Endocrine Abstracts

Background: Secretion and metabolism of glucocorticoids and sex steroids is disrupted in critical illness, and may be further disrupted in COVID-19. The host receptor (ACE-2) is expressed in endocrine tissues including adrenal cortex and gonad, and its occupancy may dysregulate the renin-angiotensin system. We hypothesise that severe COVID-19 results in glucocorticoid and sex hormone deficiency, and aldosterone excess.Methods: Plasma was obtained from 27...

Aim: A QIP to improve early recognition and treatment of adrenal crisis (AC) in adults. Issuance of new NHS emergency steroid cards (SEC) in accordance with National Patient Safety Alert (NPSA) August 2020.Background: National Reporting and Learning System found that two deaths and six incidents (severe harm) were associated with shortfalls in managing adrenal insufficiency (AI) over 4 Years. A resulting NPSA advised the care organisations to identify th...

Background: Short Synacthen Tests (SSTs) are integral to the diagnosis of Adrenal Insufficiency (AI). A 30-minute stimulated cortisol value is assessed against local assay dependent thresholds to ascertain or exclude the diagnosis. A diagnosis of AI is a life changing event requiring the initiation of life long glucocorticoid replacement therapy for survival. Glucocorticoid replacement is associated with long term morbidity and mortality, including an increased risk of diabete...

Background: Primary aldosteronism (PA) is a common, curable and high-risk subset of hypertension, mandating detection. In all but the most severe cases, learned society guidelines recommend confirmatory testing. Whilst a variety of confirmatory tests exist, data describing their safety are limited. Concerns centre around the potential of some tests to precipitate hypokalaemia or a hypertensive emergency in a patient with PA on sub-optimal anti-hypertensive medication. In this ...

Introduction: Small-group teaching (SGT) has been widely adopted in medical education to promote problem-based learning and enhance the process of deep learning. Simulation via Instant Messaging - Birmingham Advance (SIMBA) is a simulation-based learning approach using WhatsApp and Zoom to increase participants’ confidence in managing various clinical scenarios.Aim: To investigate whether SIMBA provided similar knowledge and experiences as compared ...

Introduction: Hypo-&hyperkalaemia are common laboratory abnormalities, complicating up to 10% of all hospital admissions and contributing to mortality. Ideally, patients with mild deviations can be treated as outpatients, and only those patients with objectively severe or life-threatening levels are hospitalized. Once admitted, there are few data as to whether the degree of electrolyte disturbance consumes greater resource(s). We analysed the admission and discharge data, ...

Background: SIMBA is a simulation-based learning platform designed to increase clinicians’ confidence in managing various clinical scenarios. The restriction of face-to-face learning during the COVID-19 pandemic led to switching Simulation via Instant Messaging – Birmingham Advance (SIMBA) to entirely virtual sessions.Objective: To explore SIMBA’s effectiveness to sustain medical education in endocrinology during the pandemic.<p class=...

Large animals are increasingly used a models for endocrine research. Unlike rodents they are cortisol-dominant and thus more similar to humans. In this study we use two novel analytical methods to compare the steroid profile of pigs, sheep and humans; 1. Simultaneous quantification of primary glucocorticoids, glucocorticoid precursors and mineralocorticoids in plasma (>20 steroids); 2.Quantification of glucocorticoids metabolites (>10 ...

Introduction: The RECOVERY trial2 reported patients with Covid-19 receiving requiring invasive mechanical ventilation or oxygen that the use of dexamethasone (6 mg for 10 days) resulted in lower 28-day mortality. Adrenal insufficiency (AI) from hypothalamic-pituitary-adrenal (HPA) axis suppression3 is a serious, potentially life-threatening side effect of glucocorticoids treatment.Objective: We aimed to investigate the effects of Co...

Introduction: Adrenal venous sampling (AVS) is the criterion standard method of lateralisation in primary aldosteronism (PA). Despite this pivotal role, there is limited consensus and significant variability between centres related to many of the technical aspects of AVS. In this study, we sought to address whether variations in two different technical aspects of AVS altered parameters and interpretation, namely: 1. Peripheral sample site 2. Method of adrenal vein (AV) venesec...

Introduction: Sphingosine-1-phosphate lyase (SGPL1) catalyses the final step in sphingolipid metabolism, irreversibly degrading the lipid signalling molecule sphingosine-1-phosphate (S1P). The relative abundance of S1P compared to its precursors sphingosine and ceramide finely tunes signal transduction for a wide range of cellular pathways including proliferation, apoptosis, migration and calcium handling. Loss-of-function mutations in SGPL1 cause a spectrum of disorders, incl...

