470 Horm. Metab. Res. 8 (1976) 470474
© Georg Thieme Verlag Stuttgart
Adrenal Insufficiency Secondary to Hypothalamic Corticotropin Releasing Factor (CRF) Insufficiency with Hyperpigmentation: A Case Report* H.L. FehmI, K.H. Voigt 2 , R. Lang 1 , W.D. Hetzeil and E.F. Pfeiffer 1 lCenter of Internal Medicine and Pediatrics, Department of Endocrinology and Metabolism, and 2Center of Biology and Theoretical Medicine, Department of Physiology. University of Ulm, Ulm, Germany
Kley, KTÜskemper, Morgner, v. zur Mühlen and ZeidPartial adrenocortical insufficiency as a result of an insufficiency of the hypothalamic corticotropin releasing factor ler 1972, Pittman, Haigier, Hershman and Pittman (CRF) was demonstrated in a 53-year-old female patient. 1971, Yen, Rebar, Vandenberg and Judd 1973). Somatotropic, gonadotropic and thyreotropic functions of the pituitary gland were shown to be normal by a simultane- In 1973 we reported about a patient with adrenoous pituitary stimulation test. This held true especially for cortical insufficiency which was attributed to isothe adrenocorticotrophic function: administration of lysinelated CRF deficiency (Fehm, Voigt and Pfeiffer vasopressin induced anormal rise in immunoreactive plasma1973). This patient had suffered from recurrent tuACTH. Thus, a pituitary defect as primary cause of the disease could be exc\uded and evidence was provided that there bercular meningoencephalitis for many years and then was a lack in hypothalamic stimulation of ACTH-secretion. developed severe hypoglycemia caused by secondary An enigmatic feature in this patient was that in the absence adrenocortical insufficiency. Somatotropic, gonadoof elevated ACTH levels hyperpigmentation of the skin extropic and thyreotropic functions of the anterior piisted, Possible explanations are discussed. Key-Words: Adrenocortical Insufficiency - Corticotropin Releasing Factor - Lysine- Vasopressin Test
Introduction At least 13 patients are described in the literature who are thought to have a monohormonaJ ACTH insufficiency (Abramson and Arky 1968, Cleveland, Green and Midgeon 1960, Green and Ingbar 1961, Kratz and Graef 1973, OdelI, Green and Wi/liams 1960, OdelI, Rayford and Ross 1967, Perkof!. EikNes, Cames and Tyler 1960, Steinberg, Shechter and Segal 1954, Woeber and Arky 1965). However, growth hormone has been estimated only in one case (Woeber and Arky 1965) and ACTH in another singular one (Kratz and Graf 1973). One must assurne that both monohormonaJ and polyhormonaJ hypopituitarism may result from either prirnary pituitary or primary hypothalamic deficits. To differentiate between these two conditions it would be necessary to demonstrate adequate pituitary gland responses to hypothalamic releasing or inhibiting hormones. By analogy with earlier methods of examining adrenal reserve with ACTH or thyroid reserve with TSH, isolated TRH deficiency has been identified in several cases as a cause of isolated pituitary-thyroid failure and isolated LHRH deficiency as a cause of hypogonadotropic hypogonadism and of functional amenorrhea (Costom, Grumbach and *Supported by the Deutsche Forschungsgemeinschaft, Project B2 (SFB 87) Received: 5 May 1976
Accepted: 14 June 1976
tuitary gland were shown to be normal. Lysine-vasopressin (LVP) was used to stimulate ACTH secretion of the pituitary. This test initiated a pronounced rise in plasma ACTH. Thus, a pituitary defect as primary cause of the disease was excJuded. In the patients with monohormonal ACTH insufficiency mentioned above, no attempts were made to differentiate between wh at may be called prirnary and secondary ACTH insufficiency. Therefore it cannot be excJuded that at least some of them had a deficiency in CRF rather than in ACTH. We wish now to present the endocr\ne findings of another patient thought to suffer from isolated CRF deficiency. This fern ale patient is an outstanding example inasmuch as she exhibited a marked hyperpigmentation of the skin in the absence of measurable ACTH levels. Case Presentation Case history A 53-year-old menopausal woman was admitted to the hospital because of a history of fatigue, adynamia, hyperpigmentation of the skin and peripheraJ edema. 20 years before admission, during the flIst and only pregnancy (mens seven) there had been a sudden generalized increase of pigmentation, a decrease in the daily urine output and the onset of peripheral edema. There was no history of fever, hypotension, anorexia or weight loss. The delivery was normal, melanosis of the skin and peripheraJ edema persisted, however. An adrenal insufficiency was substantiated by demonstrating decreased urinary excretion of total 17-hydroxycorticosteroids and areplacement therapy of 5 mg prednisone daily was started. However, the patient took her meditation very irregularly and there had been repeated intervaJs without therapy up to aperiod of three months. Nevertheless, she feit relatively weil most of the time during the following 20 years with only an exceptional case of high fever upon contracting an ordinary infection. During this episode,
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Kaplan 1971, KTÜskemper, Beisenherz , Hemnann,
Summary
CRF Insufficiency
471
