Margaret de Castro

Background: Primary aldosteronism (PA) is frequently underdiagnosed, resulting in prolonged exposure to aldosterone excess. In Brazilian cohorts, delayed diagnosis has been associated with high prevalence of hypokalemia, suggesting severe disease at presentation. We evaluated PA severity and its association with PA subtype using the Primary Aldosteronism Severity Classification (PASC). Methods: PA patients were retrospectively evaluated over a 25-year period at a tertiary university hospital. Severity was classified using PASC, based on blood pressure, serum potassium, and plasma aldosterone. Kobayashi score was used to estimates the probability of bilateral PA. Outcomes were assessed by Primary Aldosteronism Surgical Outcome (PASO) and Primary Aldosteronism Medical Outcome (PAMO) criteria. Results: Among 120 patients (56% female), 52 underwent unilateral adrenalectomy and 68 received medical therapy. Most diagnoses (84%) occurred in the past decade. Median ages were 32 years at hypertension onset and 53 years at PA diagnosis. Most patients presented hypokalemia (75%), more frequent in lateralized than bilateral PA (85% vs 66%; P = .03). Overall, 98% of patients had moderate or severe PASC, more common in lateralized than bilateral PA (61.5% vs 36.8%; P = .01). Severity correlated with aldosterone levels, hypokalemia, and antihypertensive medications (all P < .0001), but not with diagnostic delay. Higher Kobayashi score was associated with bilateral PA. Adrenalectomy resulted in high rates of biochemical success, while medically treated patients showed predominantly partial clinical improvement. Conclusion: Brazilian patients with PA presented substantial diagnostic delay and predominantly moderate to severe disease. PASC and the Kobayashi score may complement subtype assessment when adrenal venous sampling is unavailable.

To analyze the impact of nicotinamide nucleotide transidrogenase (NNT) enzyme impairment on cortisol production, reactive oxygen species (ROS) formation, mitochondrial activity, and mitogen-activated protein kinase 8 (MAPK8) expression in the adrenocortical cell line. siRNA NNT knockdown was performed in H295R adrenocortical cells to evaluate the effects on cortisol secretion (RIA) and reactive oxygen species (ROS) intracellular production (DCFDA) in basal conditions and after stimulation with 10 uM forskolin. MAPK8 mRNA relative expression and protein localization were evaluated using quantitative PCR (qPCR) and immunofluorescence, respectively. NNT knockdown in the H295R adrenal cells specifically reduced NNT RNA and protein levels. Under basal conditions, no changes in ROS intracellular production or cortisol secretion were seen in NNT-depleted H295R cells. However, under forskolin (10 μM), a potent steroidogenesis agent, we observed a marked reduction in cortisol production (p < 0.0001) at the expense of normal ROS intracellular production and increased MAPK8 expression (p = 0.008). NNT-deficient adrenocortical cells can maintain mitochondrial homeostasis and cortisol secretion in basal conditions. However, under stress, these cells seem to maintain the redox balance at the expense of impaired steroidogenesis. MAPK8 pathway activation appears to compensate for NNT deficiency.

Context: Premature pubarche (PP) is a frequent reason for endocrine evaluation. Between 5% and 20% of children presenting with PP may have 21OHD nonclassic congenital adrenal hyperplasia (21OHD-NCAH). Objective: To define optimal basal and ACTH-stimulated 17OHP cutoffs for diagnosing 21OHD-NCAH in children with PP, using CYP21A2 genotyping as the gold standard. Design, setting, and patients: A diagnostic accuracy study including 203 children with PP (median age: 7.5 years [6.4-8.3]; 85% female) who underwent ACTH stimulation testing. Biallelic pathogenic variants upon CYP21A2 genotyping defined 21OHD-NCAH. Main outcome measure(s): Diagnostic performance of basal and post-ACTH 17OHP levels assessed by ROC curve analysis and thresholds defined according to the Youden index. Results: 21OHD-NCAH was confirmed in 32 children (15.7%; 7.1 years [6.1-8.6]; 78% female). Basal 17OHP demonstrated excellent diagnostic accuracy (AUC = 0.98). A cutoff of 170 ng/dL (5.1 nmol/L) provided the best diagnostic balance, with 97% sensitivity and 91% specificity. A higher threshold of 410 ng/dL (12.4 nmol/L) achieved 100% specificity but reduced sensitivity (75%), whereas a lower cutoff of 118 ng/dL (3.5 nmol/L) yielded 100% sensitivity at the expense of specificity (84%). A post-ACTH 17OHP > 1104 ng/dL (33.4 nmol/L) yielded 100% sensitivity and specificity. Androgen levels overlapped substantially, and no clinical feature reliably distinguished 21OHD-NCAH from PP. Conclusion: Basal 17OHP provides excellent diagnostic accuracy for 21OHD-CAH in children with PP. A dual-threshold strategy is supported: 170 ng/dL (5.1 nmol/L) as optimal screening cutoff and 410 ng/d (12.4 nmol/L) as highly specific diagnostic threshold, obviating ACTH testing. These genotype-anchored, RIA-derived cutoffs are readily applicable in clinical settings using comparable assays.