Aim: To assess whether patients on glucocorticoids understand how to manage their medication in the event of intercurrent illness.Background: Studies have shown that, after as little as two weeks of glucocorticoid treatment, 10% of patients have adrenal suppression and it can take one year or longer for adrenal function to recover. With 7 out of 1000 people in the general population prescribed glucocorticoids, there is a large group at risk of adrenal cr...

Case history: A 62-year-old lady with no significant past medical history presented early February 2021 with a week history of epigastric pain, tiredness and poor oral intake, 5 days following her first dose of AstraZeneca Covid-19 vaccine. She was cardiovascularly stable but generalised abdominal tenderness was noted. There was no history of hypertension, hypokalaemia or symptoms consistent with phaeochromocytoma.Investigations: Admission bloods reveale...

Introduction: Covid -19 can cause serious or severe illness in anyone but those with chronic health conditions are at greater risk. Adrenal insufficiency (AI) is assumed to be associated with an increased Covid-19 infection risk, which could trigger an adrenal crisis. We conducted a retrospective study at district general hospital to assess the incidence of COVID-19 in Adrenal insufficiency patients.Method and material: Retrospective review of 43 patient...

Introduction: Congenital adrenal hyperplasia (CAH) is an inherited autosomal recessive disorder characterized by insufficient production of cortisol and high androgens. Myelolipoma is a benign neoplasm of adrenal gland composing mature adipose tissue and scattered islands of hematopoietic elements. We report a case of rare association of giant bilateral adrenal mylelolipoma in a congenital adrenal hyperplasia patient who was non-compliant with medication.<p class="abstext"...

Introduction: National audits suggest significant variation in experience of individual surgeons performing adrenalectomies. A 2016 cross specialty consensus statement recommended that adrenal surgeons perform a minimum of six adrenalectomies per year given improved outcomes with higher volume surgeons. Patients in the Scottish Highlands requiring adrenalectomy are referred to a single Consultant Urologist with a specialist interest in retroperitoneal surgery based in Raigmore...

Introduction: Patients with adrenal insufficiency (AI), continue to face many challenges including: dealing with symptoms and associated disorders; managing medication regimens; prevention and management of complications, and effective engagement and interactions with healthcare providers. In patients with AI, adrenal crisis (AC) continues to lead to unnecessary deaths. We illustrate how University Hospitals Birmingham NHS Foundation Trust used the 4E framework (En...

Autonomous cortisol secretion (ACS), a term that refers to biochemical evidence of excess cortisol, but without the overt Cushing’s syndrome in people with adrenal adenomas. Prevalence of adrenal tumours is 5-10%. Up to 50% of benign adenomas present with some degree of cortisol excess. There is little guidance for investigating and managing these patients leading to different standards of care. Cortisol secretion here is in wide range although post dexamethasone suppress...

Background: Management of adrenal insufficiency (AI) with glucocorticoid replacement is associated with increased mortality and morbidity. There is growing evidence that this is because of excess, non-physiological steroid exposure. Low dose prednisolone (2-4 mg) is a once-daily alternative to standard hydrocortisone regimens that more closely mimics the circadian rhythm and may translate to better outcomes. There is however a paucity of studies comparing the two treatments.</...

Background /Methods: Adrenal incidentalomas pose a significant burden to endocrinology services in assessing the clinical significance of these lesions. Following vetting of the incidentaloma referrals, the patients at our centre are initially seen in a nurse-led clinic for biochemical investigations and to ensure completion of radiology assessment using a structured proforma. This step facilitates efficient patient flow and quicker decision making. The clinical outcomes of th...

Aim: This is a retrospective study of imaging with adrenal incidentalomas at our DGH to assess clinical practice. Their management was followed and compared with the European Society of Endocrinology (ESE) Clinical Practice Guidelines 2016 for management of adrenal incidentalomas. The aim was to improve clinical service by developing a local management pathway.Materials and Methods: Data was collected for two years from 2018 to 2019 which included all im...

Primary adrenal lymphoma is an extremely rare type of lymphoma. There have been only about 200 cases described in the literature so far. About a half of patients can present with adrenal insufficiency. We report a case of a 70- year-old previously fit and well patient referred to Endocrinology services after a CT scan of her adrenal showed bilateral adrenal masses right measuring 6 cm and left measuring 9 cm. CT was performed as she complained of 9 kilograms weight loss in las...

Functioning adrenal masses are often a diagnostic challenge and can present with unusual symptoms. We describe a case of a 37-year-old male with a background of ulcerative colitis, who presented with gynecomastia in the breast clinic. His serumbiochemistry showed persistently elevated Oestradiol and prolactin, with low testosterone and FSH. On physical examination, he had marked breast tenderness, bilateral gynecomastia and no signs of steroid excess. He reported a decline in ...

