Licorice-induced hypertension and syndromes of apparent mineralocorticoid excess

Excessive ingestion of licorice induces a syndrome of hypokalemia and hypertension that reflects increased activation of renal mineralocorticoid receptors by cortisol. A similar syndrome of cortisol-dependent mineralocorticoid excess occurs in congenital deficiency of the enzyme 11 beta-hydroxysteroid dehydrogenase, which normally inactivates cortisol to cortisone. It has been shown that licorice inhibits 11 beta-dehydrogenase, preventing local inactivation of cortisol and allowing cortisol inappropriate access to intrinsically nonspecific renal mineralocorticoid receptors. Further studies with licorice and its derivatives have revealed a widespread role for 11 beta-dehydrogenase in regulating tissue sensitivity to cortisol. Deficient 11 beta-dehydrogenase activity provides a novel pathogenetic mechanism for hypertension, and current research suggests that several common forms of hypertension can be explained by the mechanisms that operate in licorice-induced hypertension.     

Aging and the adrenal cortex

Aging in humans is accompanied by an increase in adrenal glucocorticoid secretion and a decline in adrenal androgen synthesis and secretion. The intense interest in adrenal function in aging individuals in recent years is in large measure related to the potential impact of cortisol excess in the development of cognitive impairment and hippocampal neuronal loss, and to the desire to provide hormone replacement and healthy aging. Although the preliminary data is tantalizing, solid scientific evidence are not at hand. It is apparent that both issues are extremely complex. Dehydroepiandrosterone (DHEA) and its 3 beta-sulfate are fascinating molecules, including their synthesis and actions in the brain. Recent studies have shown that DHEA-sulfate (DHEA-S), but not DHEA, activates peroxisome proliferator-activated receptor alpha (PPAR alpha) in the liver, an intracellular receptor belonging to the steroid receptor superfamily. Thus, DHEA-S may serve as a physiological modulator of liver fatty acid metabolism and peroxisomal enzyme expression, and thereby may contribute to the anticarcinogenic and chemoprotective properties of this intriguing class of endogenous steroids. The life-sustaining role of adrenal cortisol secretion and its regulation of metabolism via catabolic actions may be modulated by its partner DHEA and DHEA-S. During the anabolic growth period (childhood and early adulthood) the body is exposed to relatively high levels of DHEA/DHEA-S but to relatively or absolutely high levels of cortisol during infancy and the aging phase. The cortisol/DHEA-S ratio during the life span follows a U-shape curve, which may be telling us to explore these two critical adrenal steroids in tandem.     

Molecular basis for hypertension in the "type II variant" of apparent mineralocorticoid excess

The syndrome of apparent mineralocorticoid excess (AME) is a heritable form of hypertension in which cortisol acts as a potent mineralocorticoid. The type I variant results in a severe clinical and biochemical phenotype and arises because of mutations in the gene encoding the type 2 isozyme of 11beta-hydroxysteroid dehydrogenase (11beta-HSD2), an enzyme responsible for the peripheral inactivation of cortisol to cortisone. Only mild abnormalities of cortisol metabolism have been found in the type II variant of AME, suggesting that it may be a separate gene defect. In an extensive consanguineous Sardinian pedigree affected with "type II" AME, a novel homozygous point mutation (C945T) was found in the human 11beta-HSD2 gene in four affected individuals. Thirteen family members were heterozygous for the resultant R279C amino acid substitution. The LOD score of linkage of the mutation to the disease was 3.23. Expression of the 11beta-HSD2 mutant cDNA resulted in an enzyme with reduced maximum velocity, but similar substrate affinity, compared with activity of the wild-type cDNA. Affected individuals were >30 years of age and had both mineralocorticoid hypertension and evidence of impaired metabolism of cortisol to cortisone. The heterozygote state was phenotypically normal but was associated with subtle defects in cortisol metabolism. AME represents a spectrum of mineralocorticoid hypertension with severity reflecting the underlying genetic defect in the 11beta-HSD2 gene; classification into distinct subtypes is inappropriate. Hypertensive populations should be screened to identify the prevalence of milder defects in 11beta-HSD2 in patients currently labeled as having "essential" hypertension.     

