Dermatological Conundrum: Puzzling Pigmentation in Vitamin B12 Deficiency and Addison's Disease.

We report a case series of two patients who had similar skin pigmentation but were caused by vitamin B12 deficiency and Addison's disease. We further discuss the pathophysiology of skin hyperpigmentation in both of these disorders and the response to treatment. Our case report highlights the importance of the identification of simple bedside clinical signs to diagnose reversible causes of skin pigmentation.

Secondary adrenocortical insufficiency after treatment with retifanlimab: a case report.

With advancements in medical oncology, immune checkpoint inhibitors (ICIs) have become the first-line treatment for many malignancies. ICIs play a significant role in improving cancer prognosis, but a series of immune-related adverse events (irAEs), including immune-related endocrine events (irEEs), caused by ICIs have also aroused concerns. Rapid clinical identification of irAEs caused by ICIs is particularly important. We describe a case of secondary adrenocortical insufficiency (AI) after PD-1 treatment in a postoperative patient with endometrial cancer. A 73-year-old female patient developed anorexia, nausea, vomiting, malaise, electrolyte disturbances, ineffective symptomatic treatment, and decreased serum adrenocorticotropin and cortisol levels six months after retifanlimab treatment. The vomiting resolved, and the electrolyte levels were corrected after 3 days of treatment with glucocorticoids (hydrocortisone, intravenous, 200 mg/day). When patients present with gastrointestinal symptoms, such as poor appetite and nausea, not only symptomatic treatment but also a search for the etiology behind the symptoms is needed, especially in immunotherapy patients who should undergo a thorough evaluation of the endocrine system and be alert for adrenocortical insufficiency.

[Diagnosis and etiology of primary adrenal insufficiency]. / Diagnostic et étiologie de l'insuffisance surrénalienne primaire.

Since its first description in 1855, our understanding of primary adrenal insufficiency has greatly evolved. However, diagnosis is often delayed, as symptoms are frequently nonspecific in the early stages of the disease. In this article, we review the classical manifestations, associated diseases, as well as the diagnostic algorithm for primary adrenal insufficiency, aiming to enable earlier diagnosis.

Depuis la première description en 1855, nos connaissances de l'insuffisance surrénalienne primaire ont beaucoup évolué. Cependant, le diagnostic est souvent retardé, les symptômes étant fréquemment aspécifiques aux premiers stades de la maladie. Dans cet article, nous rappelons les manifestations classiques, les maladies associées, ainsi que l'algorithme diagnostique de l'insuffisance surrénalienne primaire, afin de permettre un diagnostic plus précoce.

Excessive pickle consumption: beware of adrenal crisis.

Adrenal insufficiency (AI) is one of the most life-threatening disorders resulting from adrenal cortex dysfunction. Symptoms and signs of AI are often nonspecific, and the diagnosis can be missed and lead to the development of AI with severe hypotension and hypovolemic shock. We report the case of a 13-year-old child admitted for cardiac arrest following severe hypovolemic shock. The patient initially presented with isolated mild abdominal pain and vomiting together with unexplained hyponatremia. He was discharged after an initial short hospitalization with rehydration but with persistent hyponatremia. After discharge, he had persistent refractory vomiting, finally leading to severe dehydration and extreme asthenia. He was admitted to pediatric intensive care after prolonged hypovolemic cardiac arrest with severe anoxic encephalopathy leading to brain death. After re-interviewing, the child's parents reported that he had experienced polydipsia, a pronounced taste for salt with excessive consumption of pickles lasting for months, and a darkened skin since their last vacation 6 months earlier. A diagnosis of autoimmune Addison's disease was made. Primary AI is a rare life-threatening disease that can lead to hypovolemic shock. The clinical symptoms and laboratory findings are nonspecific, and the diagnosis should be suspected in the presence of unexplained collapse, hypotension, vomiting, or diarrhea, especially in the case of hyponatremia.

Clinical presentation and outcomes in patients with antiphospholipid syndrome-associated adrenal hemorrhage. A multicenter cohort study and systematic literature review.

