[Human sympathoadrenal system and adrenal cortex in prepubertal and pubertal periods].

A complex study of the functional state of the sympathoadrenal system and adrenal cortex in 10-15-year-old children of both sexes was carried out using the indices of daily excretion of adrenaline, noradrenaline, 17-ketosteroids, and 17-hydroxycorticosteroids. A synchronism in the functional activity of the mediator component of the sympathoadrenal system as well as of the androgenic and glucocorticoid functions of the adrenal cortex was observed with age and during pubertal development of children. At the same time, heterochronic maturation was observed in the sex groups: in girls at the age of 10 and 12 years and in boys at the age of 14-15 years. The changes of different direction and intensity in the excretion of the studied hormones and hormonal metabolites were observed in the sex and age groups. A sharp increase in the daily excretion of glucocorticoid metabolites accompanied by a considerable decrease in the age index of noradrenaline secretion was observed in 14- and 15-year-old boys from beginning to end of school year; in addition, an increase in the daily excretion of sex hormones was observed at the age of 15 years. In girls, these indices varied within the age range, which points to a more sophisticated neuroendocrine control of physiological functions in girls during puberty.

Preclinical Cushing's syndrome resulting from black adrenal adenoma. A case report.

A 59-year-old Japanese woman, admitted for the treatment of diabetes mellitus and hypertension, was incidentally discovered to have a solid mass of 1.4 cm in diameter by CT scan with the attenuation value of 38 Hounsfield units, relatively higher for ordinary adrenal adenomas. Magnetic resonance imaging revealed no reduction of signal intensity on opposite-phase image on T1-weighted sequence. Adrenal scintigraphy imaging with 131I-adosterol did not show any uptake of the isotope in the area corresponding to both adrenals. Although she had no characteristic feature of overt Cushing's syndrome, her serum cortisol level was not suppressed after an overnight dexamethasone administration. She was diagnosed as having preclinical Cushing's syndrome. Left adrenalectomy was performed, revealing the well-circumscribed black tumor, mainly consisted of compact cell, in which cytoplasm was filled with numerous granules pigmented with dark to golden brown colors on hematoxylin-eosin staining. These findings suggested that her incidentaloma was a black adrenal adenoma. Production of steroid hormones was confirmed by immunohistochemical analysis of steroidogenic enzymes and by measurement of the tissue contents of hormones, whose levels were comparable with those in adenomas of overt Cushing's syndrome. This is the first case report of preclinical Cushing's syndrome resulting from black adrenal adenoma.

Virilising adrenocortical tumours in children.

UNLABELLED: Adrenocortical tumours (ACT) are a rare but important cause of virilisation in infancy and childhood. Four cases of virilising ACT are presented. Two girls (age 0.9 years and 3.9 years) and two boys (age 6.2 years and 6.4 years) had symptoms and signs of virilisation before the age of 6 years. Diagnosis of a virilising adrenal tumour was confirmed by laboratory tests, diagnostic imaging and histology. However, one female patient was misdiagnosed and treated for 3 months as atypical congenital adrenal hyperplasia. Ultrasonography of the adrenal region could not visualise the tumour in three out of four cases. The most sensitive method of diagnostic imaging was MRI. In all cases, treatment consisted of complete surgical resection of the adrenal tumour by open abdominal surgery. Immunohistochemistry was performed in all patients and in two patients there was an overexpression of p53, indicating p53 mutation and in three cases the ki67 proliferation index was greater than 5%. The classification of ACT in childhood is extremely difficult. Histology scores adapted from adrenal tumours in adults and molecular markers are under investigation, but there is still not enough clinical experience since ACT are so rare. CONCLUSION: Long-term follow-up is mandatory not only because of the uncertainty in classification of adrenocortical tumours, but also for observation of growth and pubertal development.

The biochemical study of intermaxillary fixation (IMF) stress in oral surgery inpatients.

