, we have investigated if hypertensive patients are more sensitive to liquorice-induced inhibition of 11 beta-hydroxysteroid dehydrogenase (11 beta-HSD) type 2 than normotensive (NT) subjects and if the response depends on gender. Healthy volunteers and patients with essential hypertension (HT), consumed 100 g of liquorice daily, for 4 weeks, corresponding to a daily intake of 150 mg glycyrrhetinic acid. Office, 24-h ambulatory blood pressure (BP) and blood samples were measured before, during and after liquorice consumption. Effect on cortisol metabolism was evaluated by determining the urinary total cortisol metabolites and urinary free cortisol/free cortisone quotient (Q). The mean rise in systolic BP with office measurements after 4 weeks of liquorice consumption was 3.5 mmHg (p<0.06) in NT and 15.3 mmHg (p=0.003) in hypertensive subjects, the response being different (p=0.004). The mean rise in diastolic BP was 3.6 mmHg (p=0.01) in NT and 9.3 mmHg (p<0.001) in hypertensive subjects, the response also being different (p=0.03). Liquorice induced more pronounced clinical symptoms in women than in men (p=0.0008), although the difference in the effect on the BP was not significant. The increase in Q was prominent (p<0.0001) and correlated to the rise in BP (p=0.02). The rise in BP was not dependant on age, the change in plasma renin activity or weight. We conclude that patients with essential HT are more sensitive to the inhibition of 11 beta-HSD by liquorice than NT subjects, and that this inhibition causes more clinical symptoms in women than in men.

Role of immunosuppressive therapy in refractory sprue-like disease.

Patients with malabsorption and histological findings consistent with celiac disease, who are unresponsive to gluten free diet, and in whom other causes of flat mucosa have been excluded, are considered to suffer from so called unclassified or refractory sprue. Although the true nature of this condition needs to be further elucidated, it is known to represent a difficult therapeutical problem with potentially fatal course. Herein, we report a patient with refractory sprue-like disease who after failing to respond to corticosteroids and TPN was in a critical condition. He responded promptly to cyclosporine and made a remarkable recovery. In contrast to previous reports, the cyclosporine treatment in this patient was pursued only for 1 month, whereupon the patient turned responsive to steroids. Subsequent treatment with azathioprine allowed corticosteroids to be reduced to a low maintenance dose and eventually all drugs could be discontinued without reappearance of symptoms. Cyclosporine therapy might be lifesaving in occasional patients with refractory sprue-like disease and it may result in reversal of steroid resistance. Moreover, azathioprine seems to have a steroid sparing effect in this setting. Short term immunosuppressive treatment may have an advantage of lower risk for drug related side effects.

Is blood pressure commonly raised by moderate consumption of liquorice?

It is well known that excessive liquorice intake can induce sodium and fluid retention, hypokalaemia, hypertension and inhibition of the renin-angiotensin system. We tested whether regular moderate liquorice consumption (50 g and 100 g daily) raises blood pressure (BP) in a normotensive population. Ingestion of 100 g of liquorice daily (n = 30) caused a significant rise in systolic blood pressure (SBP) by a mean of 6.5 mm Hg (P < 0.001) and a fall in plasma potassium by 0.24 mmol/l (P < 0.001); the highest rise in SBP observed was 19 mm Hg. In a subgroup of 13 women the consumption of 50 g of liquorice daily also caused a significant rise in SBP of 5.6 mm Hg (P < 0.001) and DBP of 3.4 mm Hg (P = 0.002). A significant change in the cortisol/cortisone ratio in urine was observed during 100 g liquorice consumption indicating inhibition of 11 beta-hydroxysteroid dehydrogenase in kidneys. The results indicate that liquorice-induced hypertension might be more common than has been appreciated and it important for medical doctors to be on the alert for this effect in both the prevention and treatment of hypertension.