How to Explore an Endocrine Cause of Hypertension

Hypertension (HTN) is the most frequent modifiable risk factor in the world, affecting almost 30 to 40% of the adult population in the world. Among hypertensive patients, 10 to 15% have so-called “secondary” HTN, which means HTN due to an identified cause. The most frequent secondary causes of HTN are renal arteries abnormalities (renovascular HTN), kidney disease, and endocrine HTN, which are primarily due to adrenal causes. Knowing how to detect and explore endocrine causes of hypertension is particularly interesting because some causes have a cure or a specific treatment available. Moreover, the delayed diagnosis of secondary HTN is a major cause of uncontrolled blood pressure. Therefore, screening and exploration of patients at risk for secondary HTN should be a serious concern for every physician seeing patients with HTN. Regarding endocrine causes of HTN, the most frequent is primary aldosteronism (PA), which also is the most frequent cause of secondary HTN and could represent 10% of all HTN patients. Cushing syndrome and pheochromocytoma and paraganglioma (PPGL) are rarer (less than 0.5% of patients). In this review, among endocrine causes of HTN, we will mainly discuss explorations for PA and PPGL.

Effect of pulsed intravenous methylprednisolone with alternative low-dose prednisone on high-risk IgA nephropathy: a 18-month prospective clinical trial

Full-dose prednisone (FP) regimen in the treatment of high-risk immunoglobulin A nephropathy (IgAN) patients, is still controversial. The pulsed intravenous methylprednisolone combined with alternative low-dose prednisone (MCALP) might have a more favorable safety profile, which has not been fully investigated. Eighty-seven biopsy-proven IgAN adult patients and proteinuria between 1 and 3.5 g/24 h after ACEI/ARB for at least 90 days were randomly assigned to 6-month therapy: (1) MCALP group: 0.5 g of methylprednisolone intravenously for three consecutive days at the beginning of the course and 3rd month respectively, oral prednisone at a dose of 15 mg every other day for 6 months. (2) FP group: 0.8–1.0 mg/kg/days of prednisone (maximum 70 mg/day) for 2 months, then tapered by 5 mg every 10 days for the next 4 months. All patients were followed up for another 12 months. The primary outcome was complete remission (CR) of proteinuria at 12 months. The percentage of CR at 12th and 18th month were similar in the MCALP and FP groups (51% vs 58%, P = 0.490, at 12th month; 60% vs 56%, P = 0.714, at 18th month). The cumulative dosages of glucocorticoid were less in the MCALP group than FP group (4.31 ± 0.26 g vs 7.34 ± 1.21 g, P < 0.001). The analysis of the correlation between kidney biopsy Oxford MEST-C scores with clinical outcomes indicated the percentages of total remission was similar between two groups with or without M1, E1, S1, T1/T2, and C1/C2. More patients in the FP group presented infections (8% in MCALP vs 21% in FP), weight gain (4% in MCALP vs 19% in FP) and Cushing syndrome (3% in MCALP vs 18% in FP). These data indicated that MCALP maybe one of the choices for IgAN patients with a high risk for progression into ESKD.Trial registration: The study approved by the Chinese Clinical Trial Registry (registration date 13/01/2018, approval number ChiCTR1800014442, https://www.chictr.org.cn/).

Initial experience with laparoscopic posterior retroperitoneal adrenalectomy in single tertiary center

Purpose: Laparoscopic posterior retroperitoneal adrenalectomy (LPRA) is a surgical method that accesses the adrenal gland through the back. The aim of this study was to report initial experience of LPRA and evaluate possibilities for surgical application.Methods: From March 2018 to December 2019, a total of 30 consecutive patients diagnosed with adrenal tumor underwent surgical treatment at Pusan National University Hospital were enrolled. Clinicopathologic features and various peri- and postoperative parameters were analyzed by retrospective medical record review. The mean age of the patients was 48.20 ± 13.66 years.Results: The mean body mass index (BMI) was 25.50 ± 4.30 kg/m2 . Primary hyperaldosteronism was the most frequently preoperative diagnosed disease (n = 13, 43.4%), followed by adrenal incidentaloma (n = 8, 26.6%), Cushing syndrome (n = 5, 16.6%) and pheochromocytoma (n = 4, 13.3%). The mean size of postoperative adrenal tumor was 2.72 ± 1.76 cm. The mean operating time was 162 ± 58.14 minutes. Among the 30 patients, 28 patients underwent total adrenalectomy (93.3%) and two patients underwent cortical sparing adrenalectomy (6.7%). When LPRA was performed for patients with BMI > 23.16 kg/m2 , the operating time was longer than the average (P = 0.016).Conclusion: LPRA was suitable and safe for patients with benign adrenal tumors. BMI, retroperitoneal fat density and postoperative adrenal weight may be related to the operating time, so they should be considered when deciding on a surgical method for adrenalectomy.

