Дисертації з теми "Cushing's"

Hypothesis: That siRNAs could be translated into systemic therapy for Cushing's disease in man. Background and importance: Cushing's disease is an uncommon but devastating condition, with a mean age of onset of 36 years, and a five-fold excess mortality when inadequately treated. Major complications include diabetes, hypertension, osteoporosis, life-threatening infection, depression and psychosis. No established ACTH-Iowering medical therapy exists. 95% of cases are caused by a tiny benign corticotrope adenomas of the pituitary gland, often only millimetres in diameter, and in 40% of cases are invisible on MR!. These adenomas express the prohormone 'Pro-opiomelanocortin' (pOMC), which undergoes post-translational processing to adrenocorticotrophin (ACTH), before secretion into the systemic circulation. ACTH drives the adrenal glands to synthesise and secrete excessive amounts of the hormone cortisol, which causes the clinical condition of Cushing's disease. Invasive neurosurgery aimed at removal of the pituitary tumour, causes long-term remission in only 50% of patients with Cushing's disease and results in hypopituitarism in approximately half. Hypopituitarism is associated with a two-fold excess mortality. Bilateral adrenalectomy is effective treatment but is complicated by life-long hypoadrenalism (two-fold excess mortality) and the development of an expanding, and pituitary mass (Nelson's syndrome) in up to 30% of cases. Use of adrenal steroidogenesis inhibitors is not usually effective in long-term management.

Patients with Cushing’s syndrome often complain about sleep disruption and excessive day time sleepiness, which could contribute to worsening quality of life and metabolic comorbidities (obesity, hypertension, diabetes mellitus, dyslipidaemia) associated with hypercortisolism. Sleep disorders have been shown to increase the risk of developing cardiovascular disease and that the risk of cardiovascular disease in patients with hypercortisolism may be worsened by impaired sleep. Cushing’s syndrome patients may also be at increased risk for obstructive sleep apnea due to their obesity.
Dissertation (MSc)--University of Pretoria, 2020.
Physiology
MSc
Restricted

El Síndrome de Cushing (SC) es una enfermedad endocrina rara, causada por una larga exposición a la hormona cortisol. Este hipercortisolismo endógeno determina síntomas endocrinos, cognitivos y psiquiátricos. Algunos estudios de neurorradiología han investigado la estructura cerebral en pacientes con SC encontrando alteraciones. Los objetivos de los estudios de esta tesis se centran en investigar la microestructura de la Sustancia Blanca cerebral (SB), un área que hasta ahora apenas ha sido estudiada en el SC, en evaluar los síntomas neuropsiquiátricos (depresión y ansiedad) y neuropsicológicos (velocidad de procesamiento de la información) y su relación con la SB. La Imagen con Tensor de Difusión (DTI) es una técnica de resonancia magnética (RM) que permite el estudio no-invasivo in vivo del cerebro evaluando el movimiento de las moléculas de agua a través de los axones. Existen diferentes mapas de DTI que permiten estudiar la arquitectura de la SB y mostrar anomalías microestructurales de la SB. La anisotropía fraccional (FA) refleja la integridad de la SB, mientras que los incrementos en la difusividad media (MD) pueden ser debidos ​​a desmielinización y/o edema. La disminución de la difusividad axial (AD) indica la pérdida axonal, mientras que el aumento de la difusividad radial (RD) se relaciona más con la desmielinización. En este trabajo se incluyeron 35 pacientes con SC y 35 voluntarios control sanos. En un primer estudio, se realizó un análisis de DTI comparando a los pacientes con SC con los controles sanos, seguido de un segundo análisis en el cual los pacientes fueron separados en SC activo, SC controlado y SC curado. Los resultados revelaron reducciones generalizadas de la FA, aumentos de MD y RD y un aumento parcial de la AD en pacientes con SC en comparación con los controles sanos. El análisis de subgrupos demostró este mismo patrón en la SB en pacientes con SC activo, controlado y curado, lo que sugiere un inicio temprano y duradero de las alteraciones en la microestructura de la SB. Las alteraciones de la SB fueron independientes del hipercortisolismo concomitante y de la presencia o ausencia de otros factores de riesgo cardiovascular incluidos en el análisis, como fueron la hipertensión, dislipidemia y la obesidad. Nuestro objetivo en un segundo estudio fue el investigar los trastornos del estado de ánimo y neuropsicológicos en los pacientes con SC y su relación con las alteraciones que habíamos visto en la SB. Planteamos la hipótesis de que los trastornos del estado de ánimo, utilizando el Beck Depression Inventory II (BDI-II) y el State-Trait Anxiety Inventory (STAI), serían mayores en los pacientes con SC que en los controles, y que se relacionarían con las alteraciones de la SB. Además, hipotetizamos que los pacientes con SC podrían mostrar anomalías en la velocidad de procesamiento de información, utilizando el Symbol Digit Modalities Test (SDMT), posiblemente vinculadas a las alteraciones de la SB, lo que sería debido a la conectividad funcional. Los resultados mostraron mayores trastornos del estado de ánimo (síntomas de depresión y de ansiedad), sin diferencias en las puntuaciones de velocidad de procesamiento de la información, en los pacientes con SC comparados con los controles sanos. En el estudio caso-control con DTI, los síntomas depresivos se correlacionaron negativa y positivamente, respectivamente con FA y RD, lo que refleja un patrón de alteraciones funcionales en estos pacientes que está vinculado a la pérdida de mielina y de la integridad axonal. FA y AD se correlacionaron positivamente con la velocidad de procesamiento de la información. Esto parece implicar que el estado/integridad de la SB determina una mejor ejecución en el procesamiento de la información tanto en pacientes con SC como en controles.
Cushing’s syndrome (CS) is an endocrine disorder due to prolonged exposure to cortisol. This endogenous hypercortisolism determines endocrine, cognitive and psychiatric symptoms. A few imaging studies have investigated brain structures in patients with CS and have observed brain damage. The aims of the studies described in this thesis were to explore the microstructure of cerebral white matter (WM), a topic hardly investigated up to now in CS, and to evaluate neuropsychiatric symptoms (depression and anxiety) and cognitive impairment (information processing speed) and their relationship with the WM. Diffusion Tensor Imaging (DTI) is a Magnetic Resonance (MR) imaging technique that allows noninvasive, in vivo study of the brain by assessing the motion of water molecules along and across neural axons. Different DTI maps show WM architecture and can depict microstructural WM abnormalities. Fractional anisotropy (FA) reflects WM integrity, while increases in mean diffusivity (MD) may be caused by demyelination or edema. Decreases in axial diffusivity (AD) indicate axonal loss, while increased radial diffusivity (RD) is related to demyelination. Thirty-five patients with CS and 35 healthy control volunteers were included in these studies. In the first study, a DTI analysis was performed comparing patients with CS with healthy controls, followed by a second analysis in which patients were separated into active CS, remitted CS, and cured CS. Results revealed widespread reductions in whole brain FA, increases in MD and RD and partially also of AD in patients with CS compared to healthy controls. The subgroup analysis demonstrated this same pattern of WM damage in patients with active, remitted and cured CS, suggesting an early onset and persistent damage of brain WM microstructure. DTI alterations seemed to be independent of concomitant hypercortisolism and the presence or absence of other cardiovascular risk factors included into the analysis like hypertension, dyslipidemia, and obesity. Our aim in the second study was to investigate mood disturbances and cognitive impairment in CS patients, and their relationship to WM alterations on DTI. We hypothesized that mood disturbances, evaluated using the Beck Depression Inventory II (BDI-II) and State-Trait Anxiety Inventory (STAI), would be greater in CS patients than in controls, and related to widespread WM alterations on DTI. We additionally hypothesized that CS patients would show abnormalities in information processing speed, evaluated using the Symbol Digit Modalities Test (SDMT), possibly related to WM alterations, since WM state has been related to connectivity function. Results showed greater mood disturbances (depression and anxiety symptoms), but no differences in information processing speed scores, in CS patients compared to healthy controls. In the case-control DTI study, depressive symptoms correlated negatively with FA and positively with RD, a pattern which is linked to loss of myelin and axonal integrity. FA and AD correlated positively with information processing speed. These results indicate that WM integrity are associated with better information processing in CS patients and controls.

Cyclic-AMP dependent protein kinase (PKA) is a key intracellular signal transduction kinase that is modulated by Gs- and Gi-coupled GPCRs. Under normal physiological conditions, PKA exists as an inactive holoenzyme made up of two catalytic subunits and two regulatory subunits. Upon cAMP binding to the regulatory subunits, the catalytic subunits (PKACa) are released to perform various downstream phosphorylation events. However, aberrant PKA activation can cause various diseases including Cushing’s Syndrome, which is an endocrine disorder caused by the overproduction of cortisol by the hypothalamus-pituitary-adrenal hormone system. This disorder can be caused by pituitary adenomas that release unregulated amounts of ACTH, adrenal adenomas that release unregulated amounts of cortisol without ACTH stimulation, and ectopic tumors outside the hypothalamus-pituitary-adrenal axis that produce ACTH. In recent genomic studies of patients with ACTH-independent Cushing’s Syndrome, the L205R-PKACamutant has been discovered. Through various studies on the mutant enzyme multiple research groups learned that the single point mutation causes a loss in sensitivity to cAMP signaling, a loss in binding to PKA regulatory subunits, and unregulated phosphorylation of PKACasubstrates, which ultimately leads to the increased cortisol biosynthesis in these patients. The first part of this work describes the enzymology and inhibition studies of known inhibitors against both wt- and L205R-PKACa. Early in the enzymology studies we developed at medium throughput endpoint assay that used Rhodamine-kemptide as the substrate and as a chromophore separating substrate and phosphorylated product using a reverse-phase HPLC method. The analysis of the substrate peptide against both wild-type and mutant enzyme showed a 6-fold decrease in the KMand a 2-fold decrease in kcat, and a similar but lower order of magnitude effect was observed for the studies with ATP. The inhibition studies were performed using the substrate competitive inhibitor PKI(5-24), which showed a 253-fold higher potency towards the wild-type enzyme over the mutant while the ATP-competitive inhibitor was determined to be equipotent. Using this information we used modeling studies to aid in the development of mutant selective functional inhibitors for the substrate-binding pocket. Additionally, we begun to explore the use of Proteolysis Targeting Chimeras, or PROTACs, as another means for targeting the L205R mutant enzyme.