Classic adipsic vasopressin deficiency features hypotonic polyuria and absent thirst despite hypernatremia. We report a 21-year-old patient with prior resected pilocytic astrocytoma who presented dehydration and hypernatremia of 158 mEq/L (158 mmol/L) (reference range, 135-145 mEq/L [SI: 135-145 mmol/L]). He denied thirst and had no polyuria or polydipsia. Plasma and urinary osmolalities were 317 mOsm/Kg (317 mmol/Kg) (reference range, 282-295 mOsm/Kg [282-295 mmol/Kg]) and 878 mOsm/Kg (878 mmol/Kg) (reference range, 200-1200 mOsm/Kg [200-1200 mmol/Kg]), respectively. After prescribed oral water intake, serum sodium normalized and urinary volume remained normal. To assess osmoregulation, plasma copeptin and thirst visual scale were assessed during 3% saline infusion. Despite increases in serum sodium, the patient reported no change in thirst, confirming adipsia. Copeptin value was 3.2 pmol/L at the end of the saline infusion (reference range, 3.7-43.3 pmol/L) and 4.1 pmol/L during hypovolemic hypernatremia, both low-normal values considering hypernatremia, suggesting impaired osmolality-driven vasopressin secretion. This case illustrates a partial defect in osmoregulatory vasopressin release with maintained renal response and highlights the diagnostic utility of osmotic-stimulated copeptin measurement for functional characterization of vasopressin dynamics in rare adipsic disorders.

Introduction: The accuracy and safety of cortisol‐stimulating tests (CSTs) for assessing hypothalamic–pituitary–adrenal (HPA) axis integrity, including the diagnosis of central adrenal insufficiency (CAI), in children remain uncertain. Although these tests can simultaneously evaluate cortisol and growth hormone secretion, the present study focuses exclusively on cortisol measurements. Methods: We evaluated the diagnostic accuracy and safety profile of CST in pediatric patients submitted to insulin tolerance test (ITT) or glucagon‐stimulation test (GST) in a tertiary center for 15 years in this retrospective cohort study. According to cortisol (F; nmol/L), we classified patients as having CAI (Fbasal < 138 or Fpeak < 414), indeterminate (Fbasal = 138−358.7 or Fpeak = 414−496.6), and normal (Fbasal > 358.7 or Fpeak > 496.6). Cutoffs were selected based on the literature and on our University Hospital protocol. Plasma cortisol was measured using a consistent radioimmunoassay (RIA) following extraction, with duplicate analyses. The assay had a detection limit of 33.11 nmol/L, with intra‐ and inter‐assay coefficients of variation of 5% and 10.5%, respectively. We evaluated the sensitivity, specificity, likelihood ratios (LR), and clinicopathological variables associated with Fbasal and Fpeak. Results: Among 904 patients (60.1% males; median age 10.1 years [0.1−17.1]), CAI was confirmed in 79 (8.7%). Mild hypoglycemia (ITT), and nausea and vomiting (GST) occurred in 46% and 17.5%, respectively. No serious adverse events occurred. Fbasal classified 58% of patients as indeterminate. A Fbasal cutoff of 96.6 had a specificity of 99% and LR+ of 7.6, but low sensitivity (5.3%). In GST, a Fpeak of 303.5 had weak diagnostic accuracy (LR+ of 2.8) and low sensitivity (17%). Concomitant central hypothyroidism and a Fbasal < 154.5 were associated with lower Fpeak, and pituitary stalk interruption was associated with lower Fbasal and Fpeak. Conclusions: Fbasal did not present good diagnostic accuracy. However, Fbasal < 96.6 nmol/L predicted lower Fpeak. Therefore, many patients require CST to confirm or exclude CAI. ITT and GST are safe for young patients when performed in experienced centers in a controlled environment.

BACKGROUND: Bilateral macronodular adrenocortical disease is often linked to autonomous cortisol secretion, but may also present with primary aldosteronism (PA). METHODS: This international (Europe, United States, Asia) retrospective cohort study included adults with radiological evidence of bilateral macronodular adrenocortical disease and biochemically confirmed PA. The primary endpoints was major adverse cardiovascular events (MACE); secondary end points included cardiometabolic comorbidities and surgical outcomes per PA surgical outcome criteria. RESULTS: Two hundred forty-nine patients from 41 centers in 12 countries were included (median age, 55 years; 62% male). Median hypertension duration at PA diagnosis was 9.9 years. Among 178 tested, 52% had cortisol cosecretion and 47% isolated PA. At baseline, 56% had metabolic comorbidities, and 16% had ≥1 MACE. Patients with MACE were older, more often male, had longer hypertension duration, and higher diabetes rates. Eighty-nine patients underwent adrenalectomy: 50 without MRA (mineralocorticoid receptor antagonists), 38 with MRA, and 1 with steroidogenesis inhibitors. One hundred twenty-four patients received continued MRA without adrenalectomy or steroidogenesis inhibitors. Adrenal venous sampling showed lateralized PA in 89% of surgical versus 19% of MRA-treated patients ( P P =0.2), MACE occurred in 8% and 6%, respectively ( P =1.0). Blood pressure and organ damage were similar, but more MRA-treated patients needed ≥3 antihypertensives (MRA: 48% versus adrenalectomy: 14%; P <0.001). Among operated patients, complete clinical and biochemical success was 26% and 71%, respectively. CONCLUSIONS: Bilateral macronodular adrenocortical disease with PA carries a high cardiometabolic burden. Early detection and precise subtyping are key to optimizing management and preventing target organ damage.

