Pheochromocytoma With High Adrenocorticotropic Hormone Production Capacity Without Pigmentation and Cushingoid Symptoms: A Case Report With a Literature Review.

Pheochromocytoma or paraganglioma (PPGL) originating from chromaffin cells can produce diverse hormones in addition to catecholamines, including adrenocorticotropic hormone (ACTH). In pheochromocytoma, high levels of ACTH might not result in pigmentation as typically observed in Addison's disease, and patients might not exhibit the symptoms of Cushing's syndrome, despite ACTH-dependent hypercortisolism. A 63-year-old male patient with hypertension was admitted to our facility, and computed tomography (CT) revealed a large right adrenal tumor. Despite high plasma ACTH (700-1300 pg/mL) and serum cortisol (90-100 µg/dL) levels, no physical pigmentation or Cushingoid symptoms were observed. Urinary metanephrine and normetanephrine levels reached as high as 16.0 mg and 3.2 mg, respectively. 123I-metaiodobenzylguanidine (MIBG) scintigraphy was negative. Low-dose dexamethasone paradoxically increased ACTH and cortisol levels, indicating the potential positive feedback regulation of both hormones by glucocorticoids. The patient was diagnosed with an ACTH-producing pheochromocytoma and underwent successful laparoscopic surgery to remove the adrenal tumor under the intravenous administration of a high-dose α-blocker and hydrocortisone. The levels of ACTH, cortisol, and urinary metanephrine/normetanephrine returned close to normal after tumor removal. We report a rare case of pheochromocytoma with extremely high ACTH/cortisol production but without pigmentation or Cushingoid symptoms. We also reviewed previous reports of ACTH-producing PPGL regarding the paradoxical regulation of ACTH/cortisol by glucocorticoids, pigmentation, Cushingoid symptoms, and negativity of 123I-MIBG scintigraphy.

Clinical characterization of patients with primary aldosteronism plus subclinical Cushing's syndrome.

BACKGROUND: Primary aldosteronism (PA) plus subclinical Cushing's syndrome (SCS), PASCS, has occasionally been reported. We aimed to clinically characterize patients with PASCS who are poorly profiled. METHODS: A population-based, retrospective, single-center, observational study was conducted in 71 patients (age, 58.2 ± 11.2 years; 24 males and 47 females) who developed PA (n = 45), SCS (n = 12), or PASCS (n = 14). The main outcome measures were the proportion of patients with diabetes mellitus (DM), serum potassium concentration, and maximum tumor diameter (MTD) on the computed tomography (CT) scans. RESULTS: The proportion of DM patients was significantly greater in the PASCS group than in the PA group (50.0% vs. 13.9%, p <  0.05), without a significant difference between the PASCS and SCS groups. Serum potassium concentration was significantly lower in the PASCS group than in the SCS group (3.2 ± 0.8 mEq/L vs. 4.0 ± 0.5 mEq/L; p <  0.01), without a significant difference between the PASCS and PA groups. Among the 3 study groups of patients who had a unilateral adrenal tumor, MTD was significantly greater in the PASCS group than in the PA group (2.7 ± 0.1 cm vs. 1.4 ± 0.1 cm; p <  0.001), without a significant difference between the PASCS and SCS groups. CONCLUSIONS: Any reference criteria were not obtained that surely distinguish patients with PASCS from those with PA or SCS. However, clinicians should suspect the presence of concurrent SCS in patients with PA when detecting a relatively large adrenal tumor on the CT scans.

A High-Salt Diet Differentially Modulates Mechanical Activity of Afferent and Efferent Collecting Lymphatics in Murine Iliac Lymph Nodes.

BACKGROUND: The lymphatic system contributes to fluid homeostasis in various tissues. Recent evidence suggests that lymphangiogenesis induced by a high-salt diet (HSD) is associated with blood pressure regulation. Lymph nodes, located along lymphatic pathways, are not only important secondary lymphoid tissues for cancer metastasis, inflammation, and immune responses, but are also important for fluid homeostasis. Afferent lymphatics collect lymph from the pre-nodal area and efferent lymphatics drain lymph out of the lymph nodes. However, the difference in mechanical activity between afferent and efferent lymphatics and the effect of a HSD on these vessels have not been shown. METHODS AND RESULTS: Changes in mechanical activity of isolated afferent and efferent lymphatics in normal salt diet (NSD) and 4-week HSD mice in response to increases in intraluminal pressures from 3 to 7 cmH2O were measured using video-microscopy. The higher intramural pressure equivalently decreased pumping activity of afferent and efferent lymphatics in NSD mice. A HSD suppressed the amplitude, ejection fraction, and stroke volume of afferent lymphatics, leading to marked reductions in pumping activity. In contrast, the pumping activities of efferent lymphatics were resistant to a HSD and were preserved by enhancing the contraction frequency. CONCLUSIONS: A HSD differentially modulated the mechanical activity of afferent and efferent collecting lymphatics in murine iliac lymph nodes.

FRET-based sensor analysis reveals caveolae are spatially distinct Ca2+ stores in endothelial cells.