As propriedades anti-inflamatórias e imunossupressoras dos glicocorticoides (GC) justificam o uso destes esteroides em diversas condições clínicas, apesar dos seus importantes efeitos adversos. A osteoporose induzida por glicocorticoide (OIG) é considerada a causa mais importante de osteoporose secundária. Trata-se de uma doença multifatorial que envolve alterações sistêmicas, teciduais e da sinalização das células ósseas. Além disso, o hipercortisolismo também se associa à obesidade, redistribuição de gordura, resistência insulínica e diabetes mellitus. Curiosamente, nestes distúrbios metabólicos em que a massa óssea está preservada, há maior fragilidade óssea. Nos últimos anos, diversas evidências mostram complexa interação entre o metabolismo mineral e o energético, em particular entre o tecido adiposo e ósseo. Neste cenário, a doença de Cushing (DC) é um modelo clínico conveniente para avaliar diversos mecanismos envolvidos no complexo processo de desenvolvimento de osteoporose. O objetivo deste trabalho foi avaliar, em um estudo basal e em um estudo prospectivo, diversos aspectos da interação entre o metabolismo mineral e energético em mulheres com DC e o seu possível impacto sobre a massa óssea, bem como a associação entre a massa óssea e os diversos tipos de tecido adiposo. No estudo basal, avaliamos três grupos de indivíduos, pareados por sexo e idade: grupo controle (C; n=27), grupo obeso (O; n=16) e grupo doença de Cushing (DC; n=16). No estudo prospectivo, avaliamos o grupo DC em três momentos: pré-operatório (Pré-op; n=11), 6º mês pós-operatório (6º mês PO; n=10) e 12º mês pósoperatório (12º mês PO; n= 10). No estudo basal, os grupos O e DC diferiram em relação ao C quanto ao peso e IMC (p<0,05). O grupo DC apresentou valores significativamente maiores de glicemia, insulinemia, hemoglobina glicosilada (HbA1c), HOMA-IR e leptina em relação aos grupos C e O (p<0,05). Adicionalmente, o grupo DC mostrou níveis baixos de osteocalcina em relação aos grupos C e O (p<0,05) e também de PTH, 25-OH vitamina D (25(OH)D) e adiponectina em relação ao grupo C (p<0,05). Não houve diferença entre os grupos em relação às dosagens de IGF-I e preadipocyte factor 1 (Pref-1). O grupo DC apresentou menor massa óssea em coluna lombar em relação aos grupos C e O (p<0,05) e menor massa óssea em corpo total quando comparado ao grupo O (p<0,05). O Trabecular bone score (TBS) foi capaz de evidenciar prejuízo na qualidade óssea nos grupos O e DC, mostrando comprometimento maior no grupo DC (p<0,05). A adiposidade de medula óssea (AMO) de L3 foi significativamente maior no grupo DC em relação aos grupos C e O (p<0,05). O grupo DC apresentou maior teor de tecido adiposo subcutâneo (SAT), visceral (VAT), relação VAT/SAT e de lipídeos intra-hepáticos (IHL) em relação ao grupo C (p<0,05). Adicionalmente, o grupo DC apresentou maior teor de VAT em relação ao grupo O (p<0,05). A osteocalcina se correlacionou de maneira positiva com TBS (r=0,5, p<0,0001) e negativa com HOMA-IR (r=-0,4, p<0,01) e AMO de L3 (r=-0,4, p<0,01). O TBS apresentou correlação negativa com HOMA-IR (r=-0,6, p<0,0001) e AMO de L3 (r=-0,5, p<0,001). A AMO de L3 se correlacionou positivamente com IMC (r=0,4, p<0,01), HOMA-IR (r=0,3, p<0,05), leptina (r=0,3, p<0,05), relação VAT/SAT (r=0,6, p<0,0001) e IHL (r=0,5, p<0,05). No estudo prospectivo, houve redução do peso e IMC e dos níveis de glicemia, insulinemia, HOMA-IR, hemoglobina glicada e leptina (p<0,05). Adicionalmente, houve aumento dos níveis de 25(OH)D, osteocalcina e deoxipiridinolina (p<0,05). Não houve diferenças significativas entre os níveis de Pref-1 e adiponectina. O TBS manteve-se estável e não houve aparecimento de novas fraturas pelo vertebral fracture assessment (VFA). Na composição corporal por dual-energy X-ray absorptiometry (DXA), houve redução da massa gorda total e melhora no índice de massa magra apendicular pelo Foundation for the National Institutes of Health (FNIH) (p<0,05). A AMO de L3 reduziu significativamente no 6º mês PO, mantendo-se estável no 12º mês PO (p<0,05). Houve redução significativa do VAT, relação VAT/SAT e IHL no seguimento prospectivo (p<0,05). O presente estudo reafirma dados anteriores que mostram que o hipercortisolismo endógeno exerce profundo efeito negativo sobre o esqueleto, em particular sobre o osso trabecular. Além disto, é o primeiro estudo a mostrar que existe correlação negativa entre o TBS com HOMA-IR e AMO; é possível que as alterações do metabolismo energético sejam, pelo menos em parte, responsáveis pelo maior risco de fratura na DC.
The anti-inflammatory and immunosuppressive properties of glucocorticoids (GC) justify the use of these steroids in various clinical conditions, despite its significant adverse effects. Osteoporosis induced by glucocorticoids (OIG) is considered the most important cause of secondary osteoporosis. It is a multifactorial disease involving systemic, tissue and bone cell signaling changes. Furthermore, hypercortisolism is also associated with obesity, redistribution of fat, insulin resistance and diabetes mellitus. Interestingly, these metabolic disorders in which bone mass is preserved, there is increased bone fragility. In recent years, evidence shows various complex interaction between the mineral and energy metabolism, in particular between adipose tissue and bone. In this scenario, Cushing\'s disease (CD) is a desirable clinical model to evaluate various mechanisms involved in the complex process of developing osteoporosis. The objective of this study was to evaluate, in a baseline study and a prospective study, various aspects of the interaction between the mineral and energy metabolism in women with DC and their possible impact on bone mass, as well as the association between bone mass and different types of adipose tissue. In the baseline study, we evaluated three groups of individuals, matched by sex and age: control group (C, n = 27), obese (O; n = 16) and Cushing\'s disease group (CD, n = 16). In the prospective study, we evaluated the CD group at three time points: preoperative (Pre-op; n = 11), 6 months postoperative (6th month PO; n = 10) and 12 months postoperatively (12th month PO; n = 10). In the baseline study, the O and CD groups differed in relation to C as the weight and BMI (p <0.05). The CD group showed significantly higher blood glucose, insulin, glycosylated hemoglobin (HbA1c), HOMA-IR and leptin in relation to the C and O groups (p <0.05). Additionally, the CD group showed lower levels of osteocalcin in relation to the C and O groups (p <0.05) as well as PTH, 25-OH vitamin D (25 (OH) D), and adiponectin in relation to the C group (P <0.05). There was no difference between the groups regarding dosages of IGF-I and preadipocyte factor 1 (Pref-1). The CD group had lower bone mass in the lumbar spine in relation to the C and O groups (p <0.05) and lower bone mass in the total body when compared to the O group (P <0.05). The Trabecular bone score (TBS) was able to show impaired bone quality in groups O and CD, showing greater involvement in CD group (p <0.05). Bone marrow adiposity (BMA) in L3 was significantly higher in the CD group compared to the C and O groups (p <0.05). The CD group showed increased subcutaneous fat content (SAT), visceral (VAT), VAT/SAT ratio and intrahepatic lipid (IHL) in relation to the C group (p<0.05). Additionally, the CD group had a higher content of VAT in relation to the O group (p<0.05). Osteocalcin correlated positively with TBS (r = 0.5, p <0.0001) and negatively with HOMA-IR (r = -0.4, p <0.01) and AMO of L3 (r = - 0.4, p <0.01). The TBS was negatively correlated with HOMA-IR index (r = -0.6, p <0.0001) and AMO of L3 (r = - 0.5, p <0.001). The AMO of L3 positively correlated with BMI (r = 0.4, p <0.01), HOMA-IR (r = 0.3, p <0.05), leptin (r = 0.3, p < 0.05), VAT/SAT ratio (r = 0.6, p <0.0001) and IHL (r = 0.5, p <0.05). In the prospective study, there was a reduction in weight and BMI and blood glucose, insulin, HOMA-IR, glycated hemoglobin and leptin (p <0.05). Additionally, there was increased levels of 25(OH)D, osteocalcin and deoxypyridinoline (p <0.05). There were no significant differences between the levels of adiponectin and Pref-1. The TBS was stable and there was no occurance of new fractures by vertebral fracture assessment (VFA). In body composition by dual-energy X-ray absorptiometry (DXA), threre was a reduction of total fat mass and improvement in apendicular lean body mass index by Foundation for the National Institutes of Health (FNIH) (p <0.05). The BMA of L3 significantly reduced in the 6th month PO, remaining stable on the 12th month PO (p <0.05). There was a significant reduction of VAT, VAT/SAT ratio and IHL in the prospective follow-up (p <0.05). This study confirms previous data showing that endogenous hypercortisolism has a profound negative effect on the skeleton, in particular on trabecular bone. Moreover, it is the first study to show that there is a negative correlation between TBS with HOMA-IR and BMA; it is possible that changes in energy metabolism are at least partly responsible for the increased risk of fracture in DC.

INTRODUÇÃO: A hiperplasia adrenal macronodular independente de ACTH (AIMAH) é uma doença rara, caracterizada pela presença de macronódulos funcionantes nas adrenais e por uma produção aumentada, autônoma e sustentada de cortisol. Constitui uma causa incomum de síndrome de Cushing (SC). A forma esporádica da doença parece ser a mais frequente, no entanto, se desconhece a real prevalência de sua forma familial. Apesar de ser uma entidade clínica conhecida há quase 50 anos, o processo fisiopatológico que culminaria com a AIMAH, as alterações genéticas predisponentes e aspectos clínicos, laboratoriais e radiológicos relevantes da doença ainda não foram elucidados de forma clara. O diagnóstico recente de uma grande família portadora da doença viabilizou a realização do presente trabalho. OBJETIVOS: 1) Caracterizar a evolução da AIMAH em sua forma familial, correlacionando as manifestações clínicas, os dados laboratoriais e os achados radiológicos; 2) investigar a possível associação entre a AIMAH e a ocorrência de meningiomas intracranianos; 3) avaliar a atividade metabólica das adrenais hiperplasiadas na AIMAH; 4) definir o padrão de herança genética da doença na família estudada; e 5) mapear regiões cromossômicas e loci potencialmente relacionados à etiologia genética da AIMAH familial. MÉTODOS: 96 membros da família estudada foram inicialmente submetidos a uma avaliação clínica e laboratorial pormenorizada. Em seguida, foram realizados exames de tomografia computadorizada para a caracterização radiológica das adrenais. Exames de ressonância magnética e de tomografia por emissão de pósitrons com fluordesoxiglicose marcada, acoplada à tomografia computadorizada (18F-FDGPET/CT) foram realizados em pacientes com as formas familial e esporádica da doença para, respectivamente, investigar a presença de meningiomas intracranianos e caracterizar a atividade metabólica das adrenais hiperplasiadas. Foram também realizados testes in vivo para a pesquisa de receptores hormonais aberrantes nos pacientes com a forma familial da doença. Em uma outra etapa do estudo, diferentes técnicas de biologia molecular foram empregadas para a investigação da etiologia genética da AIMAH familial. Desta forma, realizou-se: o sequenciamento do gene do receptor do ACTH (MC2R), um estudo de ligação genética utilizando microssatélites específicos, um estudo de ligação genética em escala genômica utilizando polimorfismos de nucleotídeo único (SNPs) e o sequenciamento de genes suspeitos. RESULTADOS: A avaliação dos indivíduos pertencentes à genealogia permitiu o diagnóstico de 15 casos da doença (7 mulheres e 8 homens) em três gerações consecutivas. A AIMAH era transmitida para as gerações subsequentes tanto pelo sexo masculino como feminino e acometia cerca de metade dos irmãos em alguns segmentos da família. A idade média ao diagnóstico da doença foi de 52,8 +-11,3 anos (32 a 74 anos) e cerca de 86% (12/14) desses pacientes apresentavam SC subclínica. As dosagens do cortisol salivar à meia-noite e do cortisol em urina de 24 horas demonstraram baixa sensibilidade (21% e 14%, respectivamente) para o diagnóstico da doença em sua forma familial. O valor do ACTH plasmático encontrava-se baixo ( < 10 pg/mL) em 46% (5/11) dos pacientes doentes. Em cerca de 62% (8/13) dos casos, foi demonstrada uma redução do valor sérico do sulfato de desidroepiandrosterona (SDHEA). Por regressão logística simples, foi observado que a probabilidade (odds ratio) de um indivíduo apresentar a doença na família era maior diante da presença de pletora, após o diagnóstico de diabetes ou pré-diabetes ou diante do relato de ganho ponderal progressivo. O espessamento de ambas as adrenais associado à presença de nódulos bilaterais foi o achado radiológico mais frequente na forma familial da doença. No entanto, em um terço dos pacientes (5/15) foram encontradas alterações radiológicas em somente uma das adrenais. Durante os testes in vivo para pesquisa de receptores hormonais aberrantes, foram observadas, com frequência, respostas distintas entre os indivíduos doentes pertencentes à família. Nos pacientes submetidos ao exame de ressonância magnética, foram demonstradas imagens típicas de meningiomas intracranianos em um terço (5/15) dos casos. No exame 18F-FDG-PET/CT, foi observado um aumento da atividade metabólica das adrenais hiperplasiadas, tanto nos pacientes com SC manifesta como naqueles com a forma subclínica da doença. O estudo molecular permitiu delimitar nos cromossomos 16 e 11 algumas regiões genômicas potencialmente relacionadas à etiologia genética da AIMAH familial. O sequenciamento de alguns genes suspeitos (GPR56, GPR97 e GPR114), localizados nessas regiões, não demonstrou a presença de mutações. CONCLUSÕES: Na genealogia estudada, o padrão de transmissão da AIMAH foi autossômico dominante, e a SC subclínica foi a forma mais frequente de manifestação da doença. O teste de supressão com 1 mg de dexametasona via oral à meia-noite demonstrou ser o exame laboratorial de escolha para a avaliação inicial dos pacientes suspeitos de apresentarem AIMAH familial, em função, sobretudo, da baixa sensibilidade do cortisol salivar à meia-noite e do cortisol urinário para o diagnóstico da doença. Valores normais do ACTH plasmático foram um achado laboratorial frequente na AIMAH familial e valores baixos do SDHEA sérico demonstraram ser um indício relativamente precoce da SC subclínica associada à doença. Diferentes padrões radiológicos foram demonstrados nas tomografias das adrenais dos pacientes com AIMAH familial, não sendo infrequente a presença de assimetria entre as duas glândulas. Os resultados dos testes in vivo para a pesquisa de receptores hormonais aberrantes foram mais condizentes com a hipótese de que a expressão desses receptores seria um epifenômeno do processo fisiopatológico, resultante da proliferação e desdiferenciação celular. Uma alta prevalência de meningiomas intracranianos foi observada nos pacientes com AIMAH, tanto na forma familial da doença como na forma esporádica. Demonstrou-se também, pela primeira vez, que as adrenais na AIMAH podem exibir uma captação aumentada de 18F-FDG no exame de PET/CT, de forma semelhante às metástases e aos carcinomas da glândula. Por fim, foram delimitadas no cromossomo 16 (16p12.1, 16p11.2, 16q12.1, 16q13 e 16q21) e no cromossomo 11 (11q23.1) as principais regiões do genoma suspeitas de estarem ligadas à etiologia genética da AIMAH familial (genoma de referência: NCBI36/hg18)
INTRODUCTION: ACTH-independent macronodular adrenal hyperplasia (AIMAH) is a rare disease characterized by functioning adrenal macronodules and increased, autonomous and sustained cortisol production. This condition is an uncommon cause of Cushing\'s syndrome (CS). While the sporadic form of the disease appears to be the most frequent, the true prevalence of its familial form is unknown. Despite being a known clinical entity for almost 50 years, the pathophysiological process that leads to AIMAH, the predisposing genetic alterations and important clinical, laboratory and radiological aspects of the disease have not been fully clarified. The recent identification of a large group of relatives with familial AIMAH allowed the accomplishment of the present study. OBJECTIVES: The following were the aims of this study: 1) characterize the development of familial AIMAH through correlations between clinical manifestations, laboratory data and radiological findings; 2) investigate the possible association between AIMAH and the occurrence of intracranial meningioma; 3) characterize the metabolic activity of the adrenal glands in this disease; 4) define the inheritance pattern of the disease in the family studied; and 5) map chromosomal regions and loci potentially related to the genetic etiology of familial AIMAH. METHODS: 96 members of the family studied were initially subjected to a detailed clinical and laboratory evaluation. Computed tomography (CT) scans were performed for the radiological characterization of the adrenal glands. Magnetic resonance imaging scans and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) scans were performed on patients with both forms of the disease (familial and sporadic) to investigate the presence of intracranial meningioma and characterize the metabolic activity of the adrenal glands, respectively. In vivo studies for aberrant hormone receptors were also conducted on those patients with familial AIMAH. In another phase of the study, different molecular biology techniques were employed to investigate the genetic etiology of familial AIMAH. For such, sequencing of the ACTH receptor gene (MC2R), a linkage study using specific microsatellite markers, a single nucleotide polymorphism (SNP)-based genome-wide linkage study and the sequencing of suspect genes were performed. RESULTS: The evaluation of the family revealed the diagnosis of 15 cases of the disease (7 women and 8 men) in three consecutive generations. AIMAH was transmitted to subsequent generations by both genders and half of the siblings were affected in some segments of the family. Mean age at diagnosis was 52.8 +-11.3 years (range: 32 to 74 years) and about 86% (12/14) of the patients exhibited subclinical CS. Both midnight salivary cortisol and 24-hour urinary cortisol demonstrated low sensitivity (21% and 14%, respectively) for the diagnosis of familial AIMAH. Plasma ACTH levels were low ( < 10 pg/ml) in 46% (5/11) of patients with the disease. In about 62% (8/13) of cases, serum dehydroepiandrosterone sulphate (DHEAS) levels were below the normal range. Simple logistic regression models revealed that the probability (odds ratio) of an individual having the disease in the family was greater in the presence of plethora, progressive weight gain or after the diagnosis of diabetes or prediabetes. Adrenal thickening associated with the presence of bilateral nodules was the most common radiological finding in familial AIMAH. However, radiological abnormalities were found in only one of the adrenal glands in one third of the patients (5/15). Throughout the in vivo studies for aberrant hormone receptors, distinct responses were frequently observed among the individuals with familial AIMAH. One third (5/15) of the patients who underwent magnetic resonance imaging scans had typical images of intracranial meningiomas. The 18F-FDG-PET/CT scan revealed increased metabolic activity of the hyperplastic adrenals in patients with both overt and subclinical CS. The molecular studies delimited genomic regions on chromosomes 16 and 11 potentially related to the genetic cause of familial AIMAH. Some suspected genes (GPR56, GPR97 and GPR114), located in these genomic regions, were sequenced, but no mutations were found. CONCLUSIONS: In the extended family studied, AIMAH followed an autosomal dominant pattern of inheritance and subclinical CS was the most common presentation of the disease. The 1 mg overnight dexamethasone suppression test proved to be the screening test of choice for the initial evaluation of patients suspected to have familial AIMAH, due mainly to the low sensitivity of midnight salivary cortisol and 24-hour urinary cortisol as screening tests. A normal level of plasma ACTH was a common laboratory finding in familial AIMAH. Low serum levels of DHEAS proved to be a relatively early finding associated with the subclinical CS determined by the disease. Adrenal CT scans revealed different radiological patterns among patients with familial AIMAH, with a fairly frequent rate of asymmetry between glands. The distinct responses observed throughout the in vivo studies for aberrant hormone receptors, among family members, favor the hypothesis that these receptors may be an epiphenomenon resulting from cell proliferation and dedifferentiation. An increased prevalence of intracranial meningioma was demonstrated in both the familial and sporadic forms of AIMAH. For the first time, it was shown that AIMAH may exhibit increased 18FFDG uptake on the PET/CT scan, similarly to adrenal carcinoma and metastasis. The main genomic regions potentially associated with familial AIMAH were delimited on chromosome 16 (16p12.1, 16p11.2, 16q12.1, 16q13 and 16q21) and chromosome 11 (11q23.1) (reference genome: NCBI36/hg18)