Familial glucocorticoid deficiency (FGD) is characterised by isolated glucocorticoid deficiency with retention of normal mineralocorticoid production. FGD causing mutations in the MC2R accessory protein, MRAP, often occur at the canonical donor splice-site of intron 3, presumed to result in skipping of the first coding exon with unknown consequences at the protein level. DNA from three patients (0 - 6 months) with high ACTH and/or low cortisol levels underwent whole e...

Background: SARS-CoV-2 targets membrane-bound angiotensin-converting enzyme 2 (ACE2) to achieve cellular entry. Resultant loss of ACE2 function may lead to unregulated activation of the renin-angiotensin-aldosterone system (RAAS), contributing to the pathogenesis of hypertension and triggering a proinflammatory cascade. However, evidence to support this is conflicting, with either no change or an increase in the concentration of circulating aldosterone reported in patients wit...

In neonates, cardiomyocytes exit the cell cycle thus establishing cardiomyocyte number for life. Further growth is through hypertrophy. Factors that advance the timing of the switch from hyperplastic to hypertrophic growth may increase risk of cardiac disease in adulthood. Early life administration of glucocorticoids is known to increase risk of cardiovascular disease. We hypothesized that dexamethasone, a synthetic glucocorticoid, causes precocious cell cycle exit of neonatal...

Background: The gonads are the major source of classic androgens during reproductive years. Additionally, the adrenal gland produces precursors for both classic and 11-oxygenated androgen biosynthesis, with androgen activation predominantly occurring in peripheral target tissues of androgen action. We used liquid chromatography-tandem mass spectrometry to profile classic and 11-oxygenated androgens in serum and saliva across the adult age range and assessed diurnal as well as ...

Background: Primary adrenal insufficiency (PAI) predisposes patients to infections, which can precipitate life-threatening adrenal crises. PAI patients are thought to be particularly vulnerable to COVID-19; however, little is known about its true impact on this group.Aim: To assess morbidity and health promotion attitudes during the COVID-19 pandemic amongst a large cohort of PAI patients.Methods: In May 2020 COVID-19 information, ...

Patients on long term glucocorticoid replacement therapy have higher rates of morbidity and mortality. One causative factor may be non-physiological cortisol replacement. We have developed as part of the ULTRADIAN consortium (https://www.uib.no/en/ultradian) the U-RHYTHM, an ambulatory bio-sampling device that can collect clinical samples using in-vivo microdialysis every 20 minutes over the 24hour day whilst individuals continue with their normal everyday activities....

Background: Benign adrenal incidentalomas (AI) are found in 3-5% of adults. All patients should undergo a 1 mg -overnight dexamethasone suppression test (1 mg -DST) to exclude cortisol excess (non-functioning adrenal tumours, NFAT; serum cortisol ≤50 nmol/l) or diagnose possible mild autonomous cortisol secretion (MACS; serum cortisol >50 nmol/l). Current guidelines discourage repeating hormonal work-up in patients with benign AI. However, data underpinning this reco...

Introduction: Clinical Practice Guidelines1 advocate adrenal vein sampling (AVS) to distinguish between unilateral and bilateral primary aldosteronism (PA). Cannulating the right adrenal vein is difficult, and there is a lack of standardisation in sampling procedure and interpretation2. We audited our local service to identify improvements.Methods: All AVS procedures performed between January 2018-December 2020 (n = 31) wer...

Introduction: Primary aldosteronism (PA) is both the most common form of secondary hypertension and a high-risk subset associated with increased cardiovascular, cerebrovascular and renal morbidity compared to essential hypertension. Unilateral PA is amenable to surgery, biochemical cure and reversal of this excess risk; whilst bilateral disease is best treated through mechanism-directed medical therapy. Currently, PA subtype classification relies on adrenal venous sampling (AV...

Bilateral adrenal haemorrhage is an uncommon but life-threatening condition which may result from trauma, sepsis, coagulopathy, underlying tumour or autoimmune conditions. We present a 62-year-old female with a history of well controlled hypertension and asthma who was admitted with sudden onset epigastric pain and suspected cholecystitis. She received her first dose of Astrazeneca (AZ) Covid-19 vaccine seven days prior to onset of symptoms. Her systolic blood pressure was mor...

Background: Hyperandrogenism in congenital adrenal hyperplasia (CAH) is associated with virilisation in female patients and subfertility in both male and female patients. However, little is known regarding the association of hyperandrogenaemia with polycythaemia. We evaluate the association between the adrenal hormone profile and haematocrit (HCT)/haemoglobin (Hb) in a cohort of patients with classical CAH.Methods: Single centre retrospective analysis of...