Zonation of the adrenal cortex. I. Isolation of mitochondria from the zona glomerulosa of the bovine adrenal cortex

Isolation procedures for mitochondria from the zona glomerulosa of the bovine adrenal cortex are described in comparison to those isolated from the zona fasciculo-reticularis. The cristal membranes of mitochondria in the zona glomerulosa in situ are tubular or tubulo-vesicular, whereas those of mitochondria in the zona fasciculo-reticularis in situ are vesicular. When mitochondria are isolated from the former zone, they invariably showed a condensed configuration regardless of isolation media, whereas those isolated from the later zone in a ST medium showed an orthodox configuration. When Ca2+ was added to mitochondria isolated form either zone in an STE medium in the condensed configuration, transition from the condensed to the orthodox configuration took place; the cristel membrane of mitochondria from the zona glomerulosa became tubular or tubulo-vesicular and those of mitochondria from the zona fasciculo-reticularis became vesicular. Purity of mitochondria thus obtained from the zona glomerulosa was examined by electron microscope and marker enzymes. Coupling efficiency of mitochondria was found to be remarkably affected by temperature during the isolation procedures and a choice of substrates.     

Pregnenolone-binding proteins in the rat adrenal cortex

Rat adrenal cortex contains a protein(s) that binds pregnenolone with high affinity. This binding, demonstrated by gel filtration and by a dextran-coated charcoal method, was associated with the cytosol and with fractions solubilized by sonication from the mitochondria and microsomes. The binding of pregnenolone was saturable and was inhibited by mercurials and proteolytic enzymes. Pregnenolone-binding was not influenced by the presence of progesterone, deoxycorticosterone, corticosterone or aldosterone, but was inhibited by steroids with a 3beta-hydroxy-5-ene structure similar to pregnenolone, and by hydroxymethylene steroid and cyanoketone. We suggest that this protein is involved in the intracellular transport and retention of pregnenolone within adrenal cortical cells.     

Peptide growth factors and the adrenal cortex

Increasing evidence suggests that the actions of classical stimulants of adrenocortical growth and function, such as ACTH or dietary sodium restriction, may partially be mediated via locally produced regulators. Several peptide growth factors, such as basic fibroblast growth factor, insulin-like growth factors, and transforming growth factor-beta 1, have emerged in recent years as multifunctional molecules that typically play such regulatory roles. Adrenocortical cells are highly responsive to these growth factors, in particular in the regulation of cell growth and differentiated functions, such as steroidogenesis. In addition, growth factor expression in the adrenal cortex has been shown to be regulated by physiological stimulants. The spatial expression, release, and activation of these growth factors may, therefore, locally mediate or amplify the actions of the hypothalamo-pituitary axis and the renin-angiotensin system on adrenocortical proliferation, differentiation, and steroidogenesis.     

Actions of adrenomedullin on the rat adrenal cortex

The actions of adrenomedullin on cAMP and aldosterone secretion have been investigated using an intact rat adrenal capsular preparation incubated in vitro. Adrenomedullin was found to cause a dose-dependent increase in aldosterone secretion, with a parallel increase in cAMP release. The minimum concentration of adrenomedullin required for significant stimulation of aldosterone secretion was 10nmol/l. Adrenomedullin did not affect ACTH-stimulated aldosterone secretion, but significantly inhibited endothelin-1 stimulated aldosterone secretion. We conclude that adrenomedullin is an aldosterone stimulant in the rat adrenal gland, acting through cAMP generation.     

Angiotensin antagonists and the adrenal cortex and medulla

Several analogs of angiotensin in which the phenylalanine in position 8 of the peptide chain was replaced by an aliphatic amino acid residue are specific antagonists of angiotensin in aorta, the adrenal medulla, and adrenal zona glomerulosa. In the adrenal cortex and medulla, all actapeptide analogs have more agonist activity than in aortic strips. In studies with N-terminally substituted analogs, it appears that adrenal degradation of the angiotensin molecule by aminopeptidase(s) does not occur or is not retarded by N-terminal mocifications such as sarcosine substitution. The decapeptide analog [Ile8]-angiotensin I and heptapeptide analog [des-Asp1, Ile8]-angiotensin II were excellent antagonists in the adrenal medulla and each peptide was devoid of intrinsic activity. These substituted homologs of angiotensin may offer a novel approach for the development of selective antagonists of angiotensin receptors. In the adrenal cotex, [des-Asp1, Ile8]-heptapeptide possessed greater receptor affinity than any of the angiotensin octapeptides studied. This C-terminally substituted heptapeptide does have significant intrinsic activity in the adrenal cortex which would limit the use of this compound as an antagonist of vascular responses to angiotensin II. In studies with [Ile8]-angiotensin II, [Sar1, Ile8]-angiotensin II, and [des-Asp1, Ile8]-angiotensin II, the pA2 values calculated indicate that the N-terminal residue is not important for receptor binding in the adrenal cortex but may be of significance in binding to adrenal medullary and aortic smooth muscle receptors. At the present time it appears unlikely that any single animal model or assay system can reliably predict the agoinst/antagonist activities of angiotensin analogs for all the various end organs which respond to the angiotensins.     