Los estudios descritos en esta tesis se centran en las consecuencias neuropsicológicas de quienes han sufrido síndrome de Cushing (SC, debido al exceso de glucocorticoides) y acromegalia (debido al exceso de hormona de crecimiento -GH-). Las evidencias muestran que la exposición prolongada a glucocorticoides puede tener efectos adversos en pacientes con SC, los cuales no recuperan el nivel de funcionamiento y la calidad de vida después de años de curación. Por otro lado, en los pacientes con acromegalia, los potenciales efectos negativos de la GH sobre la personalidad, la cognición y el comportamiento apenas han sido considerados hasta hace poco. Tomar decisiones es un comportamiento habitual de la vida diaria y requiere seleccionar una opción entre varias posibilidades. El Iowas gambling Task (IGT) es una medida de toma de decisiones que pretende imitar situaciones de la vida real que implican incertidumbre, recompensas y sanciones. La corteza frontal tiene un rol clave en el IGT porque posee la habilidad de coordinar el procesamiento de millones de neuronas para dirigirlas a conseguir metas futuras y tomar decisiones ventajosas. Los objetivos de estos estudios son evaluar la toma de decisiones y la memoria en pacientes con SC y acromegalia, y explorar sus relaciones con la corteza frontal y los problemas afectivos. Se evaluaron 35 pacientes con SC y 35 controles sanos usando el IGT y una resonancia magnética 3Tesla para medir la corteza frontal. Treinta y un pacientes con acromegalia y 31 controles sanos fueron evaluados con el IGT, el RAVLT (Rey Auditory Verbal Learning Test), el STAI (State-Trait Anxiety Inventory) y el BDI-II (Beck Depression Inventory-II). En el primer estudio, los pacientes con SC presentaron estrategias de toma de decisiones alteradas, elegían menos cartas seguras y más cartas de riesgo. Mostraron más dificultades que los controles en aprender los perfiles correctos de ganancias y pérdidas de cada grupo de cartas. En el análisis cerebral completo, los pacientes con SC mostraron adelgazamiento del grosor cortical en la corteza frontal superior izquierda, la corteza precentral izquierda, la corteza insular izquierda, la corteza cingulada anterior izquierda y derecha y la corteza frontal medial caudal derecha, en comparación con los controles sanos. En el segundo estudio, los pacientes acromegálicos mostraron peor memoria verbal a largo plazo y más síntomas de depresión y ansiedad que los controles sanos. Respecto al IGT, los pacientes con acromegalia presentaron una alteración en la estrategia de toma de decisiones en comparación con los controles, elegían menos cartas seguras y más cartas de riesgo. Múltiples correlaciones fueron encontradas entre los síntomas depresivos y ansiosos y la ejecución en memoria y toma de decisiones. Estos estudios muestran una peor toma de decisiones en pacientes con SC y acromegalia. Los pacientes seleccionaban más opciones desfavorables que ventajosas. Mientras los controles sanos aprendían gradualmente a favor de las opciones ventajosas, los pacientes con SC y acromegalia continuaban obteniendo sanciones a lo largo de la tarea. No obtuvimos relación directa entre mala toma de decisiones y adelgazamiento de la corteza frontal, a diferencia de estudios previos en otras patologías. Los déficits en el IGT correlacionaron con los problemas de memoria en pacientes con CS y acromegalia. Además, los pacientes con acromegalia mostraron alteraciones emocionales (ansiedad y síntomas depresivos) que influenciaron la memoria a largo plazo y la toma de decisiones.
The studies described in this thesis focus on the neuropsychological consequences in patients who have suffered Cushing’s syndrome (CS, due to glucocorticoid excess) and acromegaly (due to excess of growth hormone -GH-). It is known that prolonged exposure to glucocorticoids may have long-lasting adverse effects in CS patients who do not completely return to premorbid level of functioning and quality of life despite long-term cure. On the other hand, in acromegalic patients, potential long-lasting effects of GH on the brain affecting personality, cognition and behaviour have not been considered until recently. Making a choice is a common behavior in daily life and requires selecting one option among several alternative possibilities. The Iowa Gambling Task (IGT) is a measurement of decision making that mimics real-life risk taking situations since it involves uncertainty, reward and punishment. Frontal cortex has a key role in the IGT because it has the ability to coordinate processing among its millions of neurons in order to direct them towards future goals and advantageous decisions. The aims of these studies were to evaluate memory and decision making in patients with CS and acromegaly, and explore their relationship with frontal cortex and affective disorders. Thirty-five CS patients and thirty-five matched controls were evaluated using the IGT and 3Tesla magnetic resonance imaging (MRI) to assess frontal cortical thickness. Thirty-one patients with acromegaly and thirty-one healthy controls were evaluated using the IGT, Rey Auditory Verbal Learning Test (RAVLT), State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory-II (BDI-II). In the first study, CS patients presented an altered decision-making strategy compared to controls, choosing a lower number of the safer cards and higher number of riskier cards. They showed more difficulties than controls to learn the correct profiles of wins and losses for each card group. In whole brain analysis, CS patients showed decreased cortical thickness in the left superior frontal cortex, left precentral cortex, left insular cortex, left and right rostral anterior cingulate cortex, and right caudal middle frontal cortex compared to controls. In the second study, acromegalic patients showed impairments in delayed verbal memory and more anxiety and depressive symptoms than controls. Regarding the IGT, acromegalic patients presented an altered decision-making strategy compared to controls, choosing a lower number of the safer cards and higher number of the riskier cards. Multiple correlations between anxiety and depressive symptoms and performance in memory and decision making were found. These studies show impaired decision making in both CS and acromegalic patients. They selected more disadvantageous choices than advantageous choices. Whereas healthy controls gradually learned to favor the advantageous decks, patients with acromegaly and CS continued to experience large punishment throughout training. We have not found a direct relationship between poor decision making and frontal cortical thinning in CS patients, opposite to previous studies on other clinical conditions. Decision deficits on the IGT were correlated with memory deficits in CS and acromegalic patients. Moreover, acromegalic patients show affective alterations (anxiety and depressive symptoms) that influenced delayed memory and decision making.

Appropriate regulation of gene expression is necessary for correct development and homeostasis of organisms. Epigenetic mechanisms represent an additional layer of information, besides the genetic sequence, crucial for the correct functioning of each cell. Histone modifications, which modulate and are associated to transcriptional activation or repression, are a major epigenetic feature. Thanks to predictive modelling, we have studied which histone modifications relate better to enhancer or promoter function in mouse embryonic stem cells, during differentiation and in animal development. We have found that different histone modifications relate better to enhancers or promoters, respectively. We have studied the role of poised enhancers during differentiation and development. We have seen that poised enhancer activation is not exclusive of the neural lineage, but a general mechanism implicated in differentiation of every cell type. We have characterized the epigenetic landscape of Cushing’s syndrome. We have found persistent epigenetic and transcriptional alterations after long-term remission of the disease, related to a deep alteration of the circadian rhythm. These findings promise to be relevant for future therapeutic advances.
Una regulació apropiada de l’expressió gènica és necessària per a un correcte desenvolupament i homeòstasi dels organismes. Els mecanismes epigenètics representen una informació addicional, a més de la seqüència genètica, crucial per al correcte funcionament de cada cèl·lula. Les modificacions d’histones, que modulen i s’associen a activació o repressió transcripcionals, són una característica epigenètica important. Gràcies al modelatge predictiu, hem estudiat quines modificacions d’histones es relacionen millor amb la funció dels enhancers o promotors en cèl·lules mare embrionàries de ratolí, durant la diferenciació i en el desenvolupament animal. Hem trobat que modificacions d’histones diferents es relacionen millor amb enhancers o promotors, respectivament. Hem estudiat el rol dels poised enhancers durant la diferenciació i el desenvolupament. Hem vist que l’activació dels poised enhancers no és exclusiva del llinatge neural, sinó un mecanisme implicat en la diferenciació de tot tipus cel·lular. Hem caracteritzat el paisatge epigenètic de la síndrome de Cushing. Hem trobat alteracions epigenètiques i transcripcionals després d’una remissió de la malaltia a llarg termini, relacionades amb una profunda alteració del ritme circadiari. Aquestes troballes prometen ser rellevants per a futurs avenços terapèutics.