Ca2+-regulating and Ca2+-dependent molecules enriched in caveolae are typically shaped as plasmalemmal invaginations or vesicles. Caveolae structure and subcellular distribution are critical for Ca2+ release from endoplasmic reticulum Ca2+ stores and for Ca2+ influx from the extracellular space into the cell. However, Ca2+ dynamics inside caveolae have never been directly measured and remain uncharacterized. To target the fluorescence resonance energy transfer (FRET)-based Ca2+ sensing protein D1, a mutant of cameleon, to the intra-caveolar space, we made a cDNA construct encoding a chimeric protein of lectin-like oxidized low-density lipoprotein receptor 1 (LOX-1) and D1 (LOXD1). Immunofluorescence and immunoelectron microscopy confirmed that a significant portion of LOXD1 was localized with caveolin-1 at morphologically apparent caveolar vesicles in endothelial cells. LOXD1 detected ATP-induced transient Ca2+ decreases by confocal FRET imaging in the presence or absence of extracellular Ca2+. This ATP-induced Ca2+ decrease was abolished following knockdown of caveoin-1, suggesting an association with caveolae. The X-ray spectra obtained by the spot analysis of electron-opaque pyroantimonate precipitates further confirmed that ATP-induced calcium decreases in intra-caveolar vesicles. In conclusion, subplasmalemmal caveolae function as Ca2+-releasable Ca2+ stores in response to ATP. This intracellular local Ca2+ delivery system may contribute to the complex spatiotemporal organization of Ca2+ signaling.

Aldosterone enhances ligand-stimulated nitric oxide production in endothelial cells.

Chronic and acute actions of aldosterone have been shown recently to directly affect the cardiovascular system. However, it is unclear whether the acute effects of aldosterone on vasculature are constrictive or dilatory. Here, to clarify the nongenomic effects of aldosterone on endothelial function, we examined the effects of aldosterone on nitric oxide (NO) production in cultured endothelial cells (ECs) and on vascular tone. The intracellular NO production of bovine aortic ECs loaded with DAF-2 was determined using confocal microscopy. Accumulated NO in the culture medium was quantified by a microplate reader using membrane-impermeable DAF-2. Phosphorylation of endothelial NO synthase (eNOS) at Ser(1179) was assessed by Western blotting. Changes in intracellular Ca(2+) ([Ca(2+)](i)) were determined by confocal microscopy in ECs doubly loaded with fluo-4 and Fura Red. The effects of aldosterone, acetylcholine (ACh), and other signaling molecules on the tension of phenylephrine (PE)-contracted aortas of Sprague-Dawley rats were examined in an ex vivo organ bath chamber system. Short-term pre-exposure to aldosterone (1 x 10(-7) mol/L) enhanced ATP-induced NO production in ECs with increased phosphorylation of eNOS at Ser(1179). These effects were blocked by eplerenone, a mineralocorticoid receptor (MR) antagonist, and LY294002, a phosphatidylinositol 3-kinase (PI3K) inhibitor. Notably, aldosterone alone did not affect ATP-induced [Ca(2+)](i) changes or the Ser(1179) phosphorylation. Similarly, aldosterone (1 x 10(-8) to 1 x 10(-7) mol/L) did not affect the tone of rat aortas pre-contracted by PE, but enhanced ACh-induced vasorelaxation, which was again reversed by eplerenone or LY29400. In contrast, sodium nitroprusside-induced vasorelaxation in endothelium-denuded aortas was not affected by aldosterone. Thus, aldosterone acutely enhances ligand-mediated endothelial NO production by eplerenone-sensitive mechanisms involving a PI3K that may synergize Ca(2+)-dependent eNOS phosphorylation at Ser(1179).

Induction and activation of the transcription factor NFATc1 (NFAT2) integrate RANKL signaling in terminal differentiation of osteoclasts.

Signaling by RANKL is essential for terminal differentiation of monocytes/macrophages into osteoclasts. The TRAF6 and c-Fos signaling pathways both play important roles downstream of RANKL. We show here that RANKL selectively induces NFATc1 expression via these two pathways. RANKL also evokes Ca(2+) oscillations that lead to calcineurin-mediated activation of NFATc1, and therefore triggers a sustained NFATc1-dependent transcriptional program during osteoclast differentiation. We also show that NFATc1-deficient embryonic stem cells fail to differentiate into osteoclasts in response to RANKL stimulation, and that ectopic expression of NFATc1 causes precursor cells to undergo efficient differentiation without RANKL signaling. Thus, NFATc1 may represent a master switch for regulating terminal differentiation of osteoclasts, functioning downstream of RANKL.

Sites of Ca(2+) wave initiation move with caveolae to the trailing edge of migrating cells.

The caveola is a membrane domain that compartmentalizes signal transduction at the cell surface. Normally in endothelial cells, groups of caveolae are found clustered along stress fibers or at the lateral margins in all regions of the cell. Subsets of these clusters appear to contain the signaling machinery for initiating Ca(2+) wave formation. Here we report that induction of cell migration, either by wounding a cell monolayer or by exposing cells to laminar shear stress, causes caveolae to move to the trailing edge of the cell. Concomitant with the relocation of the caveolae, sites of Ca(2+) wave initiation move to the same location. In as much as the relocated caveolae contain elements of the signaling machinery required for ATP-stimulated release of Ca(2+) from the ER, these results suggest that caveolae function as containers that carry this machinery to different cellular locations.