Although intermaxillary fixation (IMF) is performed to treat the patients with maxillary fracture, this procedure is very stressful to the patients. IMF has been reported to increase noradrenaline (NA) release in the brain and elevate plasma corticosterone contents in the rat. These changes were significantly attenuated by diazepam, an anxiolytic of the benzodiazepine family. These results suggest that IMF could greatly affect the pituitary-adrenal system as a stress. In the present study, in order to examine the influence of IMF on the human body function, we measured levels of 17-hydrocorticosteroids (17-OHCS) and 17-ketosteroid (17-KS), which are metabolites of the adreno-cortical hormone cortisol, in the urine of inpatients undergoing IMF. The subjects were requested to fill out a questionnaire on irritableness caused by IMF. In these patients, urinary 17-OHCS levels were significantly increased after IMF and well correlated to the results of the questionnaire. The finding suggested that urinary 17-OHCS levels reflect stress related to IMF, and that such stress mainly causes an irritated feeling. Natural killer cell activity (NK activity), which is considered to be related to stress, was measured in these patients. The relationship between 17-OHCS levels and NK activity was examined in reference to the results of the questionnaire. Questionnaire showed that most patients noted insomnia and an irritated feeling during IMF. To examine the influence of anxiolytic agents on stress related to IMF, an anxiolytic agent, ethyl loflazepate, was administered during IMF, and urinary 17-OHCS levels were measured. There was no correlation between 17-OHCS levels and NK activity in the patients. Furthermore, no correlation was observed between visual analogue scale (VSA) and NK activity. Increases in 17-OHCS levels in the group treated with ethyl loflazepate, an anxiolytic of the benzodiazepine family, were significantly lower than in the untreated group. This suggests that ethyl loflazepate reduced stress responses to IMF. It has been reported that NK activity is reduced inpatients with depression or chronic fatigue syndrome. However, NK activity may not be affected by mechanical stress such as IMF. The finding that an anxiolytic agent, ethyl loflazepate, inhibited stress responses to IMF further suggests that anxiolytic drugs are very useful for treatment of irritated feeling of the patients undergoing IMF.

[Cushing syndrome--a pathologic analysis based on 216 resected specimens].

OBJECTIVE: To study the morphological features of adrenal cortex in Cushing's syndrome and the correlation of morphological changes with clinical manifestations. METHODS: 216 cases of Cushing's syndrome were collected. Among these there were 160 cases of adrenal hyperplasia, 50 cases of adenoma and 6 cases of adenocarcinoma of adrenal cortex. The morphometric method was used to measure the thickness of adrenal cortex microscopically. The weight of the resected specimens were carefully recorded and correlated with clinical laboratory findings and clinical manifestations. RESULTS: In adrenal cortex hyperplasia, the thickness and weight of the adrenal cortex increased gradually in the order of mild, moderate and severe hyperplasia. The hyperplasia and hypertrophy of the compact cell are very common in these specimens. The frequency of compact cell predominant cases was also increased in severe hyperplasia. The weight and size of the tumor differed significantly between adenoma and adenocarcinoma of the adrenal cortex. CONCLUSION: In Cushing's syndrome, adrenal cortex hyperplasia is the most common. The grade of hyperplasia was well correlated with clinical laboratory findings. Increase of frequency of compact cell predominance is important morphological feature of hyperplasia of adrenal cortex. Adenoma should be considered when atrophy of adjacent cortex is present. The tumor size and weight as well as mitosis are important parameters in differential diagnosis between adenoma and adenocarcinoma of the adrenal cortex, but the infiltration of capsule and blood vessels and/or metastasis still remain the gold criteria for diagnosis of adrenal adenocarcinoma.

A cluster of cases of factitious Cushing's syndrome.

OBJECTIVE: To review the patient profiles, laboratory data, and diagnostic approaches in factitious administration of glucocorticoids. METHODS: Four cases of surreptitious use of glucocorticoids are presented. Clinical and laboratory data as well as imaging studies are summarized. Pertinent case reports in the literature are reviewed. RESULTS: We report four cases of surreptitious use of glucocorticoids encountered within a 2-year period. All four patients were women without significant psychiatric histories. In three patients, the question of factitious Cushing's syndrome was suspected because of physical evidence or symptoms of Cushing's syndrome (or both) in the setting of suppressed cortisol levels. The fourth patient had undetectable cortisol levels in both serum and 24-hour urine samples but did not have signs or symptoms of adrenal insufficiency. In three cases, the diagnosis was confirmed by direct measurement of synthetic glucocorticoids in the patient's urine or serum. The fourth case was diagnosed by correlating increased cortisol levels with decreased precursor adrenal steroids. CONCLUSIONS: Exogenous corticosteroid use in the absence of a medical indication poses a serious risk to a patient. This possibility should be considered in patients with signs and symptoms consistent with Cushing's syndrome but with low serum and urinary cortisol levels. Similarly, this diagnosis should be suggested in patients without symptoms of adrenal insufficiency and with low cortisol levels. Laboratory measurement of synthetic steroids can be helpful in confirming the diagnosis.

Variants of the type II 3beta-hydroxysteroid dehydrogenase gene in children with premature pubic hair and hyperandrogenic adolescents.