BACKGROUND: Adrenal hemorrhage (AH) can occur in patients with antiphospholipid Syndrome (APS). We aimed to characterize the clinical manifestations, treatments, and outcomes of patients presenting with APS-associated AH (APS-AH) through a retrospective cohort and a systematic literature review (SLR). METHODS: We performed a mixed-source approach combining a multicenter cohort with an SLR of patients with incident APS-AH. We included patients from Mayo Clinic and published cases with persistent positivity for antiphospholipid antibodies and presenting with AH, demonstrated by imaging or biopsy. We extracted demographics, clinical characteristics, laboratory findings, treatment strategies, and outcomes (primary adrenal insufficiency and mortality). We used Kaplan-Meier and Cox models for survival analysis. RESULTS: We included 256 patients in total, 61 (24%) from Mayo Clinic and 195 (76%) from the SLR. The mean age was 46.8 (SD 15.2) years, and 45% were female. 69% of patients had bilateral adrenal involvement and 64% presented adrenal insufficiency. The most common symptoms at presentation were abdominal pain in 79%, and nausea and vomiting 46%. Hyponatremia (77%) was the most common electrolyte abnormality. Factors associated with primary adrenal insufficiency were bilateral adrenal involvement at initial imaging (OR 3.73, CI; 95%, 1.47-9.46) and anticardiolipin IgG positivity (OR 3.80, CI; 95%, 1.30-11.09). The survival rate at five years was 82%. History of stroke was associated with 3.6-fold increase in mortality (HR 3.62, 95% CI; 1.33-9.85). CONCLUSION: AH is a severe manifestation of APS with increased mortality. Most patients developed permanent primary adrenal insufficiency, particularly those positive for anticardiolipin IgG and bilateral adrenal involvement.

A Case of Autoimmune Poly Glandular Glandular Syndrome Type 2 (Schmidt's Syndrome).

INTRODUCTION: Autoimmune polyendocrine syndrome (APS) type II (Schmidt's syndrome) is defined by the coexistence of autoimmune Addison's disease with autoimmune thyroid disease and/or type 1 diabetes mellitus. Patients also present with other organ specific autoimmune disorders like hypergonodotropic hypogonadism, vitiligo, chronic atrophic gastritis, pernicious anaemia, autoimmune chronic hepatitis and celiac disease. Many circulating organ-specific antibodies directed against endocrine organs. MATERIALS: A 40 year old female presented to the casualty with multiple episodes of vomiting and giddiness. Patient known case of hypothyroidism since past 4 years but was not on medications recently 1 month back patient was started on Thyroxine supplementation. History of menopause 8 years back present (premature). On examination patient had cold clammy extremity with signs of dehydration. Hyperpigmentation of face and gums was noted. PR -120/min thready pulse BP- 70/50 mmhg. Blood pressure was stabilised with fluid resuscitation. On investigation hyponatremia with hyperkalemia was present. In view of adrenal insufficiency co-syntropin stimulation test was done which came in favour of PRIMARY ADRENAL INSUFFICIENCY. TSH > 100 and anti TPO was positive suggesting AUTOIMMUNE THYROIDITIS. FSH was elevated and estradiol was reduced in favour of HYPERGONADOTROPIC HYPOGONADISM.ANA IF was positive. Therefore diagnosis of APS type 2 was made and appropriate substitution therapy was initiated. RESULT: Autoimmune endocrine gland disorders may regularly coexist with other endocrine autoimmune diseases. Neufeld and Blizzard organized and classified these clinical conditions and defined them as polyglandular autoimmune diseases or autoimmune polyendocrine syndromes (APS). Oegle first reported the association between Addison's disease, caused by bilateral tuberculous destruction of the adrenal glands, and diabetes mellitus in 1886. Schmidt's excisional biopsy detected lymphocytic infiltration of the adrenal cortex and thyroid gland in a patient who died from adrenal insufficiency in 1926. From that time, the coexistence of Addison's disease and autoimmune thyroid disease has been known as Schmidt's syndrome. APS II typically occurs in early adulthood with a peak onset during the third or fourth decades and is three times more common in females than in males. CONCLUSION: Autoimmune poly glandular syndrome can be treated with respective substitution therapy. Thyroxine therapy when initiated first may precipitate Addisonian crisis in patients with Schmidt's syndrome through increasing cortisol clearance and metabolic rate as evident in our case. Early detection of the disease and appropriate management may reduce morbidity and mortality significantly in the patients with autoimmune poly glandular syndrome.

