Successful outcome in a patient with chemical sensitivity. Treatment with psychological desensitization and selective serotonin reuptake inhibitor

A 49-year-old male was diagnosed as having primary aldosteronism at age 39, and he was treated with antihypertensive drugs. In 1995, a computed tomogram revealed a mass in the right adrenal gland. Radiological examinations and endocrinological data revealed the presence of a pheochromocytoma in the right and an adrenocortical tumor in the left adrenal gland. Right adrenalectomy and left partial adrenalectomy were performed. Histologically, the right adrenal mass was compatible with pheochromocytoma, and the left adrenal mass was an adrenocortical adenoma. Endocrinological data as well as blood pressure returned to normal after operation.     

A case of adrenal mixed tumor of pheochromocytoma and adrenocortical adenoma presenting diabetes mellitus and hypertension

A 61-year-old woman with hyper-catecholaminemia and hyper-glucocorticoidemia due to a mixed tumor of the right adrenal gland is described. The patient, who had been medicated for hypertension since 1977, complained of thirst and general malaise in 1986. Body weight loss was remarkable. There was neither absolute truncal obesity nor moon face. In September 1986, her blood pressure was 180/110 mmHg and blood glucose level was 400mg/dl. Noradrenaline levels in plasma and in urine were remarkably elevated (1659 pg/ml and 120 micrograms/day, respectively), and adrenaline levels were also high (397 pg/ml in plasma, 34 micrograms/day in urine). Plasma cortisol and urinary 17-OHCS were elevated (39.2 micrograms/dl and 11.9 mg/day, respectively). Plasma ACTH was in the normal range (42.6 pg/ml). Oral administration of neither 1mg nor 8 mg of dexamethasone suppressed plasma cortisol or ACTH levels. Both 131I-metaiodobenzylguanidine and 131I-adosterol accumulated in the right adrenal gland. In 1987 the adrenal tumor (3.0 x 3.5 cm, 30 g) was resected. After the operation, her blood pressure and blood glucose level returned to normal, so that the medication became unnecessary. Histologically it was revealed that the tumor was a mixed adenoma consisting of adreno-medullary and cortical cells (corticomedullary adenoma). The literature on 21 cases of pheochromocytoma associated with Cushing's syndrome was briefly reviewed. Mathison (1969) reported the first case of a mixed tumor of adreno-medullary and cortical cells. So far as we know the present case is the second.     

Para-aortic paraganglioma found by arteriography. Apropos of a case and review of the literature

A 53 years old man had an angiography for suspected renovascular hypertension (arteritis, renal insufficiency, duplex scanning). It showed a narrow right renal artery streched by a 45 mm mass arising from the adrenal. The computed tomography showed the tumor and the nuclear magnetic resonance imaging indicated a pheochromocytoma. The patient had no complain of headaches, palpitations or sweating. Biochemistry was normal except for a slight serum creatinin elevation and a non significant urinary noradrenaline level. A diagnostic of non functioning pheochromocytoma was made. The therapeutics consisted in a surgical ablation of the tumor and the right kidney (non functioning) and the patient became normotensive thereafter without treatment. The histologic feature was an aortico-sympathetic paraganglia, the adrenal was normal. Paraganglias are arising from the paraganglion system including chemodectoma and glomus jugulare tumor. Non functioning retroperitoneal paraganglias are uncommon: less than 50 in the literature between 1902 and 1992.     

