Acute Secondary Adrenal Insufficiency Misdiagnosed as Acute Cholecystitis

Hypopituitarism refers to insufficient secretion of the pituitary hormones. Patients with acute adrenocorticotropic hormone (ACTH) deficiency may be presented with fatigue, dizziness, orthostatic hypotension, hypoglycemia, nausea, vomiting, or nonspecific abdominal pain. This study described an unusual case of hypopituitarism in a patient who presented with general abdominal pain, abdominal tenderness, nausea, vomiting, hypotension, and hypoglycemia. At first, the patient was admitted with the diagnosis of acute cholecystitis, but after treatment of hypopituitarism and adrenal insufficiency, his symptoms resolved completely, without the need for surgery. Hypopituitarism and secondary adrenal insufficiency should be considered in the differential diagnosis of the patients who present with acute abdomen, hypotension, or hypoglycemia.

Risk factors of central diabetes insipidus after transnasal adenomectomy

Background: At present, surgical intervention is a major treatment strategy for pituitary adenomas. It is commonly complicated with water and electrolyte imbalance. The prevalence of post-surgical central diabetes insipidus (CDI) may amount to 30%; however, its risk factors have not been established.Aim: To assess the rates and nosological distribution of CDI after transnasal adenomectomy and to identify its risk factors.Materials and methods: This retrospective study included 96 patients aged 20 to 65 years (median [Q1; Q3] 43 [34.5; 53.5]), who had transnasal adenomectomy in 2010–2011 due to Cushing's disease, acromegaly, prolactinoma, non-functioning pituitary adenoma. All patients underwent clinical examination and laboratory work-up before and after surgery. Their post-surgical course was assessed for 5 to 7 years. Depending on identified manifestations, the patients were categorized into the permanent CDI (n=15) and transient CDI (n=34); 47 patients had no CDI.Results: Cushing's disease (odds ratio (OR) 6.1, 95% confidence interval (CI) 2.3–16.1), secondary adrenal insufficiency (OR 6.8, 95% CI 2.6– 18.3) and adrenocorticotropic hormone levels of˂15.8 pg/mL (OR 5.0, 95% CI 1.9–13.5), microadenoma (OR 4.5, 95% CI 1.7–11.5) promote transient postoperative CDI, whereas macroadenoma decrease this risk (OR 0.2, 95% CI 0.1–0.5). The transient CDI was also more common in patients with secondary hypothyroidism, cortisol level of˂200 nmol/L, adenoma's volume at magnetic resonance imaging of<0.83 cm3 at trend level and more rare in patients with acromegaly and loss of tropic hormones before surgery at trend level as well. No significant risk factors were identified for permanent CDI, but it could be more often associated with secondary hypothyroidism, absence of any adenoma at magnetic resonance imaging and pituitary injury during the surgery and less frequent in patients with macroadenomas at trend level. Conclusion: The proportion of permanent postoperative CDI was 16% (95% CI 9–24), and that of the transient form 35% (95% CI 25–45). ˂0.83 cm3 at trend level and more rare in patients with acromegaly and loss of tropic hormones before surgery at trend level as well. No significant risk factors were identified for permanent CDI, but it could be more often associated with secondary hypothyroidism, absence of any adenoma at magnetic resonance imaging and pituitary injury during the surgery and less frequent in patients with macroadenomas at trend level.Conclusion: The proportion of permanent postoperative CDI was 16% (95% CI 9–24), and that of the transient form 35% (95% CI 25–45). Cushing's disease, microadenoma, development of secondary adrenal insufficiency and adrenocorticotropic hormone levels of˂15.8 pg/mL after surgery increase the probability of transient CDI, whereas macroadenoma does decrease this risk. No significant risk factors were identified for permanent CDI.

An Unusual Case of Hypopituitarism as an Adverse Effect of Vandetanib and Remission of Breast Metastases in a Patient with Medullary Thyroid Cancer

<b><i>Introduction:</i></b> Tyrosine kinase inhibitors have been a breakthrough in the treatment of advanced medullary thyroid cancer (MTC), and they can prolong progression-free survival (PFS). <b><i>Case Presentation:</i></b> A patient with MTC and metastatic spread to the lymph nodes, lungs, bones, breast, and cerebellum started treatment with vandetanib. During treatment, she developed secondary adrenal insufficiency and hypogonadotropic hypogonadism. After 9 years of vandetanib therapy, the disease has not progressed and the patient maintains a complete response of the breast metastases and a partial response of the other metastatic lesions. <b><i>Conclusion:</i></b> To our knowledge, this is the first reported case of secondary adrenal insufficiency and hypogonadotropic hypogonadism related to therapy with vandetanib. Moreover, the prolonged PFS and the complete disappearance of some of the metastatic lesions in this patient are truly unusual.

Immune checkpoint inhibitor combination therapies very frequently induce secondary adrenal insufficiency

Immune checkpoint inhibitors (ICIs) are potent therapeutic options for many types of advanced cancer. The expansion of ICIs use however has led to an increase in immune-related adverse events (irAEs). Secondary adrenal insufficiency (AI) can be life-threatening especially in patients with delayed diagnosis. We retrospectively investigated secondary AI in ICI-treated patients. A total of 373 cancer patients treated with ICIs were included and evaluated. An adrenocorticotropic hormone (ACTH) deficiency was described in 13 patients. Among 24 patients with a combination of nivolumab and ipilimumab therapy, 7 patients (29%) developed secondary AI in a median time of 8 weeks during the combination therapy and 2 of 15 patients (13%) developed isolated ACTH deficiency during maintenance nivolumab monotherapy following the combination therapy. More than half of the patients (4/7) with a combination therapy-induced multiple anterior hormone deficiencies was diagnosed as secondary AI based on regular ACTH and cortisol tests with slight subjective symptoms. Secondary AI can arise frequently and rapidly in cancer patients receiving a combination ICI therapy, and thus we speculate active surveillance of AI using regular ACTH and cortisol tests during the combination therapy might be useful for avoiding life-threatening conditions due to secondary AI.