Aldosterone- and Cortisol Co-secreting Adrenal Cortical Neoplasm With Lipomatous and Myelolipomatous Metaplasia  .

We report a case of a 58-year-old woman with a history of hypertension diagnosed at aged 35 years, on 5 antihypertensive agents and a history of intermittent spontaneous hypokalemia, was found to have a 6-cm left adrenal mass on computed tomography scan of the abdomen. The unenhanced computed tomography attenuation of the adrenal mass was -16 Hounsfield units (HU). The biochemical evaluation showed potassium of 2.8 mEq/L (SI unit, mmol/L) (reference range, 3.5-5.0), plasma aldosterone concentration of 61.3 ng/dL (SI unit, 1701 pmol/L) with plasma renin activity of 0.4 ng/mL/h (SI unit, µg/L/h). An overnight 1-mg dexamethasone suppression test showed nonsuppressible serum cortisol of 10.8 µg/dL (SI unit, 298 nmol/L). Dehydroepiandrosterone sulfate and ACTH were measured at 24.5 µg/dL (age-adjusted, 26-200) (SI unit, 0.66 µmol/L; 0.70-5.43) and <5 pg/mL (SI unit, < 1.1 pmol/L), respectively. Left adrenalectomy was performed and hydrocortisone therapy was initiated. Postoperatively and thereafter, her blood pressure was controlled with no antihypertensive agent. Seven months later, hydrocortisone therapy was stopped once her cortisol level had normalized. Pathology showed adrenal cortical neoplasm of uncertain malignant potential with associated lipomatous and myelolipomatous metaplasia. This is a rare case of aldosterone and cortisol co-secreting adrenal cortical neoplasm of uncertain malignant potential with lipomatous and myelolipomatous metaplasia. Although the majority of cases of myelolipoma are benign and nonfunctioning, this case emphasizes the importance of thorough hormonal and morphologic evaluation of the tumor.

Hyperinsulinemia Associated Depression.

Hyperinsulinemia promotes fat accumulation, causing obesity. Being an inflammatory state, obesity can induce further inflammation and is a risk factor for HPA (hypothalamic pituitary axis) dysregulation through hypercortisolism-related hyperglycemia. In another hypothesis, the sympathetic nervous system (SNS) plays a significant role in the regulation of hormone secretion from the pancreas such as an increase in catecholamines and glucagon as well as a decrease in plasma insulin levels, a disruption on SNS activity increases insulin levels, and induces glycogenolysis in the liver and lipolysis in adipose tissue during hypoglycemia. Hyperglycemia-hyperinsulinemia exacerbates inflammation and increases the oxidative stress along with regulating the levels of norepinephrine in the brain sympathetic system. Increased inflammatory cytokines have also been shown to disrupt neurotransmitter metabolism and synaptic plasticity which play a role in the development of depression via inhibiting serotonin, dopamine, melatonin, and glutamate signaling. An increased level of plasma insulin over time in the absence of exercising causes accumulation of lipid droplets in hepatocytes and striated muscles thus preventing the movement of glucose transporters shown to result in an increase in insulin resistance due to obesity and further culminates into depression. Further hyperinsulinemia-hyperglycemia condition arising due to exogenous insulin supplementation for diabetes management may also lead to physiological hyperinsulinemia associated depression. Triple therapy with SSRI, bupropion, and cognitive behavioral therapy aids in improving glycemic control, lowering fasting blood glucose, decreasing the chances of relapse, as well as decreasing cortisol levels to improve cognition and the underlying depression. Restoring the gut microbiota has also been shown to restore insulin sensitivity and reduce anxiety and depression symptoms in patients.

Impact of preoperative BRCA1/2 testing on surgical decision making in patients with newly diagnosed breast cancer.

The utility and benefit of integrating germ-line genetic testing into the management of newly diagnosed breast cancer is not fully understood. This study evaluates the impact of preoperative genetic testing on surgical decision making in patients with newly diagnosed breast cancer. Women with newly diagnosed breast cancer were classified into preoperative or postoperative genetic testing group, depending on whether they received their genetic testing results prior to or after their first surgery. Demographics, tumor characteristics, surgical treatment, and results of genetic testing were retrospectively collected. A total of 997 patients were evaluated, 531 (53.3%) in the preoperative genetic testing group and 466 (46.7%) in the postoperative group. Majority (87.2%) of BRCA-positive women in the preoperative group underwent bilateral mastectomy as first surgery. Majority (70.6%) of BRCA-positive women in postoperative group underwent partial mastectomy as first surgery prior to receiving their genetic testing result. Nearly half (41.2%) of these women in the postoperative group with partial mastectomy underwent bilateral mastectomy after receiving their BRCA-positive result. Time from diagnosis to first surgery was longer in the preoperative genetic testing group. Younger age, bilateral cancer, BRCA1/2-positive results, and preoperative genetic testing were significant predictors of bilateral mastectomy at first surgery. Preoperative genetic testing impacts initial surgical treatment in BRCA1/2-positive patients and reduces the need for additional surgeries.

Rheumatoid Meningoencephalitis: A Feared Condition in the Era of TNF Blockers.

Central nervous system (CNS) involvement in rheumatoid arthritis (RA) is uncommon, and most of the times, it is secondary to vasculitic processes or extra-articular rheumatoid nodules. Meningeal involvement is extremely rare. In the literature, there are a few case reports, series, and retrospective studies which have demonstrated the association of rheumatoid (aseptic) meningoencephalitis after starting tumor necrosis factor (TNF) inhibitors. We present a case of rheumatoid meningoencephalitis (RME) in a 52-year-old male with a history of RA on adalimumab who presented with headaches associated with motor and sensory deficits, all of which resolved after this diagnosis was achieved and received appropriate therapy with high-dose glucocorticoids. We also present an update with high yield points summarizing clinical features, diagnostic workup, and management of RME. Finally, we post a literature review of relevant CNS rheumatoid disease in patients with and without exposure to TNF inhibitors.