INTRODUCCIÓN: El síndrome de Cushing (SC) representa una de esas enfermedades endocrinas raras, está caracterizada por una hipersecreción de cortisol; está causada por un tumor en la hipófisis (enfermedad de Cushing), o más raramente por un tumor adrenal o ectópico. La principal causa de morbilidad y mortalidad en el SC es la enfermedad cardiovascular, incluso si los pacientes han sido tratados de manera eficaz (es decir, se ha controlado el hipercortisolismo). A pesar de las múltiples complicaciones que pueden sufrir los pacientes con SC y de la presencia de numerosos factores de riesgo cardiovascular (obesidad central, diabetes, cardiopatía isquémica, hipertensión, dislipemia, etc.) potencialmente peligrosos, no existen en la actualidad programas educativos que den respuesta a este déficit formativo. Para el paciente con SC no existe hasta ahora una atención integral que permita afrontar la complejidad de esta enfermedad y conseguir una mejora de la Calidad de Vida, la disminución en la morbi-mortalidad, el aumento del confort, bienestar y autonomía en el autocuidado Dicho aspecto permite que enfermería se situé en primera línea de actuación frente a la educación en este grupo de pacientes, a través de la elaboración y el fomento de instrumentos educativos específicos que mejoren la Calidad de vida de estos pacientes. OBJETIVOS GENERALES: Evaluar la efectividad de las sesiones educativas para los pacientes con Síndrome de Cushing operados y con seguimiento ambulatorio en el HSCSP y Hospital Clínico de Barcelona, en términos de calidad de vida, indicadores de evaluación clínica, nivel de dolor y actividad física, patrones de descanso y consumo de recursos sanitarios (seguimiento realizado entre 2010 y 2011). DISEÑO,ÁMBITO Y SUJETOS DE ESTUDIO: Se realizo un ensayo clínico Multicentrico, prospectivo, con asignación aleatoria y estratificada por centros. El ámbito de estudio se desarrollo en dos centros de referencia de Cataluña donde atienden a pacientes afectados de Síndrome de Cushing (SC), uno es el Hospital de la Santa Creu i Sant Pau (HSCSP) y el Hospital Clínico de Barcelona. La muestra final fue de 61 pacientes RECOGIDA Y ANÁLISIS DATOS: La recogida de datos se realizo a través de la Historia Clínica del paciente y analizamos variables sociodemográficas, antropométricas, analíticas y clínicas y relacionadas con el SC a lo largo de todas las sesiones educativa. Así mismo se pasaran cuestionarios al inicio y al finalizar las sesiones educativas y fueron: Calidad CushingQoL, Cuestionario Internacional Physical Activity Questionnaire (IPAQ), Cuestionario Oviedo del sueño (COS), Fagerström Test for Nicotina Dependence (FTND), Cuestionario del dolor Español (CDE), Test Diagnóstico para la Disfunción Eréctil (IIDE 5), Cuestionario sobre la función sexual femenina (Spanish versión of FSFI) , Cuestionario breve perfil de la función sexual en la mujer (B-PFSF) y Cuestionario de hábitos de vida relacionados con el sobrepeso y obesidad. RESULTADOS: Se presentan mejorías significativas en el grupo intervención con respecto al grupo control en : nivel de dolor (p=0,0525), mejoría de la actividad física (p=0,0072) y hábitos de vida (p<0,0001). Así mismo se confirma asociaciones del CushingQoL con : CushingQoL basal-final (p=0,0085), mejoría del dolor (p=0,053), actividad física (p=0,0068) y nivel de descanso o sueño (p=0,0098).CONCLUSIONES: Las sesiones educativas interrumpen el deterioro de la calidad de vida, aumenta la actividad física moderada y vigoroso, favorece la adherencia al tratamiento analgésico provocando una disminución del dolor, mejora en los patrones de descanso y una disminución de los recursos consumidos en el grupo intervención.
INTRODUCTION: Cushing's syndrome (CS) is one of those rare endocrine diseases, is characterized by hypersecretion of cortisol, is caused by a pituitary tumor (Cushing's disease), or more rarely by an adrenal tumor or ectopic. The main cause of morbidity and mortality in the SC is cardiovascular disease, even if patients have been treated effectively (ie, has controlled the hypercortisolism). Despite the many complications that patients may suffer SC and the presence of several cardiovascular risk factors (central obesity, diabetes, ischemic heart disease, hypertension, dyslipidemia, etc.). Potentially dangerous, there are currently no educational programs respond to this educational deficit. For the patient with SC so far no comprehensive care that will address the complexity of this disease and achieve an improved quality of life, decreased morbidity and mortality, increased comfort, convenience and independence in self-care Said aspect allows nursing site frontline action against education in this group of patients, through the development and promotion of specific educational tools that improve the quality of life of these patients. OBJECTIVES: To assess the effectiveness of the educational sessions for patients with Cushing's syndrome and operated outpatient follow the HSCSP and Hospital Clinic of Barcelona, in terms of quality of life, clinical evaluation indicators, level of pain and physical activity, patterns of rest and use of health resources (monitoring conducted between 2010 and 2011). DESIGN, STUDY SCOPE AND SUBJECTS: We performed a multicenter, prospective, randomized, stratified by center. The field study was conducted in two reference centers in Catalonia where care for patients suffering from Cushing's syndrome (CS), one is the Hospital de la Santa Creu i Sant Pau (HSCSP) and the Hospital Clinic of Barcelona. The final sample of 61 patients DATA COLLECTION AND ANALYSIS: Data collection was performed through the patient's history and analyze sociodemographic, anthropometric, laboratory, and clinical and related SC over all educational sessions. So pass same questionnaires at the beginning and end of the educational sessions and were CushingQoL Quality, Questionnaire International Physical Activity Questionnaire (IPAQ), Oviedo Sleep Questionnaire (COS), Fagerström Test for Nicotine Dependence (FTND), Spanish Pain Questionnaire (CDE) Diagnostic Test for Erectile Dysfunction (IIEF 5), Questionnaire on female sexual function (Spanish version of FSFI) Questionnaire brief profile of female sexual function (B-PFSF) and lifestyle questionnaire related overweight and obesity. RESULTS: We present significant improvements in the intervention group compared to control group: pain level (p = 0.0525), improvement in physical activity (p = 0.0072) and lifestyle (p<0.0001). Also confirmed CushingQoL associations with: CushingQoL basal-end (p = 0.0085), improvement in pain (p = 0.053), physical activity (p = 0.0068) and level of rest or sleep (p = 0, 0098). CONCLUSIONS: The educational sessions disrupt the deteriorating quality of life, increasing moderate and vigorous physical activity, promotes adherence analgesic causing a decrease in pain, improved rest patterns and a decrease in the resources consumed in the intervention group.

Cushing's syndrome and glucocorticoid therapy lead to central obesity, insulin resistance, and symptoms of altered energy regulation similar to those observed in the metabolic syndrome. We hypothesized that excess glucocorticoids alter energy sensing/signaling in skeletal muscle through mediation of the LKB1/AMPK signaling pathway. To test this hypothesis, three 100 mg pellets of corticosterone were implanted subcutaneously in each of nine rats for two weeks. Responses were compared with sham operated controls fed ad libitum or food restricted to produce the body weights similar to the treatment group rats. After the treatment period, animals were anesthetized and the right gastrocnemius-plantaris and soleus were removed for analysis. After tibial nerve stimulation for 5 min, the left gastrocnemius-plantaris and soleus were also removed. We assessed AMPK activity and subunit expression, as well as several metabolic indicators including ATP, creatine phosphate, creatine, glycogen, and malonyl-CoA levels in rested and stimulated gastrocnemius-plantaris and soleus muscles. We found that high levels of glucocorticoids decreased AMPKγ3 subunit expression in the gastrocnemius-plantaris. We also observed reduced AMPKα2 activity in the stimulated gastrocnemius-plantaris, but not the soleus; and that this decreased activity corresponded to a significant reduction in phosphorylated TBC1D1, a protein involved in signaling GLUT-4 translocation. Finally, in the gastrocnemius-plantaris, we also noted an increase in glycogen stores in the hypercorticosteronemic rats. Our data suggest that altered energy sensing/signaling associated with high levels of glucocorticoids may be due in part to inhibition of AMPKα2 activity and the high energy state produced by increased glycogen stores. We also conclude that high levels of glucocorticoids decrease the levels of AMPKγ3 and diminish insulin/contraction signaling through phosphorylated TBC1D1.

La síndrome de Cushing (SC), una malaltia minoritària per secreció excessiva de cortisol, s'associa a augment de morbi-mortalitat, inclús després del tractament, comparat amb població de referència i s'associa a processos d'envelliment prematur. Per altra banda, els telòmers són seqüències de DNA essencials per mantenir l'estabilitat genòmica. Sense telòmers, el material genètic es perdria després de cada divisió cel·lular; quan aquests són críticament curts, es paren les divisions cel·lulars, s'indueix la senescència i apoptosi. Per evitar l'escurçament de la longitud telomèrica (LT) es produeix un complex enzimàtic anomenat telomerasa, regulada per factors genètics, epigènetics i hormonals, com el cortisol. L'hipercortisolisme també passa en trastorns depressius majors i estrés psicosocial, on la LT és més curta que els controls. A més, l'escurçament de la LT s'ha associat a malaltia cardiovascular, factors de risc cardiovasculars (FRCV) i inflamació crónica. L'escurçament telomèric és considerat un nou marcador de risc cardiovascular i s'ha associat a biomarcadors d'inflamació. Basats en aquestes evidències, hipotetitzem que l'hipercortisolisme contribuiria a envelliment prematur induint escurçament telomèric accelerat i estaria implicat en la morbiditat persistent i conseqüències clíniques de la SC inclús anys després de la remissió bioquímica. Així mateix, l'escurçament de la LT, estaria involucrat en l'estat inflamatori de “baix grau” i l'elevada prevalença de FRCV en la SC. Per tant, aquesta recerca ha estat dissenyada per contestar aquestes hipòtesis, essent els principals objectius investigar LT a la SC comparat amb controls, i evaluar relacions entre LT, FRCV i marcadors d'inflamació. És la primera recerca que avalua LT en la SC amb una sèrie relativament llarga, una oportunitat única per explorar els efectes de l'hipercortisolisme en el manteniment telomèric. Setanta-set pacients amb SC són comparats amb 77 controls aparellats per sexe, edat i tabac. Quinze SC, també són avaluats longitudinalment, durant la malaltia activa i després de remissió de l'hipercortisolisme. S'han recollit dades clíniques i analítiques (lípids, funció adrenal...). Adiponectina, interleukina-6(IL6) i proteïna-C reactiva (PCR) foren disponibles en 32 pacients. La LT leucocitària s'ha mesurat per fragment de restricció telomèrica-Southern. La LT mitjana entre SC i controls fou similar, no obstant, en l'avaluació longitudinal després d'ajustar per l'edat, la LT fou més curta en la malaltia activa que en remissió. No s'han trobat correlacions entre altres paràmetres del cortisol, duració d'exposició a l'hipercortisolisme o curació bioquímica amb la LT. Els SC dislipidèmics tenien la LT més curta que els no dislipidèmics. Després d'ajustar per edat i índex de massa corporal, SC actius i curats amb dislipidèmia tenien la LT més curta que els no dislipidèmics. A més, major escurçament telomèric s'ha observat en pacients obesos dislipidèmics que també tenien hipertensió, comparat amb aquells amb 2 o menys FRCV. El colesterol total i els triglicèrids es correlacionaren negativament amb la LT, així com la PCR i la IL6. No s'han observat diferències en la LT segons la presència d'altres FRCV en SC i controls. Les principals conclusions són que els pacients amb SC amb hipercortisolisme controlat després d'un tractament eficaç, la LT augmenta malgat ser de mitjana tres anys més grans. Per tant, podria haver-hi una inducció de l'activitat telomerasa al desaparèixer l'hipercortisolisme, i ser un dels mecanismes pels quals aquest augment de morbi-mortalitat i envelliment biològic millorin quan la malaltia està controlada. Aquests resultats suggereixen que l'hipercortisolisme podria tenir impacte negatiu en el manteniment telomèric. A més, la LT és més curta en les SC amb dislipidèmia i menor si coexisteixen hipertensió i/o obesitat; i es correlaciona negativament amb l'elevació dels marcadors d'inflamació. Pertant, l'augment dels lípids i un estat inflamatori de “baix grau” contribuirien a escurçament telomèric, a l'envelliment prematur i augment de la morbiditat de la SC.
Cushing's syndrome (CS), a rare disease due to excessive cortisol secretion, is associated with increased morbidity and mortality, even after therapy compared to background population and is associated with premature aging processes. On the other hand, telomeres are repetitive DNA sequences, essential to maintain genomic stability. Without telomeres, genetic material could be lost after every cell division; thus, when telomeres are critically short, cell division stops and senescence and apoptosis are induced. To avoid telomere length (TL) attrition an enzymatic complex called telomerase is produced. Telomerase can be regulated by genetic, epigenetic and hormonal factors such as cortisol. Hypercortisolism also occurs in chronic depressive disorders and psychosocial stress, where TL is shorter than in controls. Moreover, TL shortening has also been associated with cardiovascular disease, cardiovascular risk factors (CVRF) and chronic inflammation processes. TL shortening is considered a novel cardiovascular risk marker, and is associated with inflammation biomarkers. Based on these previous evidences, we hypothesized that hypercortisolemia could contribute to premature ageing by inducing accelerated telomere shortening, which in turn could be implied in the persistent morbidity and clinical consequences associated with CS, even years after biochemical remission. Additionally, TL shortening, might be involved in the “low grade” inflammatory state and higher prevalence of CVRF observed in CS. Therefore, this research was designed to answer our hypothesis, being the main aims of this project to investigate TL in CS patients compared to controls, and to evaluate relationships between TL, CVRF and inflammation markers in CS. This is the first research to evaluate TL in this rare disease with a relatively large series of CS patients, which could provide a unique opportunity to examine the effects of hypercortisolism on telomere maintenance. Seventy-seven CS patients were compared with 77 gender-, age-, and smoking-matched controls. Fifteen CS were also evaluated longitudinally, during active disease and after remission of hypercortisolism. Clinical data and blood samples were collected (lipids, adrenal function...). Adiponectin, interleukin-6 (IL6) and C-reactive protein (CRP) were available in a subgroup of patients (n=32). Leukocyte TL was measured by telomere restriction fragment-Southern technique. Mean TL in CS and controls was similar, however in the longitudinal evaluation after adjustment for age, TL was shorter in active disease than after remission. No correlation was found between other circulating cortisol parameters, duration of exposure to hypercortisolism or biochemical cure and TL. We observed that dyslipidemic CS had shorter TL than non-dyslipidemic subjects. After adjustment for age and body mass index, cured and active CS dyslipidemic patients had shorter TL than non-dyslipidemic subjects. Additionally, higher TL shortening was observed in dyslipidemic obese patients who were also hypertensive, compared to those with two or less CVRF. Total-cholesterol and triglycerides negatively correlated with TL, as well as CRP and IL6. No differences in TL according the presence of other CVRF were observed in CS or the control group. The main conclusions are that individual CS patients in whom hypercortisolism is controlled after successful treatment, TL increases despite being on average 3 years older. It would appear therefore that telomerase activity would be induced once hypercortisolism disappears, and this could be one of the mechanisms by which increased morbidity, mortality and biological aging improve when disease is controlled. These preliminary results suggest that hypercortisolism might negatively impact telomere maintenance. Moreover, TL is shortened in dyslipidemic CS patients, further worsened if hypertension and/or obesity coexist and is negatively correlated with increased inflammation markers. Therefore, increased lipids and a “low-grade” inflammation may contribute to TL shortening and consequently to premature ageing and increased morbidity in CS.