Sleep, Cognition and Cortisol in Addison's Disease: A Mechanistic Relationship.

Sleep is a critical biological process, essential for cognitive well-being. Neuroscientific literature suggests there are mechanistic relations between sleep disruption and memory deficits, and that varying concentrations of cortisol may play an important role in mediating those relations. Patients with Addison's disease (AD) experience consistent and predictable periods of sub- and supra-physiological cortisol concentrations due to lifelong glucocorticoid replacement therapy, and they frequently report disrupted sleep and impaired memory. These disruptions and impairments may be related to the failure of replacement regimens to restore a normal circadian rhythm of cortisol secretion. Available data provides support for existing theoretical frameworks which postulate that in AD and other neuroendocrine, neurological, or psychiatric disorders, disrupted sleep is an important biological mechanism that underlies, at least partially, the memory impairments that patients frequently report experiencing. Given the literature linking sleep disruption and cognitive impairment in AD, future initiatives should aim to improve patients' cognitive performance (and, indeed, their overall quality of life) by prioritizing and optimizing sleep. This review summarizes the literature on sleep and cognition in AD, and the role that cortisol concentrations play in the relationship between the two.

Addison's disease as a primary manifestation of extrapulmonary tuberculosis; A case report.

Tuberculosis remains an important public health problem globally. Addison's disease due to bilateral adrenal Tuberculosis as the primary manifestation of Extrapulmonary Tuberculosis is a very rare clinical entity. Previously healthy 52 years old male presented with increasing darkening of the skin, dizziness, loss of weight, loss of appetite, generalized weakness for one year and diarrhoea, vomiting for 3 months. Patient did not have any history of exposure to Tuberculosis. Physical examination revealed a hyposthenic man with generalized hyperpigmentation especially on the face, oral mucosa, palmer crease, and knuckles. Investigations revealed high erythrocyte sedimentation rate, persistent hyponatremia, and strongly positive mantoux test. Short Synacthen test confirmed the adrenal insufficiency. Ultrasound scan of the abdomen found to have bilaterally enlarged adrenal glands. Contrast-Enhanced Computed Tomography of abdomen confirmed the bilaterally enlarged adrenal glands. Magnetic resonance imaging brain has done, it was normal with no evidence of pituitary masses. Then Computed Tomography guided biopsy has done from left adrenal gland. Histology of biopsy report was compatible with Tuberculosis. With the evidence of above finding this patient diagnosed to have Addison's disease due to tuberculosis of bilateral adrenal glands. Anti-Tuberculosis Treatment started and continued for six months. Hydrocortisone and Fludrocortisone started. When there is an adrenal insufficiency, it should be always considered the possibility of existence of TB even failure to isolate bacillus Mycobacterium, failure to identify epidemiological exposure.

Autoimmune polyendocrine syndrome type 1: an Italian survey on 158 patients.

BACKGROUND: Autoimmune Polyglandular Syndrome type 1 (APS-1) is a rare recessive inherited disease, caused by AutoImmune Regulator (AIRE) gene mutations and characterized by three major manifestations: chronic mucocutaneous candidiasis (CMC), chronic hypoparathyroidism (CH) and Addison's disease (AD). METHODS: Autoimmune conditions and associated autoantibodies (Abs) were analyzed in 158 Italian patients (103 females and 55 males; F/M 1.9/1) at the onset and during a follow-up of 23.7 ± 15.1 years. AIRE mutations were determined. RESULTS: The prevalence of APS-1 was 2.6 cases/million (range 0.5-17 in different regions). At the onset 93% of patients presented with one or more components of the classical triad and 7% with other components. At the end of follow-up, 86.1% had CH, 77.2% AD, 74.7% CMC, 49.5% premature menopause, 29.7% autoimmune intestinal dysfunction, 27.8% autoimmune thyroid diseases, 25.9% autoimmune gastritis/pernicious anemia, 25.3% ectodermal dystrophy, 24% alopecia, 21.5% autoimmune hepatitis, 17% vitiligo, 13.3% cholelithiasis, 5.7% connective diseases, 4.4% asplenia, 2.5% celiac disease and 13.9% cancer. Overall, 991 diseases (6.3 diseases/patient) were found. Interferon-ω Abs (IFNωAbs) were positive in 91.1% of patients. Overall mortality was 14.6%. The AIRE mutation R139X was found in 21.3% of tested alleles, R257X in 11.8%, W78R in 11.4%, C322fsX372 in 8.8%, T16M in 6.2%, R203X in 4%, and A21V in 2.9%. Less frequent mutations were present in 12.9%, very rare in 9.6% while no mutations in 11% of the cases. CONCLUSIONS: In Italy, APS-1 is a rare disorder presenting with the three major manifestations and associated with different AIRE gene mutations. IFNωAbs are markers of APS-1 and other organ-specific autoantibodies are markers of clinical, subclinical or potential autoimmune conditions.