A comparative laboratory study of liquid nitrogen and argon gas cryosurgery systems

Impaired adrenal function during perioperative stress carries the risk of acute cortisol (Cs) deficiency (Addisonian crisis), which may be critical without Cs supplementation. Thus, with evidence of dysfunction of the adrenal glands perioperative substitution is indicated. However, it is unclear whether unilateral adrenalectomy may attenuate the adrenocorticoid response. Glucocorticosteroids are potent agents with several well-known side effects. The purpose of the present study was to evaluate if routine Cs supplementation is justified and necessary in patients undergoing adrenalectomy during nephrectomy for renal-cell cancer. METHODS: Ten consecutive patients with renal-cell cancer (5 male, 5 female; age 58 +/- 10 years; ASA class I-II) who underwent adrenalectomy with radical nephrectomy were included in this study. None of them had received steroids for at least 5 years prior to the current surgery. Anaesthesia was induced with propofol, fentanyl, and vecuronium and maintained with isoflurane (PetIso: 0.8 +/- 0.3 vol.%) in nitrous oxide (66%) and oxygen. The patients did not receive any Cs treatment perioperatively. Monitoring included heart rate (beats/min), mean arterial pressure (mm Hg), central venous pressure (mm Hg), O2 saturation (%), and body temperature (degrees C, rectal). Plasma analyses included Cs (Cs radioimmunoassay IBL; normal 120-250 ng/ml), adrenocorticotropic hormone (ACTH) (ACTH-II IRMA; normal (10-50 pg/ml), glucose, and electrolytes determined as follows: preoperatively (8 a.m.); 1-6 h (60-min intervals) after surgery; pre-corticotropin-releasing hormone (CRH) (Corticobiss: 2 micrograms/kg i.v.) administration (1st postop. day at 8 a.m. and after 30, 60, 90, and 120 min. The study was completed with plasma analyses on postoperative days 2 and 3 (8 a.m.). RESULTS: None of the patients showed any clinical signs of plasma parameter of adrenal insufficiency due to the unilateral adrenalectomy. Serum levels (median: 25%/75% percentiles) of Cs (maximum [max.]:253 [217/288] ng/ml) and ACTH (max.:347 ([68/405] pg/ml) were elevated above the normal range postoperatively). After intravenous stimulation with CRH (1st postoperative day), Cs (max.:273 [248/310] ng/ml) and ACTH (max.: 107 ([75/275] pg/ml) were also increased above normal. During postoperative days 2 and 3 (8 a.m.) Cs and ACTH remained in the high-normal range. CONCLUSIONS: Data from this study indicate that unilateral adrenalectomy was associated with adequate spontaneous Cs secretion by the remaining adrenal gland. Moreover, stimulation with CRH demonstrated adequate reactivity of the pituitary-adrenal axis. None of the patients showed any signs of Cs deficiency by clinical or serum parameters. Therefore, we do not recommend routine Cs supplementation in patients undergoing adrenalectomy during tumor nephrectomy, nevertheless, Cs supplementation remains necessary for patients with primary hypothalamic-pituitary-adrenal dysfunction (Addison's disease) or hyperfunction (Cushing's disease).     

Multicentric experience of the Belgian Group for Endoscopic Surgery (BGES) with endoscopic adrenalectomy

BACKGROUND: Adrenalectomy is not a frequent operation. Therefore the newly developed laparoscopic approach is sporadically performed by surgeons dealing with endocrine disorders. METHODS: Some 54 videoendoscopic adrenalectomies performed on 52 patients by five surgical teams between October 1993 and December 1996 were prospectively evaluated. RESULTS: Indications for endoscopic adrenalectomy were pheochromocytoma (n = 17), primary hyperaldosteronism (n = 15), Cushing's adenoma or disease (n = 7), nonsecreting adenoma (n = 7), single metastasis from adenocarcinoma (n = 2), adenoma with dehydroepiandrostenedione (DHEAS) hypersecretion (n = 3), and ACTH-secreting metastases from a thymoma (n = 1). Of the 54 adrenalectomies performed, 31 were of the left gland, 19 of the right and two bilateral. Laparoscopic adrenalectomy was successful in 50 patients (96%). Median tumor size was 4 cm (range 1.5-12), median operation duration was 80 min (range 59-360), and median postoperative stay was 4 days (range 2-13). One patient required blood transfusion. CONCLUSIONS: Endoscopic adrenalectomy can safely be performed-even sporadically-by surgeons well versed in adrenalectomy techniques for endocrine disorders and trained in endoscopic surgery.     

