Acute Adrenal Insufficiency after Unilateral Adrenalectomy in Cushing's Syndrome: Precipitation by Lithium-Induced Thyrotoxicosis during Cortisol Replacement.

Nagai, Yukihiro; Ohsawa, Kensou; Hayakawa, Tetsuo; Abe, Toshio; Sawada, Taisei; Nakajima, Kazuyoshi; Hashizume, Yasuo; Kobayashi, Kenichi

doi:10.1507/endocrj.41.177

Cited by 6 publications

(4 citation statements)

References 15 publications

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“…There have been a few reports of acute adrenal insufficiency unmasked by hyperthyroidism due to an excessive amount of thyroxine and lithium-induced thyrotoxicosis. Subclinical adrenal insufficiency had already existed before the development of acute adrenal insufficiency in both reported cases (4,5), which coincide with our case. When a patient's adrenal reserve is low, even a mild degree of thyrotoxicosis or other stressors such as surgery, trauma or severe infection can trigger the development of an acute adrenal crisis.…”

Section: Discussionsupporting

confidence: 89%

A Case of Acute Adrenal Insufficiency Unmasked During Sunitinib Treatment for Metastatic Renal Cell Carcinoma

Yoshino

Kawai

Miyazaki

et al. 2012

Japanese Journal of Clinical Oncology

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Sunitinib has recently become a standard treatment for metastatic renal cell carcinoma. However, various adverse events have been reported. We present the first case of clinically evident adrenal insufficiency during sunitinib therapy. A 72-year-old man began sunitinib therapy for bilateral lung and adrenal metastases of renal cell carcinoma. His adrenocorticotrophic hormone level was 93.6 pg/ml (7.2 -63.3 pg/ml) before sunitinib treatment, indicating that subclinical adrenal insufficiency already existed. Fatigue, which is a frequently seen adverse effect of sunitinib treatment, emerged acutely on Day 24 of the second cycle. Adrenocorticotrophic hormone and free T4 were high and thyroid-stimulating hormone was suppressed. Under the clinical diagnosis of acute adrenal insufficiency with thyrotoxicosis, a low dose of steroid was administered. Fatigue was completely ameliorated by the following morning, although free T4 was still high and thyroid-stimulating hormone was still low. Therefore, hypermetabolism due to thyrotoxicosis unmasked adrenal insufficiency in our case. Physicians should be aware of this rare but potentially fatal complication when severe acute fatigue develops in patients with subclinical adrenal insufficiency.

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Section: Discussionsupporting

confidence: 89%

A Case of Acute Adrenal Insufficiency Unmasked During Sunitinib Treatment for Metastatic Renal Cell Carcinoma

Yoshino

Kawai

Miyazaki

et al. 2012

Japanese Journal of Clinical Oncology

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“…In the literature, there have been several cases of acute adrenal insufficiency after unilateral adrenalectomy for adrenal adenoma [ 10 – 12 ]. In those cases, the contralateral adrenal glands became postoperatively unresponsive to any internal stimuli of ACTH, possibly through their atrophy, the involvement of autoimmune mechanisms, or precipitation of a certain drug in the glands, causing “primary” adrenal insufficiency.…”

Section: Discussionmentioning

confidence: 99%

Hyponatremia due to Secondary Adrenal Insufficiency Successfully Treated by Dexamethasone with Sodium Chloride