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A sindrome de Cushing (SC) endogena e rara. Pacientes com SC subclinica (SCS) apresentam hipercortisolismo sem manifestacoes clinicas. SC ocorre em 2-3% de diabeticos mal controlados. Estudamos 103 pacientes adultos obesos ambulatoriais com diabetes mellitus tipo 2 para avaliar alteracoes do cortisol e SCS. Todos coletaram cortisol salivar as 23:00h e cortisol salivar e serico apos teste de supressao com 1mg de dexametasona (DST). Pacientes cujos resultados de qualquer teste estavam no quintil superior (253ng/dL, 47ng/dL e 1,8ƒÊg/dL, respectivamente para cortisol salivar 23:00h e salivar e serico pos-DST) foram reavaliados. Os valores medios desse grupo encontravam-se 2,5 vezes acima dos valores dos demais pacientes. Apos um teste confirmatorio com 2mgx2dias DST a investigacao da SC foi encerrada para 61 pacientes com todos os testes normais e 33 com apenas um teste (falso) positivo. Todos os 8 pacientes com dois testes alterados apresentaram cortisol urinario normal, mas 3 deles mostraram maior probabilidade diagnostica de SCS (hipercortisolismo e alteracoes em exames de imagem). Contudo, o diagnostico final nao pode ser confirmado por cirurgia ou patologia em nenhum deles. Embora nao confirmatorios, os resultados deste estudo sugerem que a prevalencia de SCS seja maior em populacoes de risco do que na populacao geral.
Endogenous Cushing’s syndrome (CS) is unusual. Patients with subclinical CS (SCS) present altered cortisol dynamics without obvious manifestations. CS occurs in 2-3% of obese poorly controlled diabetics. We studied 103 overweight adult outpatients with type 2 diabetes to examine for cortisol abnormalities and SCS. All collected salivary cortisol at 23:00h and salivary and serum cortisol after a 1mg dexamethasone suppression test (DST). Patients whose results were in the upper quintile for each test (253ng/dL, 47ng/dL and 1.8ìg/dL, respectively for the 23:00h and post-DST saliva and serum cortisol) were re-investigated. Average values from the upper quintile group were 2.5- fold higher than in the remaining patients. After a confirmatory 2mgx2day DST the investigation for CS was ended for 61 patients with all normal tests and 33 with only one (false) positive test. All 8 patients who had two abnormal tests had subsequent normal 24h-urinary cortisol, and 3 of them were likely to have SCS (abnormal cortisol tests and positive imaging). However, a final diagnosis could not to be confirmed by surgery or pathology. Although not confirmatory, the results of this study suggest that the prevalence of SCS is considerably higher in populations at risk than in the general population.
TEDE
BV UNIFESP: Teses e dissertações

Endogenous Cushing’s syndrome is a rare disease due to an excess of circulating cortisol. Chronic cortisol excess can lead to different comorbidities which may persist after biochemical cure, including brain volume decrease, neuropsychological impairment, mood disorders and high cardiovascular risk. This PhD thesis aims to study some of the effects of Cushing’s syndrome on the brain, and its relationship to other clinical parameters. More specifically, the aims of this thesis include analyzing cerebellar volume in patients with Cushing’s syndrome and establishing associations with neuropsychological performance, cortisol levels and other clinical parameters. On the other hand, it pretends to analyse brain white matter lesions in patients with Cushing’s syndrome and the relationship between cardiovascular risk, white matter lesions, neuropsychological performance and brain volume. Our results showed smaller cerebellar cortex volumes in active patients, but not in patients in remission, in comparison to controls. Cerebellar cortex positively correlated with visual memory performance and quality of life, and negatively correlated with age at diagnosis and triglyceride levels. Active patients had worse memory performance than controls. Both patient groups had higher anxiety and depression levels than controls. Patients in remission (but not active patients) had a higher degree of white matter lesions than controls. White matter lesions where correlated to diastolic blood pressure and duration of hypertension. Patients in remission on hydrocortisone replacement had higher level of white matter lesions than patients in remission not taking hydrocortisone. Finally, both patient groups (active and in remission) had higher cardiovascular risk than controls. Cardiovascular risk negatively correlated with cognitive function and cerebellar volume in patients in remission. In conclusion, Cushing’s syndrome leads to different comorbidities in the two phases of the disease (active and in remission). Some of the alterations found in active patients may be, at least, partially reversible, although the cardiovascular risk associated with Cushing’s syndrome may lead to further comorbidities in the future if it is not controlled. These data highlight the importance of providing psychological support to the patients if necessary and controlling cardiovascular risk in order to prevent brain damage and to reduce the risk of stroke or heart attack.
El síndrome de Cushing endógeno es una enfermedad rara debida a un exceso de cortisol circulante. El exceso crónico de cortisol puede provocar una serie de alteraciones que no en todos los casos revierten tras la curación hormonal, y que incluyen disminución del volumen cerebral, alteraciones neuropsicológicas y del estado de ánimo y riesgo cardiovascular elevado. Esta tesis pretende estudiar algunos de los efectos que provoca el síndrome de Cushing a nivel cerebral, analizando su relación con otros parámetros clínicos. Concretamente, los objetivos de la tesis incluyen por un lado analizar el volumen cerebelar en los pacientes con síndrome de Cushing, así como establecer su relación con el rendimiento neuropsicológico, los niveles de cortisol y otros parámetros clínicos. Por otro lado, se pretende analizar la presencia de lesiones de sustancia blanca cerebral en los pacientes con síndrome de Cushing y la relación entre riesgo cardiovascular, lesiones de sustancia blanca, rendimiento neuropsicológico y volumen cerebral. Se encontraron menores volúmenes del córtex cerebelar bilateral en los pacientes activos, pero no en los pacientes curados, en comparación con los controles. El córtex cerebelar correlacionó positivamente con el rendimiento en memoria visual y la calidad de vida y negativamente con la edad en el momento del diagnóstico y el nivel de triglicéridos circulantes. Los pacientes activos presentaban peor rendimiento a nivel de memoria, y ambos grupos de pacientes presentaban mayores niveles de ansiedad y depresión que los controles sanos. Por otro lado, los pacientes en remisión, pero no los pacientes activos presentaron mayor nivel de lesiones de sustancia blanca cerebral que los controles sanos. Estas lesiones estaban relacionadas con los niveles de tensión diastólica y la duración de la hipertensión. Los pacientes en remisión que tomaban hidrocortisona presentaban mayor nivel de lesiones que los pacientes en remisión que no tomaban el fármaco. Finalmente ambos grupos de pacientes (activos y en remisión) presentaban mayor riesgo cardiovascular que los controles sanos. El riesgo cardiovascular correlacionó negativamente con la función cognitiva y el volumen cerebral en los pacientes en remisión. En conclusión, el síndrome de Cushing determina diferentes comorbilidades en las distintas fases de la enfermedad. Algunas de las alteraciones halladas en los pacientes activos podrían ser al menos parcialmente reversibles, aunque el riesgo cardiovascular asociado a la enfermedad puede llevar a otras comorbilidades en el futuro si no se controla. Estos datos remarcan la importancia de proporcionar un soporte psicológico a los pacientes en caso necesario y de controlar el riesgo vascular para prevenir la posible afectación cerebral futura y reducir el riesgo de complicaciones cardiovasculares.

Dissertação de Mestrado Integrado em Medicina Veterinária
A abordagem ao diagnóstico do hiperadrenocorticismo (Síndrome de Cushing) pressupõe a interacção de um conjunto de exames complementares sendo que, os testes funcionais desempenham um papel muito importante a esse nível. Após descrição geral da doença, na presente dissertação, é apresentado um estudo retrospectivo acerca do diagnóstico do hiperadrenocorticismo em 8 canídeos. Conjugando uma boa anamnese, um exame clínico e as alterações, mesmo inespecíficas, dos perfis laboratoriais, a intuição clínica constitui o principal ponto de partida para um bom plano de diagnóstico. A este nível distinguem-se etapas distintas: a confirmação do hiperadrenocorticismo e a pesquisa do seu diagnóstico etiológico. Para confirmação da doença há a destacar três tipos de testes funcionais: o Rácio Cortisol-Creatinina Urinário (RCCU), o Teste de estimulação pela hormona adrenocorticotrófica (ACTH) e o teste de supressão pela dexametasona (em dose baixa). Por seu lado, o diagnóstico etiológico poderá ser efectuado recorrendo ao doseamento de ACTH endógena ou ao teste de supressão pela dexametasona (em dose alta). Ainda que o plano de diagnóstico pressuponha duas etapas, este estudo permitiu concluir que, por vezes, é possível diagnosticar a doença recorrendo apenas a um tipo de teste (como o teste de supressão pela dexametasona em dose baixa) ou por associação de testes numa única abordagem (como a combinação RCCU e o teste de supressão pela dexametasona em dose alta). Tendo em conta a necessidade de exploração do quadro lesional da doença, o recurso subsequente à imagiologia é imperativo, razão pela qual a ultrasonografia constitui uma das principais técnicas de escolha aquando do diagnóstico de hiperadrenocorticismo. Dada a dificuldade em criar linhas gerais fixas para o diagnóstico do hiperadrenocorticismo, a utilização e combinação de testes funcionais deverá ser adequada a cada caso clínico cabendo ao Médico Veterinário a realização de uma correcta aplicação dos mesmos.
ABSTRACT Several functional tests play a major role in the diagnosis of Hyperadrenocorticism. Examining the disease retrospectively as it presented in eight dogs sheds light on the practitioner’s multimodal means of diagnosis, their utility and efficacy. A good history, clinical examination and baseline laboratorial data may lead the practitioner to suspect a case of hyperadrenocorticism. To confirm these suspicions, the following diagnostic tests are available: the Urine Cortisol:Creatinine Ratio (UCCR), the Corticotropin (ACTH) stimulation test and the Low-Dose Dexamethasone Suppression Test. Once hyperadrenocorticism is confirmed, the practitioner must then determine whether the condition is primarily pituitary-dependent, or adrenal-dependent. This etiologic diagnosis can be made using the Plasma Endogenous ACTH Concentration or the High-Dose Dexamethasone Suppression Test. Although both a diagnosis of hyperadrenocorticism should be made as well as a determination of the primary organ responsible for disease, by means of two different testing methods as aforementioned, sometimes, it is possible to diagnose the hyperadrenocorticism with only one functional test (as the low-dose dexametasone suppression test) or with a test’s association (as the combined Urinary Cortisol:Creatinine Ratio and the High-Dose Dexamethasone Suppression Test). Imaging also plays an important role in revealing the pattern of the lesion and characterizing the disease. In fact, ultrasonography represents the most used resource to diagnose the hyperadrenocorticism. Recognising the difficulty to prepare diagnostic guidelines for hyperadrenocorticism, the aforementioned functional tests should be used according with individual clinical cases and the practitioner should recognize the advantages and disadvantages of each one of them.

INTRODUÇÃO: O diagnóstico diferencial da síndrome de Cushing (SC) ACTH-dependente é um dos maiores desafios da endocrinologia, devido ao comportamento clínico e laboratorial semelhante de alguns tumores carcinóides com a doença de Cushing (DC). Assim, testes dinâmicos de secreção de ACTH e cortisol têm sido utilizados com o objetivo de identificar respostas que sejam preditivas e específicas no diagnóstico diferencial. O padrão dessas respostas é atribuído à superexpressão de receptores; entretanto, poucos estudos foram realizados para comprovar tal associação. O objetivo deste estudo foi verificar se a secreção de ACTH e cortisol em resposta aos testes do CRH humano (hCRH), da desmopressina, e do peptídeo liberador do GH (GHRP-6) é dependente da magnitude de expressão dos seus respectivos receptores (CRHR1, AVPR1B e GHSR-1a) em amostras de tumores de pacientes portadores da SC ACTH-dependente. CASUÍSTICA E MÉTODOS: Entre 2002 e 2004, foram avaliados 22 pacientes (20 com DC e dois com Secreção Ectópica de ACTH [SEA], carcinóide de pulmão e timo), idade mediana de 32 anos (15-54 anos), sendo 18 do sexo feminino e quatro do sexo masculino, provenientes da Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina da Universidade de São Paulo. Os pacientes foram submetidos aos testes do hCRH (100 µg), desmopressina (10 µg) e GHRP-6 (1 µg/kg) com dosagens de ACTH e cortisol e também de GH no caso do GHRP-6. Vinte e um indivíduos controles, pareados por sexo e idade, foram submetidos ao teste do GHRP-6. Durante o ato operatório, fragmentos de tumor foram coletados para posterior extração do RNA total. O estudo da expressão foi feito por meio de PCR quantitativo em tempo real dos genes CRHR1, AVPR1B e GHSR-1a em relação ao GAPDH. Fragmentos de tecidos normais (hipófise, pulmão e timo) procedentes de necropsias foram utilizados como controles. RESULTADOS: Observamos maior expressão de GHSR-1a nos pacientes responsivos ao GHRP-6, tanto naqueles com DC quanto no paciente com carcinóide pulmonar. Não houve maior expressão dos receptores CRHR1 e AVPR1B nos pacientes com DC responsivos aos respectivos testes, observando-se, no entanto, uma forte associação entre respostas in vivo e a expressão desses receptores nos pacientes com SEA. As concentrações de ACTH e cortisol induzidas pela administração de GHRP-6 foram mais elevadas nos pacientes com DC quando comparados aos controles, havendo, no entanto, superposição entre as respostas. Observamos também elevação dos níveis séricos de GH nos indivíduos controles e, em menor intensidade, nos pacientes com DC. CONCLUSÕES: Houve maior expressão do receptor GHSR-1a em pacientes com SC ACTH-dependente responsivos ao GHRP-6, estabelecendo-se uma relação direta entre a expressão do receptor e a resposta in vivo ao secretagogo, tanto em pacientes com DC quanto nos portadores de SEA. Uma associação entre a expressão dos receptores CRHR1 e AVPR1B com a resposta in vivo aos respectivos secretagogos foi observada nos pacientes com SEA e não nos pacientes com DC. Tendo em vista a resposta ao GHRP-6 em paciente com SEA, limita-se o uso desse peptídeo no diagnóstico diferencial da SC ACTH-dependente.
INTRODUCTION: The differential diagnosis of ACTH-dependent Cushing\'s syndrome (CS) is one of the major challenges in endocrinology, especially in view of the similar clinical and laboratorial behavior between some carcinoid tumors and Cushing\'s disease (CD). Hence, dynamic tests of ACTH and cortisol release have been carried out with the aim to identify predictive and specific responses for this differential diagnosis. The pattern of the responses has been attributed to receptors overexpression, yet few studies have been undertaken to confirm such association. The aim of the present study was to verify whether ACTH and cortisol release in response to human CRH (hCRH), desmopressin, and GH releasing peptide (GHRP-6) depends on the magnitude of expression of their respective receptors (CRHR1, AVPR1B e GHSR-1a) in samples of tumors from patients with ACTH-dependent CS. PATIENTS AND METHODS: Twenty two patients (20 with CD and 2 with Ectopic ACTH Syndrome [EAS], lung and thymus carcinoid tumors) from the Division of Endocrinology and Metabolism of University of Sao Paulo School of Medicine, median age of 32 years (15-54 years), being 18 females and 4 males, were evaluated between 2002 and 2004. The patients were submitted to dynamic tests with hCRH (100 µg), desmopressin (10 µg) and GHRP-6 (1 µg/kg), with measurement of ACTH and cortisol levels, and also of GH in the case of GHRP-6 stimulation. Twenty one age and sex-matched controls were submitted to the GHRP-6 test. During surgery, tumor fragments were collected and subsequently processed for total mRNA extraction. Gene expression of CRHR1, AVPR1B and GHSR-1a relative to GAPDH was quantitated by real-time qPCR. Tissue samples of normal pituitary, lung and thymus from necropsy were used as controls. RESULTS: Greater expression of GHSR-1a was observed in patients responsive to the GHRP-6 test, both in those with CD and in the one with pulmonary carcinoid tumor. No enhanced expression of receptors CRHR1 and AVPR1B was found in CD patients responsive to the respective dynamic tests, yet there was a strong association between the in vivo responses and the expression of those receptors in the two patients with EAS. GHRP-6 -induced ACTH and cortisol release was more marked in patients with CD as compared with control individuals, but there was overlap of the responses. GH stimulation was observed in control individuals and, to a lesser extent, in patients with CD. CONCLUSIONS: There was greater expression of GHSR-1a in patients with ACTH-dependent CS who responded to GHRP-6, establishing a direct association between receptor gene expression and the in vivo response to the secretagogue in both CD patients and those with EAS. An association between expression of CRHR1 and AVPR1B and the in vivo response to the respective secretagogues was found in patients with EAS but not in those with CD. In view of the response to GHRP-6 in a patient with EAS, we considered the use of this peptide in the differential diagnosis of ACTH-dependent CS of limited value.