To ascertain the potential role of heterozygosity for 3beta-hydroxysteroid (3beta-HSD) deficiency in children with premature pubic hair and adolescent girls with hyperandrogenism, we performed single-strand conformational polymorphism (SSCP) analysis of the 3beta-hydroxysteroid dehydrogenase type 2 (3beta-HSD2) gene in 34 hyperandrogenic patients. Three sequence variants, two missense mutations and a 3'-UTR sequence variant, were detected among seven patients and in none of 100 healthy control subjects. One of these seven patients carried Leu236 --> Ser on one 3beta-HSD2 allele and Glu318 --> STOP on one 21-hydroxylase (CYP21) allele. ACTH stimulation tests were performed in 5/7 patients with sequence variants and were compatible with decreased 3beta-hydroxysteroid dehydrogenase activity in three. Thus, 7 of 34 (20.6%) mildly hyperandrogenic patients carry heterozygous sequence variants of the 3beta-HSD2 gene. Since obligate heterozygotic carriers for congenital adrenal hyperplasia are typically asymptomatic, other genetic or environmental influences may contribute to the expression of hyperandrogenic symptoms in our patients.

Insulin infusion amplifies 17 alpha-hydroxycorticosteroid intermediates response to adrenocorticotropin in hyperandrogenic women: apparent relative impairment of 17,20-lyase activity.

Recent data suggest that insulin is a modulator of ovarian and adrenal steroidogenesis and that, in the ovary of hyperandrogenic women, hyperinsulinemia might cause dysregulation of cytochrome P450c17 alpha activity. To further assess in vivo the effects of insulin on adrenal steroidogenesis, ACTH stimulation was carried out in 21 hyperandrogenic women during a 3-h hyperinsulinemic (80 mU/m2-min) euglycemic clamp. In all of these women the procedure was repeated during saline infusion as n control. In nonamenorrheic patients, the tests were performed in the early follicular phase of two different menstrual cycles. Serum cortisol, progesterone, 17-hydroxypregnenolone (17-OHJPREG). 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone (DHEA), and androstenedione (A) were measured after 2 h of insulin or saline infusion (zero time) and, subsequently, 30 and 60 min after an iv bolus of 0.25 mg ACTH-(1-24). At zero time, no difference was found in the serum steroid concentrations between the two protocols. ACTH-stimulated serum 17-OHPREG and, to a lesser extent, 17-OHP were significantly higher during insulin than during saline infusion (peaks, 60.6 +/- 9.0 vs. 40.7 +/- 7.9 and 7.7 +/- 7.7 vs. 6.6 +/- 0.6 nmol/L; P < 0.005 and P < 0.01, respectively). Serum DHEA was also slightly higher during hyperinsulinemia, although only after 30 min (54.5 +/- 3.0 vs. 48.2 +/- 4.2 nmol/L; P < 0.05). No statistically significant difference in the cortisol, progesterone, or androstenedione response to ACTH was found between the two protocols. ACTH-stimulated 17-OHPREG/DHEA and 17-OHP/A molar ratios, indexes of apparent 17,20-lyase activity, were significantly higher during the clamp studies than during saline infusion (by ANOVA, F = 12.8; P < 0.001 and F = 6.7; P < 0.005, respectively), suggesting an impaired enzyme activity. These in vivo data support the hypothesis that insulin potentiates ACTH-stimulated steroidogenesis. This effect of insulin seems to be associated with a relative impairment of 17,20-lyase activity.

[Diagnosis, surgical treatment and prognosis in endocrine hypertension of adrenal origin]. / Diagnostika, khirurgicheskoe lechenie i prognoz pri endokrinnykh gipertoniiakh nadpochechnikovogo geneza.

162 patients with adrenal hypertension have been examined. 48 of them had Cushing's syndrome, 10--aldosteromas, 85 --icenko--Cushing disease. The examination of patients with endocrine hypertension included hormonal background study, computer and MR tomography thin-needle biopsy and made it possible to make valid clinical and topical diagnosis in all cases. Magnetic-resonance tomography appeared to be the most efficient diagnostic method in the syndrome of hypercorticoidism. Ultrasound examination is the most available and highly informative method of revealing hormonally active adrenal tumors when they are more than 1 cm in size. An adequate preoperative preparation equally with an optimal scope of surgery and efficient postoperative substitution hormonal therapy are key factors in treatment of endocrine adrenal hypertension.

Studies on circadian periodicity of plasma 17-hydroxycorticosteroids (17-OHCS) in carcinoma of the breast.