Autoimmune polyendocrine syndrome type 1 (APECED) in the Indian population: case report and review of a series of 45 patients.

BACKGROUND: Autoimmune polyendocrinopathy-candidiasis-ectodermal-dystrophy (APECED) or autoimmune polyglandular syndrome type 1 (APS-1) is a rare autosomal recessive genetic disease due to mutations in the AIRE (AutoImmune REgulator) gene. The clinical diagnosis is classically based on the presence of at least two of the three main components: chronic mucocutaneous candidiasis, hypoparathyroidism and primary adrenal insufficiency. Patients often suffer from other endocrine or non-endocrine autoimmune conditions throughout life. APECED etiopathogenesis is mediated by T lymphocytes. Autoantibodies against proteins of the affected organs are found in the serum of APECED patients as well as neutralizing antibodies against cytokines. We report here the clinical and genetic characteristics of 45 Indian APECED patients in comparison to Finnish, Sardinian, Turkish and North/South American cohorts from their published results. We also report a new case of APECED of Indian origin, a 2-year old child suffering from chronic mucocutaneous candidiasis since the age of 8 months, with confirmatory AIRE homozygous mutation c.274C > T (p.R92W). CONCLUSION: With the inherent limitations of a retrospective study, analysis of Indian APECED patients suggested that compared to classic criteria, application of Ferre/Lionakis criteria validated in North/South American patients could help in earlier diagnosis in 3 of 8 (37.5%) patients for whom adequate information for evaluation was available.

Pediatric Primary Adrenal Insufficiency: A 21-year Single Center Experience

Objective: Primary adrenal insufficiency (PAI) is a rare but potentially life-threatening condition. In childhood, PAI is usually caused by monogenic diseases. Although congenital adrenal hyperplasia (CAH) is the most common cause of childhood PAI, numerous non-CAH genetic causes have also been identified. Methods: Patients aged 0-18 years and diagnosed with PAI between 1998 and 2019 in a tertiary care hospital were retrospectively evaluated. After the etiologic distribution was determined, non-CAH PAI patients were evaluated in detail. Results: Seventy-three PAI patients were identified. The most common etiology was CAH (69.9%, n=51). Non-CAH etiologies accounted for 30.1% (n=22) and included adrenoleukodystrophy (ALD; n=8), familial glucocorticoid deficiency (n=3), Triple A syndrome (n=5), autoimmune adrenalitis (n=1), adrenal hypoplasia congenital (n=1), IMAGe syndrome (n=1), and other unknown etiologies (n=3). The median age at the time of AI diagnosis for non-CAH etiologies was 3.52 (0.03-15.17) years. The most frequent symptoms/clinical findings at onset were hyperpigmentation of skin (81.8%), symptoms of hypoglycemia (40.9%), and weakness/fatigue (31.8%). Hypoglycemia (50.0%), hyponatremia (36.4%) and hyperkalemia (22.7%) were prominent biochemical findings. Diagnosis of specific etiologies were proven genetically in 13 of 22 patients. A novel p.Q301* hemizygous frameshift mutation of the DAX1 gene was identified in one patient. Conclusion: Etiology was determined in 86.3% of children with non-CAH PAI through specific clinical and laboratory findings with/ without molecular analysis of candidate genes. ALD was the most common etiology. Currently, advanced molecular analysis can be utilized to establish a specific genetic diagnosis for PAI in patients who have no specific diagnostic features.