11 beta-Hydroxysteroid dehydrogenase activity in Cushing's syndrome: explaining the mineralocorticoid excess state of the ectopic adrenocorticotropin syndrome

A characteristic feature of the ectopic ACTH syndrome is a state of mineralocorticoid excess, although the etiology remains obscure. Some forms of endocrine hypertension, such as licorice ingestion, have been explained by cortisol acting as a mineralocorticoid in the setting of inhibition or deficiency of 11 beta-hydroxysteroid dehydrogenase (11 beta HSD). This enzyme is responsible for the conversion of cortisol (F) to hormonally inactive cortisone, and its activity in vivo can be inferred from the ratio of the urinary excretion of tetrahydrocortisol (THF) and its isomer (5 alpha THF) to tetrahydrocortisone. Twenty-two patients with Cushing's syndrome (11 pituitary dependent, 9 ectopic, and 2 adrenal adenomas) and 13 controls were studied. Compared to controls. Cushing's patients had a significant increase (P < 0.001) in the excretion of all principal metabolites of F, secondary to a 5- to 6-fold increase in the cortisol secretion rate [median, 34.0 (range, 13.3-327) mg/day in Cushing's vs. 6.1 (range, 2.5-10.3) mg/day in controls]. The THF plus 5 alpha THF/tetrahydrocortisone ratio was significantly increased in Cushing's syndrome regardless of etiology [mean, 1.81 (range, 1.09-9.99) in Cushing's vs. 0.81 (range, 0.51-1.47) in controls; P < 0.001), indicative of defective 11 beta HSD activity. Furthermore, compared to patients with pituitary-dependent Cushing's, this ratio was significantly higher in patients with the ectopic ACTH syndrome (4.12 vs. 1.49; P < 0.01) and was inversely correlated with serum potassium levels (r = -0.57; P = 0.01; n = 22). One explanation for the mineralocorticoid excess state of the ectopic ACTH syndrome appears to be that cortisol gains inappropriate access to the mineralocorticoid receptor through failure of its normal metabolism by 11 beta HSD. The reason for the defective 11 beta HSD activity is unclear, but it may be secondary to substrate saturation, inhibition by other adrenal steroids, or product inhibition.     

Aging alters zonation in the adrenal cortex of men

Whereas aging has been shown to be associated with striking reductions in circulating levels of adrenal androgens in humans, the alteration in adrenal function that occurs in aging has not been identified. We sought to determine if there are changes in the zonation of the adrenal in aging men by performing histomorphologic analyses of adrenal specimens that had been obtained at autopsy following sudden death due to trauma. We evaluated adrenals from 21 young men (20-29 yrs) and 12 older men (54-90 yrs); inclusion criteria required the presence of medullary tissue in the specimen and fixation within the first 24 hrs postmortem. Sections stained with H/E were examined microscopically and areas of the cortex that included adjacent medullary tissue were chosen for quantitative evaluation by use of a computerized image analysis system. The average width (arbitrary units, pixels) of the zona reticularis and that of the combined zonae fasciculata/glomerulosa were determined from sections stained for reticulum fibers. The zona reticularis represented 37.1 +/- 1.9% of the total cortical width in the young men, which was significantly greater than that of the older men (27.1 +/- 3.3%, P = 0.0082). The zona fasciculata/glomerulosa to zona reticularis ratio in the young men (1.84 +/- 0.15) was significantly less that that of the older men (3.29 +/- 0.47, P = 0.0011). There was no significant difference in the total width of the cortex in young compared to older men. These data suggest that aging results in alterations within the cortex of the adrenals in men such that there is a reduction in the size of the zona reticularis and a relative increase in the outer cortical zones. A reduced mass of the zona reticularis could be responsible for the diminished production of dehydroepiandrosterone and dehydroepiandrosterone sulfate that occurs during aging.     

The adrenal cortex in cystic fibrosis of the pancreas

The morphologies of the adrenal cortical zones of 25 children with cystic fibrosis and 24 control patients are presented. A technic for objective measurement of these zones is described. Hyperplasia of the zona glomerulosa in the children with cystic fibrosis is significant and may be related to chronic loss of salt in the sweat or demands placed on renal salt-conserving mechanisms.     