A 56-year-old woman presented with progressive swelling of her face and fatigability. Investigating for Cushing’s, her 24-hour Urine Free Cortisol was negative at 43 and 70nmol/24hr (Reference interval or R.I. < 146 nmol/24hr) with overnight dexamethasone suppression test showing full suppression of cortisol to 34nmol/l. Her short synacthen test was normal at 30-minute cortisol of 753nmol/l (R.I.>420); on Zumenon. Other pituitary function tests were unremarkable b...

Aim: In light of recent publications - could a lower cortisol cut off value of ~350 nmol/l be used to safely rule out adrenal insufficiency (AI) compared to current local guideline cutoff value of either a baseline or 9am cortisol of 420 nmol/l? If so could this potentially help reduce the number of Co-syntropin stimulation tests (CST) performed?Background: Current local guidelines recommend a cortisol cut value of 420 nmol/l to rule out adrenal insuffic...

Incidentally discovered adrenal masses on abdominal imaging for unrelated reasons have a prevalence of 1-7%. A great majority of these are non-functioning adenomas, but 5-30% are associated with autonomous cortisol secretion (ACS), which is mainly subclinical, and 1-5% with phaeochromocytoma or Conn’s syndrome. Here we report two cases of overt functioning adrenal adenoma with coexisting ACS. We could not find any other reports of such cases in the literature.<p class...

Introduction: Short Synacthen Tests (SSTs) are the gold standard for diagnosis of Adrenal Insufficiency. An early morning cortisol may be an acceptable alternative. We wished to establish current local practice in testing and what lessons could be learned. Clyde uses the Architect Cortisol Assay – adequate response taken as post-Synacthen cortisol of ≥430nmol/l.Methods: We aimed to gather data on ≥100 SSTs and this took 11 weeks (20/05/1...

A 63 year old man was admitted with headache, nausea, vomiting and BP of 247/155 mmHg. He had a 4 month history of headache. Past medical history of depression, back pain and 40 pack year smoking history. There was no history of chest pain, palpitation or neurological disturbance. ECG: sinus rhythm, Rate 110, LVH. Cholesterol 6.1 mmol/l. Creatinine 118umol/l. CT head unremarkable. He was commenced on amlodipine. Tramadol and pregabalin were stopped due to possible serotonin sy...

The non-specific symptoms of Addison’s disease may be attributed to other conditions with consequent delay in diagnosis. We describe such a case of novel presentation. A 61 year old female presented with a one-day history of vomiting, abdominal pain and 15kg weight loss over 6 months. PMH: hypertension of 15 years duration, chronic kidney disease (CKD3) for 7 years and hysterectomy for endometrial carcinoma 8 years earlier. Examination: dehydrated, sinus tachycardia 110 b...

Introduction: Iatrogenic Cushing’s syndrome (ICS) can be caused by virtually all forms of steroid treatment with or without suppression of hypothalamic–pituitary–adrenal (HPA) axis. Here we report betamethasone nasal drops used as treatment post septorhinoplasty as a cause of iatrogenic Cushing’s syndrome.Case: A 36 years old female with background history of depression presented to endocrinology clinic for evaluation of progressive w...

The four major hypertensive disorders in pregnancy are preeclampsia/eclampsia/HELLP syndrome, gestational hypertension, chronic hypertension and pre-eclampsia superimposed on chronic hypertension. The prevalence of hypertension in pregnancy has been reported to be around 6%. The commonest aetiology was found to be gestational hypertension which made up 40% of all cases. To our knowledge, secondary causes of hypertension in pregnancy has never been well described. We present a ...

Introduction: Cushing’s syndrome can impair the gonadotrophic axis in women of child bearing age if left untreated. Furthermore undergoing endoscopic transphenoidal surgery can render patients hypogonadal, thereby reducing the chances of spontaneous conception. In such cases, pregnancy is usually achieved by assisted contraceptive techniques. We present a case of spontaneous pregnancy following transphenoidal surgery and bilateral adrenalectomy.Case...

Background: Primary hyperaldosteronism (PHA) is characterised by inappropriately high aldosterone production, most commonly caused by unilateral/bilateral adrenal adenoma or bilateral adrenal hyperplasia. It usually manifest as hypertension and/or hypokalaemia. There is emerging evidence to support the prevalence of PHA in more than 10% in hypertensive patients but only a minority will have a confirmed diagnosis and receive specific treatment.Aim: To pro...

Primary adrenal lymphoma is a rare cause of adrenal insufficiency, accounting for only approximately 1% of non-Hodgkin lymphoma cases. Most common subtype of PAL is diffuse large B cell lymphoma. A 71-year-old gentleman with the past history of hypertension, type 2 DM and the incidental finding of adrenal hyperplasia, presented with the general ill health with lethargy, weight loss and reduced appetite. He has the past history of hypertension, type 2 DM and the incidental find...