Clinical and endocrinological manifestations of childhood-onset craniopharyngioma before surgical removal: A report from one medical center in Taiwan.

BACKGROUND: Craniopharyngiomas are benign tumors of embryologic origin located in the sellar region. Patients have both neurological and endocrinological symptoms. Symptoms may be subtle in the early clinical course, which leads to delayed diagnosis. This study evaluated the clinical and endocrinological manifestations of childhood-onset craniopharyngioma. METHODS: We retrospectively reviewed medical records of 45 children diagnosed as having craniopharyngioma between 1995 and 2019. We collected data on clinical symptoms and signs, height, weight, biochemical and hormone data, images, operation records, and pathology reports. A three-graded classification system was applied to define the degree of hypothalamic damage (HD). We analyzed clinical and endocrinological manifestations among patients with and without obesity, with short and normal stature, and with differing degrees of HD. RESULTS: Clinical endocrinologic manifestations included adrenocortical insufficiency (42%), central hypothyroidism (37%), short stature (31%), obesity (20%), weight < third percentile (19%), and polyuria or polydipsia (11%). The distribution of height and body mass index (BMI) revealed that a relatively large proportion of patients had short stature and obesity compared to the general population. Patients with grade 2 HD were significantly taller (height median SDS -0.07 vs. -2.05, P = 0.032), and had higher BMI (BMI median standard deviation scores [SDS] 1.14 vs. -0.54, P = 0.039) and shorter time to diagnosis (0.27 vs. 8.29 months, P = 0.007) than were those in the grade 0-1 HD. Delayed diagnosis was associated with short stature (6/7 vs. 4/26, P = 0.001) and no initial neurological symptoms (4/7 vs. 2/28, P = 0.009). CONCLUSION: Growth patterns may change variously depend on the tumor location and the severity of hypothalamic damage. Therefore, monitoring possible neurological symptoms and evaluating the growth patterns of patients during regular outpatient clinical visits are paramount.

Suspected bilateral adrenal gland tumour causing primary Addison's disease in a dog.

A 13-year old miniature poodle presented with a 3-day episode of vomiting, anorexia, and lethargy. Lack of micturition had been noted for 2 days. Clinical examination indicated dehydration and a tense, painful abdomen. Laboratory parameters (severe azotaemia, hyperkalaemia, severe hyponatraemia, hypochloraemia, and hyperphosphataemia with glucosuria and proteinuria) were consistent with anuric acute kidney injury (AKI). Abdominal ultrasound revealed bilateral adrenal masses. ACTH stimulation test was diagnostic for Addison's disease. Computed tomography confirmed bilateral adrenal masses and indicated multifocal liver nodules. Additionally, infiltration of the caudal vena cava with partial luminal occlusion was demonstrated. Surgical removal of the adrenal masses with venous plasty intervention and stenting of the vessels deemed unrewarding in this patient in respect to progressed tumour growth with assumed metastatic spread. The dog was treated for Addison's disease and discharged with good overall condition. Eight weeks later, the dog was euthanized due to progressive caudal vena cava occlusion. Whilst hypoadrenocoticism typically affects young to middle aged dogs, in old dogs primary Addison's disease might be caused by neoplastic bilateral adrenal gland destruction. This is the first case report of hypovolaemia leading to AKI secondary to bilateral adrenal masses causing Addison's disease in a dog.

Cushing's syndrome - Disease monitoring: Recurrence, surveillance with biomarkers or imaging studies.

Pituitary surgery is the first-line treatment for patients with Cushing's disease. For patients who are not considered candidates for pituitary surgery, pituitary radiation and bilateral adrenalectomy are further treatment alternatives. Not all patients are cured with pituitary surgery, and a substantial number of patients develop recurrence, sometimes many years after an apparently successful treatment. The same applies to patients treated with radiotherapy. Far from all patients are cured, and in many cases the disease recurs. Bilateral adrenalectomy, although always curative, causes chronic adrenal insufficiency and the remaining pituitary tumour can continue to grow and cause symptoms due to pressure on adjacent tissues, a phenomenon called Nelson's syndrome. In this paper the rate of recurrence of hypercortisolism, as well as the rate of development of Nelson's syndrome, following treatment of patients with Cushing's syndrome, will be reviewed. The aim of the paper is also to summarize clinical and biochemical factors that are associated with recurrence of hypercortisolism and how the patients should be monitored following treatment.