Circadian periodicity of plasma 17-hydroxycorticosteroids (17-OHCS) was studied in 25 histopathologically proved breast cancer patients pre operatively and on the 9th postoperative day and in 15 healthy women under tropical conditions. A marked rhythm in plasma 17-OHCS concentration was noticed in healthy controls. The maximal concentration occurred at 06:00 followed by a consistent decline throughout the daytime, reaching a minimum at 00:00 with an amplitude statistically significantly different from zero and an acrophase around 08:56. The plasma 17-OHCS concentration was found to be elevated at all sampling hours in breast cancer patients, irrespective of the stage of the disease. However, the degree of elevation and disruption of rhythm was more pronounced in advanced sages, preoperatively, in comparison to other groups. Moreover, the values declined markedly at all collection hours after mastectomy, approaching usual values and rhythm characteristics on the 9th postoperative day.

[Diagnosis and treatment of congenital adrenal hyperplasia in women]. / Rozpoznawanie i leczenie wrodzonego przerostu nadnerczy u kobiety.

In 32 women with signs of androgenization, menstrual disturbances and distinct elevated values of 17-KS, DHEA, pregnantriole, testosterone and very reduced level of 17-OHCS congenital adrenal hyperplasia was diagnosed which established 12.5% individuals with intersexualism. The method of conservative or/and operative treatment and the prognosis were discussed.

Deletion of amino acids Asp487-Ser488-Phe489 in human cytochrome P450c17 causes severe 17 alpha-hydroxylase deficiency.

17 alpha-Hydroxylase deficiency blocks the biosynthesis of cortisol and sex steroids, resulting in mineralocorticoid excess, hypertension, sexual infantilism, and female phenotype in both genetic sexes. The disease is caused by mutations in the gene encoding cytochrome P450c17, which is the single enzyme that mediates both 17 alpha-hydroxylase and 17,20-lyase activities. We report a 14-yr-old patient from Thailand with a classical clinical presentation of this rare disorder. Analysis of her P450c17 gene by polymerase chain reaction amplification and sequencing showed a nine-base deletion, eliminating codons 487-489 (Asp-Ser-Phe) near the carboxy-terminus of P450c17. This deletion creates a BclI site in the mutant DNA, permitting accurate demonstration that the patient was homozygous for this lesion, whereas one parent and two siblings were heterozygous. By use of site-directed mutagenesis, we created a vector that could express this mutated form of P450c17 when transfected into non-steroidogenic COS-1 cells. Such transfected cells produced immunodetectable P450c17 protein, but had no 17 alpha-hydroxylase or 17,20-lyase activity, whereas cells similarly transfected with a vector expressing normal human P450c17 could 17 alpha-hydroxylate either pregnenolone or progesterone and convert 17 alpha-hydroxypregnenolone to dehydroepiandrosterone, showing the presence of both activities. This is the first report of the molecular genetic basis of 17 alpha-hydroxylase deficiency in a Southeast Asian patient.

Familial adrenocorticotropin-independent Cushing's syndrome with bilateral macronodular adrenal hyperplasia.

Familial Cushing's syndrome is rare, and when it occurs, it is usually associated with primary micronodular dysplasia. We report two cases, a mother and daughter, who each presented with clinical features of Cushing's syndrome at age 38 yr and were found to have ACTH-independent macronodular adrenal hyperplasia. In each case, bilateral adrenalectomy revealed the massively thickened adrenal cortex with nodules up to 1.3 cm in diameter and hyperplasia between nodules. Dynamic testing showed no suppression of free cortisol with high dose dexamethasone and no stimulation of 17-hydroxycorticosteroids with metyrapone. Two samples of serum obtained preoperatively from one patient that showed ACTH immunoreactivity of 4.6 and less than 2.2 pmol/L, respectively, each showed less than 2.2 pmol/L ACTH bioactivity. The lack of suppression with high dose dexamethasone, lack of stimulation with metyrapone, and low levels of ACTH immunoreactivity and bioactivity suggest that the bilateral hyperplasia was not dependent upon ACTH. These patients represent the first cases of ACTH-independent macronodular adrenal hyperplasia occurring in two generations of one family and illustrate the expanding clinical spectrum of Cushing's syndrome.

[Psycho-electroregulation in conservative treatment of patients with uterine myoma]. / Psikhoélektroreguliatsiia v konservativnoi terapii bol'nykh miomoi matki.

Basing on the concept of the uterine myoma presenting as a psychosomatic process that manifests in ischemic disease of the uterus, the author has tried psychoelectrostimulation in 76 patients with interstitial and subserous interstitial myomas as a method of psychotherapy and electrotranquilization. Indications for such treatment are the presence of psychoemotional stress syndrome (high anxiety level, pain and hemorrhagic syndromes, dysuria) and a rapid growth of the tumor. The reference group consisted of 73 patients with the same myoma forms, treated by hormonal therapy. Psychoelectroregulation has exerted a regulating effect on the central nervous, cardiovascular, endocrine and reproductive systems, it eliminated or alleviated the neurotic symptoms, and slowed down or arrested the tumor growth.