We present the case of a 7-month-old baby with Cushing’s disease due to an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma combined with cells producing thyreotropin-secreting hormone (TSH). In MRI scans, a contrast-enhancing lesion was seen inside the pituitary fossa, and it extended into the suprasellar region. On the assumption of a pituitary adenoma, surgery was performed. Corresponding with biochemical findings, histopathological evaluation revealed an ACTH- and TSH-producing tumor. Genetic analysis did not demonstrate an alteration at codon 201 (Arg) and 227 (Glu). To our knowledge, this is the first case described in a child of this age
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich

Introdução: Hiperplasia Macronodular Adrenal Primária (PMAH) é uma causa rara de Síndrome de Cushing (SC), caracterizada por macronódulos funcionantes geralmente acometendo ambas as glândulas adrenais. Recentemente, o exame 18F-FDG PET/CT detectou três pacientes com PMAH apresentando captação aumentada de 18F-FDG. No entanto, ainda não foi elucidado o mecanismo pelo qual a PMAH apresentaria uma alta captação de 18F-FDG. Objetivos: Os objetivos deste estudo foram investigar se a expressão de GLUT1, HK1, HK2 e/ou HK3 estão relacionados à alta captação de 18F-FDG na PMAH e comparar estas expressões com tecidos adrenais provenientes de pacientes com AAC e CAA. Métodos: 12 pacientes com PMAH que realizaram 18F-FDG-PET/CT, previamente à adrenalectomia. A captação de 18F-FDG foi quantificada como maximum standardized uptake value (SUVmax). Expressão do RNAm foi investigada através de RT-PCR e a expressão proteica através de técnicas de imunoistoquímica. Expressão gênica e proteica dos pacientes com PMAH foi comparada com 15 pacientes com AAC e 10 pacientes com CAA. As correlações foram realizadas através do teste de coeficiente de correlação de Pearson e as comparações, através do teste Kruskal-Wallis, seguido do ajuste de Dunn. Significância estatística foi considerada quando p < 0.05. Resultados: Todos os pacientes com PMAH apresentaram alta captação de 18F-FDG, cujo SUVmáx variou de 3.3 a 8.9 e o tamanho do maior nódulo variou de 3.5 a 15cm. Foi observada forte correlação positiva entre o tamanho do maior nódulo e o SUVmáx nos pacientes com PMAH. No entanto, não foi estabelecida correlação entre a expressão de GLUT1, HK1, HK2 e HK3 e o SUVmáx nos pacientes com PMAH. A expressão do SLC2A1 e HK2 foi significativamente maior nos pacientes com CAA do que nos pacientes com AAC e PMAH. Conclusões: A captação aumentada de 18F-FDG na PMAH não está relacionada ao aumento da expressão de GLUT1, HK1, HK2 e HK3. Estudos futuros serão necessários para elucidar a via glicolítica que é responsável pelo metabolismo da glicose na PMAH
Introduction: Primary macronodular adrenal hyperplasia (PMAH) is a rare cause of Cushing\'s syndrome, characterized by functioning adrenal macronodules and increased cortisol production. Recently, integrated 18F-FDG-PET/CT examination revealed an increased 18F-FDG uptake in patients with PMAH. However, it is still unclear the mechanism by which PMAH would present with a high 18F-FDG uptake in PET/CT. Objectives: The aim of this study was to investigate whether GLUT1, HK1, HK2 and/or HK3 expression would account for the high18F-FDG uptake in PMAH and compare these expressions with ACA and ACC adrenal tisuue. Methods: 12 patients undergoing adrenalectomy for PMAH with previous 18F-FDG-PET/CT. 18F-FDG uptake was quantified as the maximum standardized uptake value (maxSUV). mRNA expression was investigated through quantitative RT-PCR and protein expression was investigated using immunohistochemical studies. PMAH gene and protein expression were compared to 15 patients with ACA and 10 with ACC. Correlations were performed through Pearson\'s correlation coefficient test and comparisons through Kruskal-Wallis test, followed by Dunn adjust. Statistical significance was considered when p < 0.05. Results: All patients with PMAH presented with high 18F-FDG uptake, the range of SUVmax in these patients varied from 3.3 to 8.9 and the nodule sizes varied from 3.5 to 15 cm. There was a strong positive correlation between the nodule size and 18F-FDG uptake. However, no correlation could be established between gene and protein expression of GLUT1, HK1, HK2 and HK3 and 18F-FDG uptake. SLC2A1 and HK2 expression was significantly higher in patients with CCA than in patients with AAC and PMAH. Conclusions: Increased 18F-FDG uptake in PMAH does not arise from the overexpression of GLUT1, HK1, HK2 or HK3. Further investigation is required to elucidate the glycolytic pathway involved in glucose metabolism in PMAH

Dissertação de Mestrado Integrado em Medicina Veterinária
Com o aumento da esperança média de vida do cavalo, o aparecimento de doenças como a disfunção da pars intermedia da pituitária (DPIP), também conhecida por síndrome de Cushing, tem-se tornado mais frequente. A laminite é a principal consequência desta doença e manifesta-se sobretudo sob a forma subclínica, com evolução progressiva e carácter crónico. A manifestação clínica de laminite é incapacitante para o cavalo, afetando o seu bem-estar e a sua atividade física. O objetivo deste estudo preliminar foi encontrar fatores que se relacionassem com a rotação da terceira falange (P3) e possibilitassem prever a ocorrência de laminite em cavalos com um fenótipo compatível com DPIP, antecipando a manifestação clínica desta doença e permitindo prevenir as suas consequências. Neste estudo foram incluídos oito cavalos das zonas de Lisboa e Santarém, caracterizados através da realização de um exame clínico geral e específico, um questionário aos proprietários, seguido de recolha de amostras de sangue para hemograma e determinação da concentração plasmática de hormona adrenocorticotrópica (ACTH), bem como para determinação dos níveis séricos de insulina e de glucose plasmática após realização de um teste de glucose oral. Para investigar a existência de laminite foi realizada uma avaliação radiográfica e macroscópica das extremidades distais e a medição da pressão arterial de forma indireta, a partir da artéria coccígea, recorrendo à utilização de um esfigmomanómetro. A partir dos dados obtidos neste estudo foi possível identificar uma correlação positiva, segundo o método de Spearman, entre o aumento da pressão arterial (sistólica e diastólica) e a ocorrência de rotação da terceira falange. Os resultados deste estudo apontam também para a possível existência de um valor de rotação da terceira falange a partir do qual são notáveis alterações macroscópicas da estrutura do casco. Pelo facto de não existirem intervalos de referência para avaliação da concentração basal plasmática da ACTH específicos para a latitude de Portugal, três dos oito equinos obtiveram um resultado duvidoso, reforçando a importância da realização de estudos futuros para obtenção de intervalos adequados.
ABSTRACT - Preliminary study in order to identify potential predictors of laminitis in horses aged ≥ 15 years, with a phenotype for pituitary pars intermedia dysfunction (PPID) - The equine average life expectancy has been increasing and with it the frequency of pathologies like pituitary pars intermedia dysfunction (PPID), also known as equine Cushing’s syndrome. A chronic and progressive appearance of laminitis is the most clinically relevant consequence of this pathology and it drastically affects the horse’s well-being and performance. This preliminary study focused on finding factors related to the rotation of the third phalanx (P3), which could potentially anticipate the occurrence of laminitis in horses with a phenotype for PPID, making it possible to prevent its clinical manifestation and its consequences. This study included eight horses from the districts of Lisbon and Santarém, Portugal. The characterization process of the sample included a general and specific clinical examination, a questionnaire for the owners, followed by blood sample collection for a complete blood count and plasmatic adrenocorticotropic hormone (ACTH) concentration measurement, as well as for measuring the serum insulin and plasma glucose levels after an oral sugar test. To investigate the presence of laminitis we performed a radiological and macroscopic evaluation of the distal extremities and measured the arterial blood pressure in the coccygeal artery (indirect method) with the use of a sphygmomanometer. From the data collected in this study we observed a positive correlation, according to Spearman’s rank correlation coefficient, between the raise in arterial (systolic and diastolic) pressure and the occurrence of rotation of the third phalanx. The results of this study also point to the existence of a possible cut-off value for P3 rotation from which macroscopic deformities of the hoof occur. Because there aren’t specific reference intervals for the evaluation of basal ACTH for Portugal’s latitude, three out of eight horses presented dubious results, reinforcing the importance of future studies to define appropriate reference intervals.
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We present the case of a 7-month-old baby with Cushing’s disease due to an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma combined with cells producing thyreotropin-secreting hormone (TSH). In MRI scans, a contrast-enhancing lesion was seen inside the pituitary fossa, and it extended into the suprasellar region. On the assumption of a pituitary adenoma, surgery was performed. Corresponding with biochemical findings, histopathological evaluation revealed an ACTH- and TSH-producing tumor. Genetic analysis did not demonstrate an alteration at codon 201 (Arg) and 227 (Glu). To our knowledge, this is the first case described in a child of this age.
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