Idiopathic adrenal hemorrhage: a case report

A 77-year-old man with a low grade fever persisting for 30 days consulted a local physician. A computed tomographic scan of the abdomen showed a mixed density mass on the left adrenal gland. He was referred to our hospital for further examination. Hormonal assay demonstrated a slightly high level of noradrenalin in the serum (18 pg/ml) and vanillyl mandelic acid in the urine (6.2 ng/ml). Magnetic resonance imaging revealed a heterogeneous mass lesion 3 cm in diameter with a high signal intensity on both T1 and T2 weighted images. Angiography showed a hypovascular mass in the supra-renal region suggesting an adrenal tumor or malignancy. Left adrenalectomy combined with en bloc nephrectomy was performed because of severe adhesion. Histologic evaluation showed hematoma without malignant cells due to idiopathic adrenal hemorrhage.     

Bilateral adrenocortical adenomas and the pheochromocytoma syndrome

A 43-year-old man with clinical signs of pheochromocytoma and adrenal adrenal enlargement underwent adrenalectomy. Bilateral adrenocortical adenomas accompanied by a pressure atrophy of surrounding cortex and normal adrenal medulla were found. The tumours exhibited neither immunohistochemical nor ultrastructural signs of medullar differentiation. As the clinical symptoms of pheochromocytoma slowly disappeared during the 18 month-postoperative period we consider the local tumour activity most probably responsible for the pseudopheochromocytoma symptomatology.     

Esophageal manometric studies in children with achalasia before and after operative treatment

A 68-year-old woman was found crouching in the kitchen with severe upper abdominal pain. She entered a state of shock at our emergency clinic. Abdominal computed tomography (CT) scan demonstrated a 3 cm cystic mass dorsal to the pancreas tail accompanied with a hematoma. On angiography, a bleeding from the left middle adrenal artery was identified and embolized for hemostasis. An operation was performed 3.5 months after embolization. Preoperative evaluation showed the tumor to be endocrinologically inactive. Metoclopramide stimulation test was negative, too. Left adrenalectomy was performed uneventfully without intraoperative increase in blood pressure. However, histopathological diagnosis was pheochromocytoma. Transarterial embolization is an effective treatment for adrenal bleeding. In our case, however, embolization might have caused the tumor to be falsely "endocrinologically inactive".     

Increased urinary catecholamines in a hypertensive child with renal artery stenosis

We report a hypertensive child with renal artery stenosis who exhibited increased urinary excretion of norepinephrine (NE) and normetanephrine (NMN), while vanillylmandelic acid (VMA) excretion was within the normal range. The NMN values prompted us to investigate the patient for pheochromocytoma; for this purpose, NE was determined by plasma catecholamine assays in venous samples obtained by catheterization. The moderately increased NE levels could not be localized to any particular sampling site. Arteriography demonstrated right renal artery abnormalities. Following right nephrectomy with preservation of the right adrenal gland, arterial blood pressure returned to normal. The cause of increased NMN excretion without a concomitant rise in VMA during hypertension is discussed.     

Benign desoxycorticosterone-producing adrenal tumor

A woman with a benign tumor of the left adrenal cortex had a six-year history of hypertension. Serum potassium level and plasma renin activity were low. Plasma aldosterone and cortisol levels were low normal, and plasma desoxycorticosterone (DOC) level was extremely high. Iodine 131-labeled cholesterol accumulated in the tumor in the left upper quadrant of the abdomen. At laparotomy, a benign adrenal tumor was excised; thereafter, the blood pressure and plasma DOC levels returned to normal. We believe that this is the first case of a benign DOC-producing adrenal tumor.     

Is gastric lymphoma an infectious disease?