Cushing with transition from pituitary to adrenal origin. Study with SPECT scintigraphy of the adrenal cortex with norcholesterol-I 131 in a case

The case of a 49 yr old alcoholic women with clinical and laboratory findings that suggested a Cushing syndrome is presented. The functional tests showed cortisol suppression greater than 50% of the basal value with 8 mg of dexamethasone and no response in the combined dexamethasone/desmopressin test. Pituitary Nuclear Magnetic Resonance (NMR) was negative, Abdominal Computed Axial Tomography suggested hyperplastic adrenal glands; adrenal nodules were not found in the NMR. Pituitary or hipothalamic Cushing with secondary autonomous micronodular adrenal hyperplasia was suspected. Norcholesterol-I131 SPECT scintigraphy under dexamethasone suppression demonstrated a functional adrenal hyperplasia which was hystologically confirmed.     

Steroidogenesis in the zona glomerulosa of the adrenal cortex. II. Distribution of cytochrome P-450 in the zona glomerulosa of the bovine adrenal cortex

Microsomes were obtained from the zona glomerulosa of the bovine adrenal cortex. Contamination of microsomes with other cellular organelles was examined using various marker enzymes and the electron microscope. Distribution of cytochrome P-450 in mitochondria and in microsomes was determined to be 0.73 and 0.32 nmol/mg protein, respectively. The CO difference spectrum was affected not only by the concentration of added deoxycholate but also by the incubation time after addition. Approximately 40-50% of cytochrome P-450 in the samples was converted to cytochrome P-420 within 20-30 sec of incubation with deoxycholate. The content of RNA, phospholipids, and cytochrome b5 in microsomes obtained from the zona glomerulosa is also evaluated in comparison to that in microsomes obtained from the zona fasciculoreticularis.     

Steroidogenic electron transport in adrenal cortex mitochondria

The flavoprotein NADPH-adrenodoxin reductase and the iron sulfur protein adrenodoxin function as a short electron transport chain which donates electrons one-at-a-time to adrenal cortex mitochondrial cytochromes P-450. The soluble adrenodoxin acts as a mobile one-electron shuttle, forming a complex first with NADPH-reduced adrenodoxin reductase from which it accepts an electron, then dissociating, and finally reassociating with and donating an electron to the membrane-bound cytochrome P-450 (Fig. 9). Dissociation and reassociation with flavoprotein then allows a second cycle of electron transfers. A complex set of factors govern the sequential protein-protein interactions which comprise this adrenodoxin shuttle mechanism; among these factors, reduction of the iron sulfur center by the flavin weakens the adrenodoxin-adrenodoxin reductase interaction, thus promoting dissociation of this complex to yield free reduced adrenodoxin. Substrate (cholesterol) binding to cytochrome P-450scc both promotes the binding of the free adrenodoxin to the cytochrome, and alters the oxidation-reduction potential of the heme so as to favor reduction by adrenodoxin. The cholesterol binding site on cytochrome P-450scc appears to be in direct communication with the hydrophobic phospholipid milieu in which this substrate is dissolved. Specific effects of both phospholipid headgroups and fatty acyl side-chains regulate the interaction of cholesterol with its binding side. Cardiolipin is an extremely potent positive effector for cholesterol binding, and evidence supports the existence of a specific effector lipid binding site on cytochrome P.450scc to which this phospholipid binds.     

Carcinosarcoma of the gallbladder]

The authors analyse and comment on a case of carcinosarcoma of the gallbladder which they have recently observed. Given the rarity of this form of cancer, it is interesting to note that this case presents some peculiar aspects which have not been recorded in the few cases previously published on the subject. The peculiarities are such that they require a revision of what have until now been considered as intrinsic characteristics in the clinical observation of this kind of cancer. The authors maintain that the peculiarities of this case concern: a) the clinic onset of the illness and the relative aspecific symptomatology: b) that fact that laboratory tests did not signal any biochemical alteration; c) that the instrumental investigation's results pointed toward a non neoplastic pathology; d) that even the intra-operatory examination did not reveal any suspicious element; and last but by no means least the good survival of the patient which is definitely superior to other cases already reported in literature. The neoplasia, which manifested itself through a hemorrhage in the gallbladder, represented in fact the very initial stage of the illness, a condition rarely observed.