Autoimmune Addison's disease.

Primary adrenal insufficiency (PAI) occurs in 1/5000-1/7000 individuals in the general population. Autoimmune Addison's disease (AAD) is the major cause of PAI and is a major component of autoimmune polyendocrine syndrome type 1 (APS1) and type 2 (APS2). Presence of 21-hydroxylase autoantibodies (21OHAb) identifies subjects with ongoing clinical or pre-clinical adrenal autoimmunity. AAD requires life-long substitutive therapy with two-three daily doses of hydrocortisone (HC) (15-25 mg/day) or one daily dose of dual-release HC and with fludrocortisone (0.5-2.0 mg/day). The lowest possible HC dose must be identified according to clinical and biochemical parameters to minimize long-term complications that include osteoporosis and cardiovascular and metabolic alterations. Women with AAD have lower fertility and parity as compared to age-matched healthy controls. Patients must be educated to double-triple HC dose in the case of fever or infections and to switch to parenteral HC in the case of vomiting, diarrhoea or acute hypotension.

Addison's Disease Secondary to Bilateral Adrenal Gland Metastatic Mammary Carcinoma in a Dog.

A 12 yr old intact female Siberian husky was referred with a 2 wk history of progressive weakness, paraparesis, anorexia, and panting. A 4 cm diameter grade 3 mammary solid carcinoma involving the fifth right mammary gland had been removed 2 days prior to the current visit. While hospitalized, the dog was diagnosed with Addison's disease based on electrolyte disturbances and low serum cortisol levels following adrenocorticotropic hormone stimulation test. An abdominal ultrasound revealed adrenal glands at the upper limit of normal size. Despite treatment, the dog deteriorated and died 4 days after presentation. A postmortem examination revealed a neoplastic infiltrate of epithelial malignant cells in both adrenal glands, popliteal lymph nodes, vertebral bodies, and paralumbar musculature, compatible with metastasis from mammary carcinoma. To our knowledge, this is the first reported case of Addison's disease secondary to metastatic mammary carcinoma in a dog.

[The Schmidt's Syndrome]. / Das Schmidt-Syndrom.

HISTORY AND CLINICAL FINDINGS: We report the case within a 22-year-old patient, initially seen because of fatigue, weight loss and discoloration of the skin. A Hashimoto-Thyroditis had been diagnosed a few months prior to the clinical presentation. DIAGNOSTICS: Blood samples showed a hyponatremia and hyperkalemia. Addison's disease was diagnosed by management of cortisol, ACTH and adrenal antibodies. In combination with the previously diagnosed Autoimmune thyreoiditis the criteria for a Schmidt's Syndrome were fulfilled. TREATMENT AND CLINICAL COURSE: We initiated the substitution of Hydrocortisone (20 mg/d) and Fludrocortisone (0.1 mg/d) in combination with an increased levothyroxin-dosage (100 µg/d). The patient's condition improved over the course of a few days. CONCLUSION: The presented case underlines the importance of focused examinations and diagnostics when dealing with a patient with unspecific symptoms and a pre-existing autoimmune disease. This also applies to patients with a positive family history for autoimmune disorders.

Epidemiology, pathogenesis, and diagnosis of Addison's disease in adults.

BACKGROUND: Addison's disease (AD) is a rare disorder and among adult population in developed countries is most commonly caused by autoimmunity. In contrast, in children genetic causes are responsible for AD in the majority of patients. PURPOSE: This review describes epidemiology, pathogenesis, genetics, natural history, clinical manifestations, immunological markers and diagnostic strategies in patients with AD. Standard care treatments including the management of patients during pregnancy and adrenal crises consistent with the recent consensus statement of the European Consortium and the Endocrine Society Clinical Practice Guideline are described. In addition, emerging therapies designed to improve the quality of life and new strategies to modify the natural history of autoimmune AD are discussed. CONCLUSIONS: Progress in optimizing replacement therapy for patients with AD has allowed the patients to lead a normal life. However, continuous education of patients and health care professionals of ever-present danger of adrenal crisis is essential to save lives of patients with AD.