In a 10-year-old ovariohysterectomized standard Schnauzer, the finding of dexamethasone-resistant hypersecretion of cortisol, the results of computed tomography, and elevated plasma concentrations of ACTH suggested the presence of both adrenocortical tumour and pituitary-dependent hyperadrenocorticism. The dog made an uneventful recovery after bilateral adrenalectomy and remained in good health for 31/2 years with substitution for the induced hypoadrenocorticism. Then the enlarged pituitary caused neurological signs and eventually euthanasia was performed. The surgically excised right adrenal contained a well-circumscribed tumour of differentiated adrenocortical tissue and in the left adrenal there were two adrenocortical tumours and a pheochromocytoma. The unaffected parts of the adrenal cortices were well developed and without regressive transformation. At necropsy there were no metastatic lesions. The cells of the pituitary tumour were immunopositive for ACTH and had characteristics of malignancy. The present combination of corticotrophic tumour, adrenocortical tumours, and pheochromocytoma may be called 'multiple endocrine neoplasia' (MEN), but does not correspond to the inherited combinations of diseases known in humans as the MEN-1 and the MEN-2 syndromes. It is suggested that the co-existence of hyperadrenocorticism and pheochromocytoma may be related to the vascular supply of the adrenals. Some chromaffin cells of the adrenal medulla are directly exposed to cortical venous blood, and intra-adrenal cortisol is known to stimulate catecholamine synthesis and may promote adrenal medullary hyperplasia or neoplasia.     

A case of pheochromocytoma incorrectly diagnosed before and during surgery

In a patient with an adrenal tumor, although norepinephrine levels in the blood and urine were abnormally high, findings in CT and 131 I-MIBG scintigraphy denied pheochromocytoma. The preoperative diagnosis was metastatic adrenal tumor. The surgical manipulation of the tumor increased the blood pressure from 110/60 to 210/110 mmHg. However, intraoperative microscopic examination in frozen section excluded again possibility of pheochromocytoma. Later, findings in the permanent specimen confirmed that the tumor was pheochromocytoma. The problem of this case was that each specialist made judgment only on the subject of his own interest without considering of the patient's status as a whole. Anesthesiologist should have the ability to make preoperative assessment of a patient by using all available information with his unbiased mind.     

Immunological effects of an arginine side chain contaminating synthetically prepared peptides

We examined the effect of a nitric oxide (NO) quencher, stroma-free human hemoglobin A (HbA0; 0.01, 0.05, 0.1, 0.2 g/kg), on the blood flow measured using the Doppler flow technique, tumor oxygen pressure (pO2) and the diameter of the arterioles using R3230Ac mammary adenocarcinoma as the tumor model. In female Fischer 344 rats with 1-cm-diameter tumors implanted in the lateral aspect of the left quadriceps, intravenous infusion of 0.1 and 0.2 g/kg HbA0 decreased both central tumor and peripheral tumor blood flow by 20-30% (P < 0.05). Tumor pO2 decreased 28% with 0.2 g/kg HbA0, from 15 mm Hg (baseline) to 11 mm Hg at 10 min (P = 0.02). Although 0.2 g/kg HbA0 increased blood flow 55% in the left quadriceps muscle proximal to the implanted tumor (P < 0.05), HbA0 had little effect on blood flow in right quadriceps muscle with no tumor implanted, and increased right quadriceps pO2, from 21 mm Hg (baseline) to 23 mm Hg at 10 min (P = 0.03). HbA0 increased mean arterial pressure 5-10% in a manner that was dependent on dose while heart rate concurrently decreased 9-19%. The diameter of the arterioles supplying the tumor was rapidly reduced 10% by 0.2 g/kg HbA0 (P = 0.037) and remained stable through 60 min of observation (P = 0.005). HbA0 selectively reduces tumor blood flow and tumor pO2 through vasoconstriction of the arterioles supplying the tumor. Vascular NO quenching provides an alternative to NO synthase inhibition as a means to achieve the goal of selective tumor hypoxia.     