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Introdução: Existem quatro medicações disponíveis como tratamento complementar da doença de Cushing: pasireotida, cabergolina, cetoconazol e mifepristone. Contudo, não existe um consenso sobre qual medicação é mais efetiva e segura para o controle dessa neoplasia. Objetivo: comparar a segurança e a efetividade destas quatro medicações no controle de indivíduos com doença de Cushing não curados pela cirurgia, recidivados ou que não puderam realizar esse procedimento. Metodologia: para isso foi realizada uma revisão sistemática de acordo com a metodologia da colaboração Cochrane, no qual seriam incluídos estudos randomizados das comparações destas medicações entre si e fossem avaliados como desfechos primários a remissão do hipercortisolismo por meio da normalização do cortisol livre urinário (CLU), melhora na qualidade de vida, frequência de eventos adversos, melhora das comorbidades e sintomas associadas a essa doença. Foram realizadas três estratégias de busca adaptadas as bases eletrônicas de saúde: EMBASE, PubMed e CENTRAL-Cochrane. Os estudos foram selecionados por dois revisores independentes e os dados extraídos a partir de um formulário padronizado. Resultados: Foram incluídos dez estudos randomizados, um comparando cabergolina versus cetoconazol, e nove avaliando doses diferentes do pasireotida, sendo que oito se referiam ao mesmo protocolo de estudo. A normalização do CLU em seis meses de tratamento foi inferior na cabergolina em relação ao cetoconazol (33% versus 62,5%, respectivamente), porém, com uma qualidade da evidência muito baixa, essa diferença não foi significativa (RR: 0,53, IC 95%: 0,15-1,87). Comparando a dose maior do pasireotida (900μg subcutâneo duas vezes ao dia ou 30mg de liberação lenta intramuscular a cada 28 dias) com uma dose menor (600μg ou 10mg), a normalização do CLU em seis e 12 meses foi de 29% vs 21% e 25% vs 24%, respectivamente, a metanálise não mostrou diferença significativa entre os grupos (RR 1,35, IC 95%: 0,85 a 2,14 e RR 1,12, IC 95% 0,15 a 1,87, respectivamente). Quanto a segurança, ambas as doses do pasireotida ocasionaram diabetes mellitus, sem diferença ente os grupos (frequência de 25% vs 24%, RR 1,12 IC 95%: 0,44 a 2,89). Nessa mesma comparação, houve melhora na qualidade de vida, dos sintomas e das complicações associadas, também sem diferença significativa entre as doses. Conclusão: um único estudo comparativo entre duas drogas foi encontrado (cabergolina versus o cetoconazol), e a taxa de normalização do CLU em seis meses não foi significativamente diferente entre os grupos. A comparação de duas doses do pasireotida (uma dose maior versus uma menor) em seis meses, sem ajuste de dose e 12 meses com ajuste também não foi significativamente diferente. Em relação à segurança, em 12 meses de seguimento, o evento adverso Diabetes Mellitus ocorreu em 25% dos pacientes que utilizaram o pasireotida. Para todos esses achados a qualidade da evidência de acordo com o GRADE (Grading of Recommendations Assessment, Development, and Evaluation foi baixa.
There are four medications available for the medical treatment of Cushing’s disease: pasireotide, cabergoline, ketoconazole and mifepristone. However, there is no consensus as to the most effective or safe medication. Objective: The aim of this systematic review was to compare these four medications in patients with Cushing’s disease who did not achieve disease control after transsphenoidal surgery, in recurrence cases, or in individuals no candidate for surgery. Methodology: We performed a systematic review according to Cochrane collaboration to include randomized studies comparing these four medications. The primary outcomes were normalization of urinary free cortisol (UFC), quality of life, adverse events and improvement of comorbidities and symptoms related to this condition. Search strategies were applied to the following electronic database: Medline, EMBASE and CENTRAL - Cochrane. Studies were selected by two independent reviewers and data were extracted using a standard form. Results: Ten studies were included, one that compared cabergoline versus ketoconazole, and nine that performed indirect comparisons between two different dosages of pasireotide, although eight referred to the same study protocol. Normalization of UFC in six months of treatment with cabergoline was worst than with ketoconazole (33% versus 62.5%, respectively). However, in the meta-analysis this difference was not statistically significant (RR: 0.53, 95% CI: 0.15- 1.87). Pasireotide 900μg/30mg when compared to pasireotide 600μg/10mg to the normalization of UFC in six and 12 months, presented cure rates of 29% vs 21% e 25% vs 24%, respectively. The meta-analysis did not show significant difference between the groups in six (RR: 1.35 95%CI: 0.85 a 2.14) and in 12 months (RR: 1.12, 95%CI 0.15 a 1.87). Concerning safety, including both groups, 25% of patients using pasireotide presented Diabetes Mellitus without significant difference between the groups (RR: 1.12 95%CI (0.44 a 2.89). Pasireotide was associated with improvement of quality of life, symptoms and comorbidities, although with non-significant differences between dosages. Conclusion: we found a single comparative study between two drugs (cabergoline versus ketoconazole), and the UFC normalization rate at six months was not significantly different between the groups. The comparison of two doses of pasireotide (one higher versus one lower dose) at six months, no dosis adjustment, and 12 months after dosis adjustment was also not significantly different. Regarding safety, at 12 months of the follow-up, the adverse event Diabetes Mellitus occurred in 25% of the patients who used pasireotide. For all these findings the quality of evidence according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was very low.

Introdução: A doença de Cushing apresenta elevada morbimortalidade. Seu tratamento de escolha é a cirurgia transesfenoidal que possui resultados satisfatórios em cerca de 70% dos casos. Na doença persistente ou recorrente, reabordagem cirúrgica, radioterapia e adrenalectomia bilateral podem ser realizadas, porém, essas opções apresentam como desvantagens o desenvolvimento de hipopituitarismo e a dependência de terapia de reposição. Até o momento, nenhuma droga tem se mostrado eficaz no tratamento do corticotrofinoma. Os esquemas terapêuticos mais eficazes são os inibidores da esteroidogênese que não atuam no tumor hipofisário. Objetivos: avaliar o efeito do octreotide e da cabergolina administrados isoladamente e em associação nas concentrações urinárias de cortisol e plasmáticas de ACTH em pacientes com corticotrofinomas; correlacionar esse efeito com a expressão tumoral dos receptores SSTR2, SSTR5 e DRD2; correlacionar a expressão tumoral desses receptores através de RT-PCR quantitativa e imunohistoquímica; avaliar se o uso prévio dessas drogas altera a expressão desses receptores. Casuística e Métodos: grupo controle composto por 11 pacientes (10 mulheres e 1 homem) entre 21 e 43 anos sem tratamento prévio à neurocirurgia e um grupo tratado formado por 11 pacientes (2 homens e 9 mulheres) entre 22 e 53 anos que receberam o seguinte tratamento antes da cirurgia: coleta de três amostras de cortisol urinário e ACTH plasmático, seguida da introdução de octreotide 100 g, subcutâneo, 8/8h durante 30 dias e nova coleta de três amostras de cortisol urinário e ACTH plasmático. Em seguida, iniciou-se a cabergolina 0,5 mg via oral 3 vezes na semana durante 30 dias com nova coleta de três amostras de cortisol urinário e ACTH plasmático. A seguir, o octreotide era associado por mais 30 dias com nova coleta de três amostras de cortisol urinário e ACTH plasmático. Resultados: Os valores de cortisol urinário apresentaram queda significante após o uso de cabergolina isolada (P = 0,016) e em associação ao octreotide (P = 0,012). A eficácia do tratamento combinado não foi maior que a da cabergolina isolada. Os valores de ACTH plasmático não revelaram diferença significante durante o tratamento e não se correlacionaram com os valores de cortisol. A média de expressão do mRNA do gene DRD2 foi maior no grupo tratado (1,170 ± 0,417) quando comparada ao grupo controle (0,776 ± 0,252) (P = 0,036). Houve dissociação entre os conteúdos de mRNA e da proteína desse receptor. Não foi possível analisar a expressão do mRNA do gene SSTR5, pois o tratamento das amostras com DNAse causou degradação do RNA. A imunorreatividade para SSTR5 esteve presente em todos os pacientes e não foi alterada pelo tratamento prévio. Não houve diferença estatística na expressão do gene SSTR2 entre os grupos controle (1,253 ± 0,511) e tratado (1,267 ± 0,386) bem como diferença significante da imunoexpressão do SSTR2 entre os grupos. Houve correlação entre os conteúdos de mRNA e da proteína desse receptor (P = 0,021). Não houve correlação entre a expressão dos receptores analisados e a resposta ao octreotide e à cabergolina isoladamente ou em associação. Conclusões: a cabergolina isolada representa opção terapêutica na doença de Cushing persistente ou recorrente. A associação de octreotide na dose estudada por 30 dias não foi mais eficiente em reduzir o cortisol urinário. A resposta a essas drogas não está relacionada à expressão dos receptores SSTR2, SSTR5 e DRD2
Introduction: The Cushings disease presents high morbimortality. Its treatment of choice is transsphenoidal surgery which has satisfactory results in about 70% of cases. In persistent or recurrent disease, a second transsphenoidal surgery, radiotherapy and bilateral adrenalectomy can be carried through, however, these options present disadvantages as development of hypopituitarism and lifelong dependence on hormone replacement therapy. Presently, no drug has shown efficacy in corticotrophinomas treatment. The most efficient agents are the inhibitors of steroidogenesis which have no effect at pituitary tumor. Objectives: To evaluate isolated octreotide and cabergoline effects and their association on plasma ACTH and urinary cortisol in Cushings disease patients, to correlate this effect with tumoral expression of SSTR2, SSTR5 and DRD2 receptors; to correlate tumoral expression of these receptors by quantitative RT-PCR and immunohistochemistry; to evaluate whether these drugs modifies these receptors expression. Patients and methods: control group with 11 patients (10 women and 1 man) between 21 and 43 years who underwent pituitary surgery with no prior treatment and a treated group with 11 patients (2 men and 9 women) between 22 and 53 years that received the following treatment before surgery: : after three baseline urinary cortisol samples and one plasma ACTH sample, patients received octreotide 100 g, subcutaneous 8/8h for 30 days collecting three urinary cortisol samples and one plasma ACTH. After that, cabergoline was introduced 0,5 mg 3x/week for 30 days collecting three urinary cortisol samples and one plasma ACTH sample. Then, octreotide was associated to cabergoline for another 30 days followed by three urinary cortisol and one plasma ACTH sample. Results: Urinary cortisol concentrations significantly decreased after isolated and combined cabergoline use (P = 0,016 and P = 0,012, respectively). Combined treatment efficacy was not greater than isolated cabergoline administration. Plasma ACTH did not change statistically during treatment and did not correlate with urinary cortisol. The average of DRD2 gene expression was higher in control group (0,776 ± 0,252) in relation to treated group (1,170 ± 0,417) (P = 0,036). It had dissociation between mRNA and protein contents of this receptor. SSTR5 gene mRNA expression was not analyzed due to RNA degradation after DNAse tissue treatment. SSTR5 immunoreactivity was present in all patients and it was not modified by previous treatment. No statistic difference was observed between SSTR2 gene expression in control group (1,253 ± 0.511) and in treated group (1,267 ± 0,386). There was no significant difference in SSTR2 immunoexpression between groups. It had correlation between the mRNA and protein contents of this receptor (P = 0.021). No significant relationship was found between hormonal response to isolated and combined therapy and receptors mRNA expression levels. Conclusions: cabergoline represents therapeutical option in persistent or recurrent Cushings disease. Octreotide-cabergoline association in the studied dosage and for the period of 30 days was not more efficient in eliciting urinary cortisol reduction. The responsiveness to these drugs did not correlate to SSTR2 and DRD2 mRNA expression

L’hyperplasie bilatérale macronodulaire des surrénales (HBMS) conduit au développement de nodules corticosurrénaliens bilatéraux entraînant un syndrome de Cushing diagnostiqué souvent au cours de la cinquième décennie. L’étiologie de cette maladie n’était que partiellement connue mais le caractère bilatéral de l’atteinte surrénalienne et l’observation de cas familiaux suggéraient, au début de ce travail, une origine génétique. L’analyse de l’ADN tumoral et leucocytaire d’une série de 33 patients opérés a permis de mettre en évidence chez 25% des patients une perte d’hétérozygotie neutre en nombres de copies (LOH) de tout le bras court du chromosome 16 (16p) au niveau du tissu surrénalien. Un séquençage complet du génome de 5 patients (ADN germinal et tumoral) a permis de mettre en évidence une mutation du gène ARMC5 localisé en 16p pour 4 patients. Le séquençage direct des parties codantes d’ARMC5 à partir de l’ADN somatique et germinal de l’ensemble des patients opérés de la cohorte a montré qu’au total, 55% des patients avaient une mutation d’ARMC5. L’inactivation du gène se fait selon la théorie de Knudson (un événement germinal inactivant le premier allèle associé à un autre événement somatique inactivant le second allèle) ce qui laisse supposer qu’ARMC5 est un gène suppresseur de tumeur. L’analyse de la cohorte d’HBMS de nos collaborateurs américains au National Institute Health (laboratoire de CA. Stratakis, Bethesda, USA) a permis de confirmer que les mutations d’ARMC5 étaient un événement fréquent. Des variants de ce gène sont aussi associés à l’hypertension à rénine basse chez les patients noirs-américains. Afin de déterminer des corrélations génotype-phénotype, notre cohorte initiale a été élargie pour constituer une série consécutive de 98 cas index de patients présentant des formes légères à sévères de la maladie, opérées ou non. Vingt-quatre patients (25%) présentaient une altération d’ARMC5. Par ailleurs, 31 nodules surrénaliens de 19 patients ont été analysés en somatique. Le second événement était une mutation dans 68% des cas et une LOH du locus pour les 32% restant. Chez un même patient, le second événement était différent dans chaque nodule présenté. Les patients mutés avaient un syndrome de Cushing plus sévère cliniquement et biologiquement par rapport aux patients non mutés. La taille de leurs surrénales étaient plus grandes avec un plus grand nombre de nodules. Les patients mutés étaient aussi plus jeunes au diagnostic et plus souvent hypertendus. Ces patients étaient ainsi plus souvent opérés. La fonction de la protéine ARMC5 n’était pas connue lors de son identification comme gène de l’HBMS. In vitro, la surexpression du gène sauvage induit l’apoptose. La surexpression des mutants faux-sens et du mutant p.F700del retrouvés chez les patients entraîne moins d’apoptose qu’ARMC5 sauvage. La protéine ARMC5 contient des domaines Armadillo et BTB, connus pour être impliqués dans l’interaction protéine-protéine. En physiologie, l’ACTH stimule la production d’AMPc et la voie de la protéine kinase A (PKA) est impliquée dans différentes pathologies corticosurrénaliennes. Nous avons pu montrer qu’ARMC5 interagissait avec la sous-unité catalytique alpha de la PKA. L’invalidation d’ARMC5 conduit in vitro à une diminution de l’expression d’enzymes de la stéroïdogénèse, de la production de cortisol et une diminution de l’activité PKA. Ainsi, l’hypothèse pour expliquer les HBMS liées à une inactivation d’ARMC5 est que la perte d’apoptose conduit à une hyperplasie nodulaire du tissu corticosurrénalien et que, même si la production de cortisol est diminuée à l’échelle unicellulaire, l’effet de masse global conduit au total à un hypercortisolisme. Nos travaux ont donc identifié et caractérisé un premier gène causal, ARMC5, fréquemment impliqué dans l’HBMS et associé à des formes plus sévères de la maladie. Cette découverte ouvre des perspectives pour le diagnostic familial et la prise en charge des patients. (...)
Primary bilateral macronodular adrenal hyperplasia (PBMAH) is a rare cause of adrenal Cushing’s syndrome and bilateral adrenal tumors. We suspected a genetic origin of the disease on the basis of the report of some familial cases and the involvement of both adrenal glands. The aim of this study was to find a genetic cause of non syndromic PBMAH. To look at chromosomal abnormalities, we use single-nucleotide polymorphism (SNP) arrays and microsatellite markers analysis in a first series of 33 patients all operated for PBMAH. We realize whole genome sequencing of 5 patients (blood and tumor DNAs matched). Then we genotyped by Sanger sequencing the gene Armadillo Repeat Containing 5 (ARMC5) in this first series and 66 additional patients. Clinical data were collected to establish genotype-phenotype correlation. In addition, the cohort of patients of our collaborators at the National Institute Health (Dr. Stratakis, Bethesda, USA) was studied. The effects of ARMC5 inactivation and overexpression and the partners of the protein were sought in cell-culture models. The most frequent somatic alteration was a loss of heterozygosity at 16p observed in tumors of 25% of the patients. The gene ARMC5, located at 16p11.2, was the most frequently mutated by whole genome sequencing: a mutation was found in 4/5 patients. 55% of the patients of the first cohort (33 patients treated by adrenalectomy for PBMAH) had ARMC5 alteration. One patient presented with germline microdeletion of the locus identified by SNP array. Every patient had two events: either a mutation or a deletion at the germline level, either a second mutation or a LOH at the somatic level. We showed that the two events were present on different alleles suggesting that ARMC5 is a tumor suppressor gene. In addition, we showed for several patients that the second hit was different in each adrenal nodules of a same patient. This first cohort included only operated patients with serious forms of the disease. The study of the American cohort and the analysis of the total cohort of our lab including non-operated patients and milder forms showed an alteration of ARMC5 in about 25% of the patients. Genotype-phenotype correlation showed that ARMC5 defects are associated with younger age at the diagnosis, higher hypercortisolism, bigger adrenals and higher number of nodules. In addition, a mutation of ARMC5 was shown in a patient with a PBMAH secreting both aldosterone and cortisol. Analysis of a series of patient affected by primary hyperaldosteronism suggested that ARMC5 may be associated with hypertension especially in African-American subjet. Overexpression of ARMC5 leads in vitro to cell apoptosis. We showed that this apoptosis was reduced when transfecting vector harboring missense mutations or single amino-acid deletion found in our cohort. Invalidation of ARMC5 leads to a decreased steroidogenic enzymes expression, cortisol production and reduced protein kinase A (PKA) activity. We showed that ARMC5 interacts with the calaytic subunit alpha of the PKA dissociated from the cAMP-bound regulatory subunits. More than one quarter of sporadic PBMAH patients present a pathogenic germline ARMC5 defect and these index cases present a more severe disease. Systematic genotyping of ARMC5 may help for early diagnosis of PBMAH, familial counseling, and patients’ management. ARMC5 appears to be a new regulator of PKA and might represent a new target for the development of pharmacological agents controlling PKA function and cortisol production