Unilateral nodular adrenocortical hyperplasia presenting as Cushing’s syndrome: a case report

Cushing syndrome results from chronic exposure to excess cortisol. Nodular adrenal hyperplasia is usually bilateral and has only a few case reports of unilateral presentation. Biochemically it is presented as hyperaldosteronism or as Cushing’s syndrome. Here, we are reporting a 17-year-old female presenting with weight gain over 5 months and uncontrolled hypertension. Biochemically she was found to have diabetes mellitus, secondary hypothyroidism and hypogonadotrophic hypogonadism due to Cushing’s syndrome of adrenal origin. Unilateral adrenal adenoma/hyperplasia in right adrenal gland was evident by radiology. Histopathological examination was done after laparoscopic adrenalectomy showed nodular adrenocortical hyperplasia in right adrenal mass. Following surgery, clinical features of the patient improved notably. Cushing syndrome due to unilateral nodular adrenocortical hyperplasia is a rare entity. Biochemical evaluation of hypothalamo-pituitary-adrenal axis, radiological evidence and histopathology are the important armaments can guide to final diagnosis. BIRDEM Med J 2022; 12(1): 78-82

EPONYMS IN THE FIELD OF MEDICINE AND PAEDIATRIC DENTAL MEDICINE IN BULGARIAN AND ENGLISH

Introduction. Eponyms have been an inseparable part of medicine ever since the science exists. The need to name diseases and conditions after the physicians who came upon them and explored them arose (e.g., Addison’s disease, Cushing syndrome etc). This method of term formation continues to be employed even nowadays and its main advantage is that it facilitates remembering the condition. The purpose of the present paper is to establish the main principles of formation of eponyms and to compare them within the Bulgarian, English and Latin terminology. Another comparison which is intended is the use of eponyms in clinical medicine and clinical paediatric dental medicine. Background and motivations. The purpose of eponyms is to name diseases and conditions and to facilitate remembering. However, there are underlying principles of term formation and usage in the different fields of medicine which need to be clarified and traced. Methodology. The main methods used are lexicographical excerption and comparative analysis. The eponyms are classified according to the manner of their formation and usage. The expected results are related to the differences in the use of eponyms in the medical terminologies of Bulgarian and English clinical setting and to compare those to their source languages- Latin and ancient Greek.

The impact of curative treatment on hyperglycemia in patients with Cushing syndrome

Context Hyperglycemia is a common complication of Cushing syndrome (CS). Objective We aimed to determine the impact of curative procedure on hyperglycemia and its management in patients with CS. Design Retrospective longitudinal cohort study, 2000-2019. Setting Referral center. Patients Adults with endogenous CS and hyperglycemia. Main outcome measure Hemoglobin A1c (HbA1c), intensity of hyperglycemia therapy, improvement of hyperglycemia. Results In 174 patients with CS (pituitary in 106, ectopic in 25, adrenal in 43), baseline median HbA1c was 6.9% (range 4.9-13.1), with 41 (24%) patients not on any therapy for hyperglycemia, 93 (52%) on oral medications, and 64 (37%) on insulin (median daily units of 58, range 10-360). Following CS remission, at the end of follow up (median 10.5 months), 37 (21%) patients demonstrated resolution of hyperglycemia, 82 (47%) demonstrated improvement, and 55 (32%) had no change or worsening in hyperglycemia. At the end of follow up, HbA1c decreased by 0.84% (p &lt; 0.0001) and daily insulin dose decreased by a mean of 30 units, p &lt; 0.0001. Biochemical hypercortisolism severity score (severe vs moderate/mild: Odds ratio (OR) of 2.4 (95%CI of 1.1-4.9)), and CS subtype (nonadrenal vs adrenal: OR of 2.9 (95%CI 1.3-6.4)), but not type of hyperglycemia (diabetes vs prediabetes: OR of 2.1 (0.9-4.9)) were associated with hyperglycemia improvement at the end of follow up. Conclusion Two thirds of patients with CS and hyperglycemia demonstrate resolution or improvement of hyperglycemia after a curative procedure. Close monitoring during CS recovery is needed to assure appropriate therapy modification.

Synergistic cortisol suppression by ketoconazole–osilodrostat combination therapy

Summary Here, we describe a case of a patient presenting with adrenocorticotrophic hormone-independent Cushing’s syndrome in a context of primary bilateral macronodular adrenocortical hyperplasia. While initial levels of cortisol were not very high, we could not manage to control hypercortisolism with ketoconazole monotherapy, and could not increase the dose due to side effects. The same result was observed with another steroidogenesis inhibitor, osilodrostat. The patient was finally successfully treated with a well-tolerated synergitic combination of ketoconazole and osilodrostat. We believe this case provides timely and original insights to physicians, who should be aware that this strategy could be considered for any patients with uncontrolled hypercortisolism and delayed or unsuccessful surgery, especially in the context of the COVID-19 pandemic. Learning points Ketoconazole–osilodrostat combination therapy appears to be a safe, efficient and well-tolerated strategy to supress cortisol levels in Cushing syndrome. Ketoconazole and osilodrostat appear to act in a synergistic manner. This strategy could be considered for any patient with uncontrolled hypercortisolism and delayed or unsuccessful surgery, especially in the context of the COVID-19 pandemic. Considering the current cost of newly-released drugs, such a strategy could lower the financial costs for patients and/or society.