Juvenile thyroid carcinoma with metastasis to the bilateral cervical lymph nodes--a case report

A case of juvenile thyroid carcinoma with metastasis to the bilateral cervical lymph nodes in a 9-year-old male is reported. The clinical picture of juvenile thyroid carcinoma is characterized by early metastasis to the lungs and cervical lymph nodes. In Europe, there have been many reports of thyroid carcinoma after radiation. However, our patient had received no radiation. Surgery consisted of subtotal thyroidectomy and right modified neck dissection. The tumor was a papillary adenocarcinoma and metastasis was seen in 24 out of 38 lymph nodes removed. The serum thyroglobulin level, determined by radioimmunoassay, was 184 ng/ml preoperatively, but by 8 months postoperatively the level fell to 48 ng/ml. No signs of recurrence have been found to date (30 months after the operation).     

The effect of minoxidil on blood pressure and plasma renin activity in patients with essential and renal hypertension

The effect of the new vasodilator, minoxidil, on blood pressure and plasma renin activity was studied in 21 hypertensive patients: 12 patients with essential and 9 with renal hypertension. The average maximum dosage of minoxidil was 27.9 +/- 6.0 mg/day (M +/- SD). Average duration of treatment was 84.5 days. During the observation period the average systolic blood pressure fell from 195 +/- 18 to 159 +/- 7 mm Hg (M +/- SD), and the mean diastolic blood pressure fell from 120 +/- 8.3 to 92.5 +/- 8 mm Hg (p less than 0.01). These patients had been treated earlier with other antihypertensive agents, such as reserpine, saluretics, hydralazine, alpha-methyldopa, and clonidine, without any significant reduction in blood pressure. Before treatment, plasma renin activity after resting was 59 +/- 6.4 ng/ml/16 h (M +/- SE) and after saluretics and orthostasis 89 +/- 12.7 ng/ml/16 h. After treatment, the decline in renin value after resting was statistically significant: 42.7 +/- 3.3 ng/ml/16 h (p less than 0.05), and the stimulated renin had fallen to 70 +/- 3.4 ng/ml/16 h (p greater than 0.1). A comparison of the renin stimulation values of patients with renal hypertension also revealed a significant reduction (p less than 0.01). Side effects which appeared at a daily dose of 15 to 30 mg consisted mainly of tachycardia and fluid retention and could be controlled by the administration of propranolol and chlorthalidone. In 5 women and in 1 man was observed a cosmetically disturbing, reversible hypertrichosis. Orthostatic hypotension was observed in one patient. Minoxidil is an effective antihypertensive agent. However, because of its side effects, it generally must be administered with beta-receptor blocking agents and saluretics. It is possible that its blood pressure lowering effect is due, at least in part, to a suppression of the plasma renin activity.     

Primary and idiopathic hyperaldosteronism. Course 1 year after operation. Apropos of 28 cases

The course of mean arterial pressure was compared in two series concerning 18 primary or tumoral hyperaldosteronism and 8 idiopathic ones. Identification of the nature of the hyperaldosteronism should not yet motivate a decision on principle, surgical in case of tumor, medical in an idiopathic case. In the latter case cooperation and tolerance of medical treatment, severity of hypertension also come into consideration. A positive spirolactone test, a hypertension course of less than six years were in our experience a good indication of successful surgery, as opposed to a normal unilateral renal biopsy. In case of operation, the removal protocol should adapt to the peroperative findings; 80% adrenalectomy is the most common procedure, except in the case of isolated adenoma of more than 10 mm diameter.     

Lipopolysaccharide induces sickness behaviour in rats by a vagal mediated mechanism

A 52-year-old man was hospitalized for a right adrenal tumor which had been incidentally found by abdominal CT scan for examination of colon cancer. Laboratory and endocrine findings were within the normal limits except for increased urinary concentrations of noradrenaline and dopamine. Adrenal angiography revealed that the feeding artery of the tumor was the inferior suprarenal artery. Adrenal venous blood sampling studies detected no abnormalities in the concentrations of catecholamine, cortisol or aldosterone. Right adrenalectomy was performed and the tumor was histologically diagnosed as ganglioneuroma. Ganglioneuroma is a benign tumor originating from the sympathetic nerve ganglion. The adrenal origin of the tumor is relatively rare and 60 cases of adrenal ganglioneuroma including our case have been reported in Japan.     