Introdução: Os sintomas neuropsiquiátricos são uma marca importante do Síndrome de Cushing, com repercussões significativas na qualidade de vida desses pacientes. O objetivo deste trabalho é avaliar a prevalência das manifestações psicológicas/psiquiátricas no Síndrome de Cushing e a sua evolução após correção do hipercortisolismo. Metodologia: Recolha de artigos científicos com estudos nesta área e seleção da bibliografia mais relevante, utilizando os motores de busca PubMed e Google Académico. Resultados: Em onze artigos, com um total de 654 doentes com Síndrome de Cushing, a prevalência dos distúrbios psiquiátricos foi de 40% a 86%. Existiu uma melhoria dos sintomas neuropsiquiátricos e da qualidade de vida global dos pacientes logo após a cura da doença de base, apesar de se notarem sintomas residuais a longo-prazo na maioria dos doentes. Discussão e conclusão: O tratamento dirigido à disfunção endócrina de base é, numa primeira fase, suficiente para a melhoria dos sintomas neuropsiquiátricos. Contudo, deve continuar a dar-se atenção às manifestações que permanecem, as quais têm um impacto significativo na qualidade de vida dos pacientes, podendo ser necessário acompanhamento psicológico ou psiquiátrico e terapêutica psicotrópica.
Introduction: Neuropsychiatric symptoms are an important mark of Cushing’s syndrome, with significant impact on patient’s quality of life. The aim of this revision is to evaluate the evolution of psychological or psychiatric manifestations and quality of life of these patients after correction of hypercortisolism. Methods: Search of scientific articles with studies in this area, and selection of the most relevant ones, by using PubMed and Academic Google. Results: In eleven articles, with a total of 654 patients with Cushing’s syndrome, the prevalence of psychiatric disorders was between 40% and 86%. Following treatment of subjacent disease, there was an improvement of neuropsychiatric symptoms and global quality of life, although there were residual symptoms on a long-term basis in most of the patients. Discussion and Conclusion: The treatment directed to the endocrine dysfunction is initially enough to improve neuropsychiatric symptoms. However, care should be taken to observe residual symptoms, which have a significant impact on patient’s quality of life, and psychiatric or psychological support and psychotropic therapy may be necessary.

Este trabalho descreve as atividades desenvolvidas no estágio curricular em clínica de animais de companhia na Clínica Veterinária Arco do Cego, tendo-se verificado que as áreas em que se observou maior número de procedimentos foram a gastroenterologia, a dermatologia e a otorrinolaringologia. O hiperadrenocorticismo, aqui abordado através da revisão bibliográfica e da análise do caso clínico, segundo a bibliografia, é uma síndrome rara em gatos e, quando presente, encontra-se associada a diabetes mellitus, o que não se verifica no caso clínico apresentado, no qual se diagnosticou o hiperadrenocorticismo após a persistência da poliúria e polidipsia numa gata cuja piómetra tinha sido resolvida. Assim, nunca se deve excluir um diagnóstico à partida, sem antes se averiguar, por muito improvável que seja; Abstract – Small Animals’ Practice: Hyperadrenocorticism in small animals – development of a Cushing’s Syndrome’s case in a cat The present work describes the activities developed during the curricular internship of small animals’ clinic at Clínica Veterinária Arco do Cego, and it was verified that gastroenterology, dermatology and otorhynolaryngology were the clinical subjects where the majority of the procedures occurred. The hyperdrenocorticism, approached here by the literature review and the clinical case report, according to the bibliography, is a rare syndrome in cats, and when present, is associated with diabetes mellitus, which did not arise in the presented clinical case, in which hyperadrenocorticism was diagnosed after persistent polyuria and polydipsia in a cat whose pyometra had been resolved. So, one should never pre-exclude a diagnosis without further analysis, in spite of being very unlikely.

Le syndrome de Cushing est une maladie rare mais dont la prévalence est sous-estimée et dont le diagnostic, difficile et souvent tardif, est à l'origine de nombreuses complications pouvant engager le pronostic vital. Le médecin généraliste doit être le premier à l'évoquer et à le dépister. Nous avons étudié une série de neuf patients diagnostiqués pour un syndrome de Cushing au Centre Hospitalier Universitaire de Pointe-à-Pitre entre 2006 et 2010. Sur les 9 cas, un seul diagnostic de syndrome de Cushing a été évoqué par le médecin généraliste. La Haute Autorité de Santé recommande de dépister les patients présentant des symptômes discriminants tels que la répartition facio-tronculaire des graisses, des signes d'hypercatabolisme cutané, musculaire et osseux et les enfants présentant un ralentissement de la courbe de croissance, en particulier s'il est associé à une prise de poids paradoxale. Il faut également dépister les groupes à risque tels que les diabétiques impossibles à équilibrer, les hypertendus résistants au traitement, les ostéoporotiques sans cause évidente, les patients psychiatriques atypiques et les patients présentant un incidentalome surrénalien. Les tests de dépistage à réaliser en première intention sont un cortisol urinaire des 24h, un test de freinage minute ou un cortisol salivaire nocturne. IL faut savoir répéter les examens en cas de suspicion de syndrome de Cushing cyclique
Cushing syndrome is a rare disease, but its prevalence is underestimated and the diagnosis difficult and often delayed that causes many complications which can be life-threatening. The General Practitionner should be the first to discuss and track it. We studied a series of nine patients diagnosed with Cushing's syndrome at the University Hospital of Pointe-à-Pitre between 2006 and 2010. Of the 9 cases, a single diagnosis of Cushing's syndrome has been referred by general practitioners. The High Authority of Health recommends screening patients with discriminating symptoms such as facio-truncal distribution of fat, signs of hypercatabolism skin, muscle and bone as weIl as children with a slower growth curve, especiaIly if it is associated with paradoxal weight gain. Screening should also detect risk groups such as diabetics impossible to balance, treatment resistant hypertension, osteoporosis without obvious cause, atypical psychiatrie patients and patients with adrenal incidentaloma. First line testing to be conducted are urine free cortisol, 1 mg overnight dexamethaseone suppression test and late-night salivary cortisol. Tests should be repeated for suspeeted cyclic Cushing's syndrome

Glucocorticoids are well known for altering bone structure and elevating fracture risk. Nevertheless, there are very few reports on pelvic ring fractures, compared to other bones, especially with a predominantly ligamentous insufficiency, resulting in a rotationally unstable pelvic girdle.We report a 39-year-old premenopausal woman suffering from an atraumatic symphysiolysis and disruption of the left sacroiliac joint. She presented with external rotational pelvic instability and immobilization. Prior to the injury, she received high-dose glucocorticoids for a tentative diagnosis of rheumatoid arthritis over two months. This diagnosis was not confirmed. Other causes leading to the unstable pelvic girdle were excluded by several laboratory and radiological examinations. Elevated basal cortisol and adrenocorticotropic hormone levels were measured and subsequent corticotropin-releasing hormone stimulation, dexamethasone suppression test, and petrosal sinus sampling verified the diagnosis of adrenocorticotropic hormonedependent Cushing’s disease. The combination of adrenocorticotropic hormone-dependent Cushing’s disease and the additional application of exogenous glucocorticoids is the most probable cause of a rare atraumatic rotational pelvic instability in a premenopausal patient. To the authors’ knowledge, this case presents the first description of a rotationally unstable pelvic ring fracture involving a predominantly ligamentous insufficiency in the context of combined exogenous and endogenous glucocorticoid elevation.

La sindrome di Cushing (SC) è una delle endocrinopatie più comuni nel cane. La diagnosi richiede l'integrazione di anamnesi, segnalamento, segni clinici, esami ematobiochimici, test endocrini specifici e diagnostica per immagini . Nel corso degli anni diversi sono i principi attivi testati per la terapia della SC del cane. In passato, il mitotane è stato il farmaco più utilizzato, sebbene il suo uso risulti complicato e non privo di potenziali effetti collaterali. Recentemente, il trilostano ha dimostrato di essere un trattamento efficace per il controllo dei sintomi ed è stato approvato per tale uso nel cane. Al fine di testare metodiche non invasive per la diagnosi di SC nel cane abbiamo valutato le concentrazioni di cortisolo nel pelo (HCC) .Queste risultavano significativamente più elevate nei cani con SC rispetto ai cani sani e malati. Questo test può essere quindi considerato una procedura diagnostica non invasiva in cani con un elevato sospetto di SC. Inoltre, a causa della difficile reperibilità dell’ACTH esogeno sono state valutate le concentrazioni di cortisolo basale come strumento di monitoraggio in cani con SC trattati con trilostano. Tuttavia la singola valutazione del cortisolo basale non rappresenta un parametro efficace ed accurato per il monitoraggio della terapia con trilostano. Sono stati inoltre valutati i fattori prognostici in cani con SC alla diagnosi. L' iperfosfatemia è risultata un riscontro comune nei cani SC, rappresentando un fattore prognostico negativo. La terapia chirurgica non è una procedura di routine nella SC del cane, tuttavia abbiamo descritto l'approccio di ipofisectomia transsfenoidale in un Galgo spagnolo di 8 anni con SC . Il cane è stato sottoposto per due volte ad ipofisectomia transsfenoidale che ha permesso di rimuovere completamente il macroadenoma ipofisario. In conclusione, questi studi ci hanno permesso di indagare alcuni aspetti patogenetici, clinici e diagnostici della SC del cane.
The Cushing Syndrome is one of the most common canine endocrinopathies. The diagnosis requires the integration of anamnesis, signalment, clinical signs, blood work, specific endocrine tests and the diagnostic imaging. Over the years several drugs were tested for the treatment of canine Cushing's syndrome (CS). In the past, mitotane has been the most widely used drug, although its use is complicated and with many potential side effects. Recently, trilostane has been proven to be an effective treatment for the control of symptoms and it is approved for this use in dog. In order to test noninvasive techniques as a diagnostic tool for dogs with CS we measured the hair cortisol concentrations (HCC). HCC were significantly higher in CS dogs compared with healthy dogs and sick control dogs.Because of the lack of specificity, this test could be considered a noninvasive procedure only in dogs with a high suspicion of HC. Moreover due to the difficult supplying of exogenous ACTH we evaluated the baseline cortisol concentration as a monitoring tool in dogs with CS treated with trilostane. It is evident from our study that the ACTH stimulation test cannot be replaced by basal cortisol concentration. We investigated the prognostic factors of dogs with newly diagnosed hypercortisolism and this study the hyperphosphatemia is a common finding in newly diagnosed CS dogs and represents a negative prognostic factor. The surgical therapy it is not a routine procedure in the canine CS however we described the transsphenoidal hypophysectomy approach in 8-year-old, female Spanish Galgo dog with CS. The dog was underwent for two time at transsphenoidal hypophysectomy that have removed the completely the pituitary macroadenoma. In conclusion, these studies allowed us to investigate some aspects of pathogenetic, clinical and diagnostic of the SC of the dog.