[Endocrine and ultrasound examination of hirsutism]. / Endokrinologische und ultrasonografische Untersuchung des Hirsutismus.

One hundred and fourteen nontumorous hirsute women were investigated. The degree of hirsutism, the menstrual abnormalities and the level of 17-ketosteroids, of DHEA, of 17-OH-corticoids in urine and RIA of total and free testosterone and of sex binding globulins (SHBG) in blood were performed. On the basis of endocrinological and ultrasonographic determinations 3 patients were diagnosed as congenital adrenal hyperplasia, 35 patients as late onset adrenal hyperplasia and 57 women as polycystic ovary syndrome (PCO). The maximal mean level (X + SD) of total and free testosterone above 0.5 ng/ml relatively above 5.05 pg/ml were performed in 94.3% relatively 97.1% in late onset adrenal hyperplasia and in 78.9% relatively 87.7% in PCO. The diagnosis of PCO is possible among 75% of all hirsute patients after exclusion the patients with late onset adrenal hyperplasia. The PCO is confirmed by hormonal or/and ultrasonographic examination. The diagnosis of late onset adrenal hyperplasia is allowable only by hormonal investigation.

Inadequate cortisol synthesis in prophyria cutanea tarda.

Many common clinical features suggest that between corticosuprarenal insufficiency (CSRI) and porphyria cutanea tarda (PCT) there may be some pathogenic relationships. In order to further understand these relations we have performed the ACTH-depot stimulation test (1 mg, i.m.) in 9 patients (from 13 males) with PCT. In 8 patients cortisolemia was assayed 1, 2, (12) and 24 hours post-stimulation. In all 13 cases the basal eliminations of cortisol metabolite (17-OH-corticosteroids) were under normal limits: 2.88 mg/24 h/g creatinine vs 15 controls with 7.06 mg/24h/g creatinine. After ACTH four cases showed lack of stimulation, considered on the second day for 17-OH-corticosteroids. In one case, after one year of PCT treatment, the early post-stimulation level is only moderately decreased. In one case, the test was normal. In four cases the ACTH stimulation was over-normal, i.e., greater than on the first day, suggesting supraphysiological responses. In this group 2 patients showed unexpectedly low early stimulation slopes on cortisolemia (at 1 and 2 hours) associated with concordant high late stimulation levels. This later phenomenon suggests a functional impaired secretion of cortisol in PCT, which seems to be similar to that of insulinemia after glucose in NIDDM, as a receptor lesion. The lesions of cortisol secretion in PCT could have been made by porphyrin storage, impaired hem-enzyme synthesis (cyt P-450) and as a new and attractive hypothesis, could be due to mitochondrial porphyrin receptor decreased activity.

Continuous adrenocorticotropin administration in hypopituitarism produces asynchronous increases of deoxycorticosterone and 11-deoxycortisol relative to other reduced zona fasciculata steroids.

Short term suppression of ACTH by dexamethasone effects limited reduction in plasma deoxycorticosterone (DOC) while cortisol levels are almost completely suppressed in normal control subjects. The zona fasciculata (ZF) microsomal cytochrome P-450(21) appeared less influenced by lack of ACTH than mitochondrial cytochrome P-450(11 beta-18). Eleven patients with hypopituitarism were studied to quantitate basal ZF microsomal and mitochondrial derived steroids and their acute and extended responses to ACTH. Basal levels of 11-deoxycortisol (S) and DOC were modestly reduced (70% and 53%, respectively), while other ZF steroids were almost completely absent. Acute and prolonged ACTH treatment amplified the discrepancy in both plasma levels and production rates. DOC and S demonstrated prompt and sustained increases similar to those in normal controls, while cortisol, 18-hydroxydeoxycorticosterone, and corticosterone showed a slow subnormal recovery of steroid production. The preservation of microsomal cytochrome P-450(21) and P-450(17 alpha) to maintain DOC and S levels contrasts the reduced and delayed responses of steroids dependent on mitochondrial cytochrome P-450(11 beta-18), cortisol, corticosterone, and 18-hydroxydeoxycorticosterone. A greater effect of ACTH deficiency on mitochondrial over microsomal cytochrome P-450 activity is demonstrated, and in addition, the possibility is raised that other non-ACTH regulators sustain microsomal cytochrome P-450(21) and P-450(17 alpha) in a setting of reduced ACTH-stimulated factors.