2015

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Patient: Female, 60Final Diagnosis: Hyponatremia due to secondary adrenal insufficiencySymptoms: prolonged general fatigue and anorexiaMedication: —Clinical Procedure: Successfully treated by dexamethasone with sodium chlorideSpecialty: NephrologyObjective:Rare co-existance of disease or pathologyBackground:Patients who were surgically treated for Cushing’s syndrome postoperatively surrender to “primary” adrenal insufficiency. However, the preoperative over-secretion of cortisol or the postoperative administration of excessive glucocorticoids can cause “secondary” adrenal insufficiency, in which the prevalence of hyponatremia is usually lower than that of primary adrenal insufficiency.Case Report:A 60-year-old woman with a past medical history of Cushing’s syndrome developed hyponatremia with symptoms of acute glucocorticoid deficiency, such as prolonged general fatigue and anorexia, after upper respiratory tract infection. A decrease in the serum cortisol level and the lack of increase in the ACTH level, despite the increased demand for cortisol, enabled a diagnosis of “secondary” adrenal insufficiency. Although the initial fluid replacement therapy was not effective, co-administration of dexamethasone and sodium chloride quickly resolved her symptoms and ameliorated the refractory hyponatremia.Conclusions:In this case, the hypothalamic-pituitary axis of the patient was thought to have become suppressed long after the surgical treatment for Cushing’s syndrome. This case suggested a mechanism of refractory hyponatremia caused by secondary adrenal insufficiency, for which the administration of dexamethasone and sodium chloride exerted additional therapeutic efficacy.

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“…Because the hypothalamic‐pituitary axis and the contralateral adrenal gland are suppressed by prolonged cortisol over‐secretion, these patients have a postoperative adrenal insufficiency and require glucocorticoid replacement therapy both during and following surgery until the remaining adrenal gland recovers 1 . To date, cases a number of cases of acute adrenal insufficiency after unilateral adrenalectomy have been reported 3–5 . Those reported have been primary adrenal insufficiency, caused by a disorder of the adrenal glands themselves, with an insufficient response to ACTH.…”

Section: Discussionmentioning

confidence: 99%

“…1 To date, cases a number of cases of acute adrenal insufficiency after unilateral adrenalectomy have been reported. [3][4][5] Those reported have been primary adrenal insufficiency, caused by a disorder of the adrenal glands themselves, with an insufficient response to ACTH.…”

Section: Discussionmentioning

confidence: 99%

Delayed adrenal insufficiency long after unilateral adrenalectomy: Prolonged glucocorticoid therapy reduced reserved secretory capacity of cortisol

Kazama

Komatsu²,

Ohiwa³

et al. 2005

Int J of Urology

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A 51-year-old woman with Cushing's syndrome underwent unilateral adrenalectomy for left adrenal adenoma. After 7 years of prednisolone treatment (with some interruptions), followed by 4 years of total withdrawal from prednisolone treatment, she presented with hypotension, weight loss, general fatigue, nausea, hyponatremia and hypoglycemia. These clinical features together with a low response in the rapid adrenocorticotropic hormone test led to the diagnosis of acute adrenal insufficiency. Relatively low serum adrenocorticotropic hormone levels in the face of increased demand for cortisol during adrenal crisis suggested a disordered hypothalamic-pituitary function, indicating secondary adrenal insufficiency. This patient demonstrated the etiology of acute adrenal insufficiency long after unilateral adrenalectomy in association with subsequent glucocorticoid therapy. A reduction in the reserved secretory capacity of cortisol after prolonged prednisolone treatment was considered to have induced secondary adrenal insufficiency, even after 4 years of total withdrawal from prednisolone.

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Acute Adrenal Insufficiency after Unilateral Adrenalectomy in Cushing's Syndrome: Precipitation by Lithium-Induced Thyrotoxicosis during Cortisol Replacement.

Abstract: Abstract. We present a patient with Cushing

Cited by 6 publications

References 15 publications

A Case of Acute Adrenal Insufficiency Unmasked During Sunitinib Treatment for Metastatic Renal Cell Carcinoma

A Case of Acute Adrenal Insufficiency Unmasked During Sunitinib Treatment for Metastatic Renal Cell Carcinoma

Hyponatremia due to Secondary Adrenal Insufficiency Successfully Treated by Dexamethasone with Sodium Chloride

Delayed adrenal insufficiency long after unilateral adrenalectomy: Prolonged glucocorticoid therapy reduced reserved secretory capacity of cortisol

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