Hypercortisolism induces immunosuppression, and infections represent the second leading cause of death among patients with Cushing syndrome. We report the case of an adult man with a silent corticotroph pituitary adenoma that evolved into a functioning adrenocorticotropic hormone-secreting tumor. The patient had diabetes mellitus and was treated with dapagliflozin. Prior to transsphenoidal adenomectomy, he developed Fournier gangrene, a necrotizing fasciitis of the perineal and genital regions. Infectious management included debridement, antibiotics, and hyperbaric oxygen therapy. After adequate control of the infection, pituitary surgery was performed, resulting in hypercortisolism remission. Although Cushing syndrome is well known to predispose patients to infections, the association between endogenous hypercortisolism and Fournier gangrene has been scarcely described in the literature. The present case highlights the risk of this severe soft tissue infection in patients with Cushing syndrome. Dapagliflozin and other sodium–glucose cotransporter 2 inhibitors have been investigated as potential contributors to Fournier gangrene in patients with diabetes mellitus, prompting a discussion about the safety of prescribing these agents in the setting of hypercortisolism.

Objective: This study evaluated the QoL of Brazilian adult patients with childhood-onset growth hormone deficiency GHD (CO-GHD), comparing those who continued GH replacement therapy (GHRT) after transition to adulthood with those who discontinued treatment and with healthy subjects. Subjects and methods: In this cross-sectional study, quality of life (QoL) was assessed using the Quality of Life Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA) questionnaire in 61 Brazilian adults aged 18-50 years. The sample included 31 patients with CO-GHD confirmed during the transition period, who continued or discontinued GHRT, and 30 matched controls. Results: GHD patients had poorer QoL, as indicated by higher QoLAGHDA scores than controls (median 8 [IQR 5-14] vs 4 [IQR 2-8]; p < 0.01). Continued GHRT in adulthood did not impact QoL compared with discontinued GHRT (8 [IQR 6-16] vs. 9 [IQR 5-12], p = 0.33). Overall, women had lower QoL irrespective of GHD (9 [IQR 6-13] vs. 5 [IQR 2-8.5], p = 0.01, women and men, respectively). We found no association between QoL-AGHDA scores and education level (p = 0.51), short stature (p = 0.78), associated pituitary deficiencies (p = 0.34), or overweight/obesity (p = 0.16). Conclusion: GHD impairs quality of life in young adults; however, our cross-sectional cohort did not show significant improvements in quality of life associated with GH replacement therapy. A multidisciplinary approach combining individualized treatment and psychosocial interventions remains essential.

To investigate the involvement of regulators of pluripotency and self-renewal of embryonic stem cells in adrenocortical tumors (ACT). Clinicopathological data and tissues from 114 ACT patients (96 pediatric-pACT; 18 adults) were analyzed. Normal fetal (n = 33) and postnatal adrenals (n = 26) were used as controls. STAT3, NANOG, SOX2, and OCT4 expression was evaluated by qPCR and IHC. We evaluated intracellular NANOG localization by immunofluorescence and its interaction with beta-catenin after inhibiting the Wnt pathway in a beta-catenin-mutated ACT cell line (NCI-H295). IHC showed NANOG, OCT4, SOX2, and STAT3 expression in fetal adrenals until mid-pregnancy, disappearing thereafter. Positive OCT4 nuclear staining was found in 32% of pACT samples and was associated with metastasis (OR = 2.28; 95% CI:1.13-4.59; P < 0.05). ACTs presented lower SOX2 mRNA expression (P < 0.01). STAT3 mRNA levels were higher in cortisol-secreting ACT (P = 0.01) and in adult adenomas (P < 0.01). NANOG mRNA was higher in p.S45P CTNNB1 mutated ACT (P < 0.01). NCI-H295 cells exhibit nuclear NANOG expression, which was decreased by inhibiting the Wnt/beta-catenin pathway (P < 0.01). Markers of pluripotency and self-renewal of embryonic stem cells are expressed until mid-pregnancy, contributing to the adult adrenal stem cell niche. They are absent postnatally but are expressed in a subset of ACT. Specifically, pS45P beta-catenin-mutated ACTs express more NANOG. Increased OCT4 expression in pACT is associated with worse prognosis, and inhibiting the Wnt/beta-catenin pathway in these cells impairs NANOG expression.