Simulation of a pheochromocytoma--Munchausen syndrome

A 46-year old female nursing sister was admitted to three different hospitals because of blood pressure crises of 300/150 mmHg which occurred up to six times a day. The rises in blood pressure were accompanied by headache, tachycardia and outbreaks of sweating. Raised catecholamine concentrations were repeatedly measured in the 24-hour urine and in the blood. The diagnosis of pheochromocytoma could therefore be regarded as confirmed. The investigations to establish the localization (including MIBG scintigrams carried out several times) showed negative results. Octreotide scintigraphy finally revealed a raised concentration of nuclides in the right adrenals. Selective venous blood samples showed markedly raised concentrations of adrenaline and noradrenaline in all regions investigated. After removing the right adrenal, which was of normal histological appearance, there was an improvement for six months. Afterwards, up to six blood pressure crises per day were observed once more. Fresh determination of catecholamines at various levels demonstrated the highest concentrations in the left iliac vein. It was then shown that the patient injected catecholamines intravaginally even during the angiographic investigation. A search of the patient s room revealed several ampoules containing noradrenaline and adrenaline as well as syringes and needles. - This case shows that in clinical pictures with typical clinical symptoms and negative results of repeated investigations a factitious disorder must be considered in terms of differential diagnosis especially when female patients with medical knowledge who have ready access to drugs are involved with a history comprising several stays in hospital which have not produced any clarification of their condition.     

Effect of acute hypoxia on blood catecholamine and whole blood platelet aggregation

Experiments were performed on 250-300 g male Sprague-Dawley rats under urethane (700 mg/kg) and alpha-chloralose (35 mg/kg) anesthesia. Plasma catecholamine concentration and the whole blood platelet aggregation were measured during normoxia, acute hypoxia, reoxygenation, acute hypoxia immediately after bilateral adrenalectomy and acute hypoxia at the end of 15 and 30 min after bilateral adrenalectomy. The plasma adrenaline concentration and the whole blood platelet aggregation increased markedly (P < 0.01), while the plasma noradrenaline concentration tended to increase (P > 0.05) during acute hypoxia. The plasma adrenaline concentration and the whole blood platelet aggregation are capable of restoring to the normal level during reoxygenation. The plasma noradrenaline concentration did not change, while the plasma adrenaline concentration and the whole blood platelet aggregation decreased significantly (P < 0.001 or 0.05) during acute hypoxia for 15 min immediately after bilateral adrenalectomy. On the other hand, plasma adrenaline and noradrenaline were not detectable during acute hypoxia 30 min after bilateral adrenalectomy while the whole blood platelet aggregation deceased markedly (P < 0.01). When adrenaline (1 ng/ml) was added to the blood (in vitro), the whole blood platelet aggregation increased significantly (P < 0.01). All the above results indicate that acute hypoxia leads to increament of whole blood platelet aggregation and plasma adrenaline concentration due to release from the adrenal gland and the increament of the whole blood platelet aggregation may be partly mediated by increased plasma adrenaline.     

Laceration of a benign adrenal adenoma mimicking a splenic rupture

Lacerations of adrenal tumors are very rare events and have been described for myelolipoma, pheochromocytoma, and cortisol-producing adenoma. We report on a patient who was admitted with suspected splenic rupture. Computed tomography showed a mass 14 cm in diameter adjacent to the spleen, but selective angiography revealed blood supply by the left suprarenal artery. A ruptured adrenal tumor was therefore diagnosed and resected. No hormone production was detected. Histologically a benign adrenal adenoma was found. Frequency, diagnosis and therapy of adrenal masses are discussed.