ble 1. To test the reserve of the adenohypophysis, a simultaneous pituitary stimulation test was used as described reC/inical features cently (Voigt, Dahlen. Fehm, Birk, Schröder, Schneider, RoExamination revealed a we11-appearing woman with typical thenbuchner and' Pfeiffer 1974). In short, at one time 200 hyperpigmentation of the skin as seen in Addison's disease. 118 TRH and ~5.pg. LHR.H were injected intravenously as a Especially the exposed parts of the body (face, neck, arms bolus and an mfuslon wlth 5 I. U. Iysme-vasopressm .(~ VP) and hands), nipples, genitalia and creases of the palms showed and 0.5 g/kg I-argmme ~as started. InfusIOn of I-argmme was dlscontmued after 30 mmutes and of LVP after 6(} mmutes. exaggerated pigmentation. Distension of neck veins and lip Blood was drawn for radioimmunologic measurement of cyanosis were present as weil as pretibial and malleolar edema. No further anomalies were noted. Height 5'2", body TSH, LH, FSH, proactin, GH and ACTH at -30, 0, 15, 30, weight 56.5 kg, blood pressure 115/70 mm Hg, pulse 60,blin, 45, 60, 90 and 120 minutes. Gonadotropin radioimmunoassays were carried out according to OdelI, Rayford and Ross body temperature 36.20C. (1967). Prolactin was measured using a kit from Sero no Co. (Rome). Radioimmunoassay of ACTH was performed after Laboratory findings extraction of ACTH from plasma as described recently Sedimentation rate (Westergren) was 18 mm in one hour. (Fehm. Voigt and Pfeiffer 1972, Voigt, Fehm. Reck and Hematologic values pertaining to erythrocytes were a11 norPfeiffer 1974). In our assay system the cross reaction with mal, leucocytes 4,300, in the differential ce11 count were 39% human I}MSH was 1: 1,000. Tbe results of the simultaneous segmented neurophils, 2% eosinophils, 57% Iymphocytes and pituitary stimulation test are given in Table 2. Table 3 shows 2% monocytes. Blood glucose had been estJmated repeatedthe results of further endocrine examinations under basal ly throughout the day: the lowest value observed was 51 mg%. conditions. * On x-ray examination of the chest and of the skull there were no abnormalities. Frontal and sagittal views of the se11a turDicussion cica demonstrated normal length and depth of the pituitary fossa, no erosion or destruction of the anterior and posterior The diagnosis of incomplete adrenal insufficiency clinoids. no intrasellar or suprase11ar calcifications.
is clearly established on the basis of the following findings: decreased excretion of total 17-ketosteroids Replacement therapy with prednisone had been discontinued in urine, 10w normal values for urinary total 17-hydroxycorticosteroids, decreased levels of plasma-cor4 weeks prior to the first endocrine examination. Tbe responsiveness of the adrenal gland to ACTH was assessed by tisol and the diminished response of plasma-cortisol infusion of 0.5 mg synthetic ßI-24 ACTH (Ciba Co., Basel) du ring an 8-hr ACTH stimulation test (Tables 1 and during 8 hours. Plasma cortisol was measured f1uorometricalIy (Spencer·Peet, Daly and Smith 1965) be fore and 4, 6 and 3). The symptoms fatigue, adynamia, lymphocytosis and the tendency to hypotensive blood pressure va8 hours after beginning of the infusion. Tbis test was repeated on 4 consecutive days. Tbe results are given in Talues as weH as the tendency to hypoglycemia are weH explained by this diagnosis. The fact that most of Table I. Plasma-cortisol values during the ACTH stimulation the time the patient feit relatively weH while on the test performed on four consecutive days. 0.5 mg synthetic replacement therapy of a daily average of less than ßI-24 ACTH were infused du ring 8 hours. Normal range for plasma-cortisol 5.0 to 25 pg per 100 m!. 2.5 mg prednisone is attributed to the preservation of a certain amount of endogenous steroid secretion. Endocrine examinations
plasma cortisol pg/IOO ml day day day day
time interval hours
1 2 3 4
0
4
3.9 6.7 6.2 5.0
9.9 18.9 22.7 28.7
6
ACTH stimulation tests on four consecutive days revealed that an alm ost normal sensitivity of the adrenal glands to ACTH could be achieved. This is usually taken to indicate adrenal insufficiency secondary 11.8 8
10.8 24.0 24.8 31.7
24.6 *For measurement of so me of the various hormonal para25.5 meters in plasma and urine we would like to thank Drs. Birk 32.0 (TSH), Schröder (HGH) and Pal (corticosteroids).
Table 2. Results of the simultaneous pituitary stimulation test. At time zero, 200 pg TRH, 25 pg LHRH were injected intravenously as a bolus and an infusion with 5 LU. LVP and 0.5 g/kg I-arginine was started. Infusion of I-arginine was discontinued after 30 minutes, of LVP after 60 minutes. LH and FSH were grossly elevated since the patient was menopausal for 2 years. Basal levels of HGH, PRL and TSH were in the normal range and increased normally after stimulation. ACTH- and cortisol values are depicted in Figure 1. time min HGH ng/ml LH ng/ml FSH ng/ml PRL ng/ml TSH IlU/ml ACTHpg/ml cortisol 118/100 ml
-30
0
15
30
45
60
90
120
1.7
2.0
21.6
163
>30 >250 1280 28 6.2 235
>30
6.2 53
24.2 >250 1300 25 7.8 16
>30 >250 1350 24
0
1.3 250 1120 6 4.2 57
3
4.6 0
6.7
5.6
6.5
7.0
9.2
11.6
12.5
10.3
250 1370 6
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she was unconscious briefly, and feIt entirely debilitated.
H.L. Fehm, K.H. Voigt, R. Lang, W.D. Hetzel and E.F. Pfeiffer
Table 3. Results of endocrine measurements under basal conditions. In case of multiple estimations the two extreme values are given. Normal range in parenthesis. immunoreactive plasma ACTH plasma-cortisol at 8 a.m. urinary total 17-hydroxycorticosteroids urinary total 17-ketosteroids protein-bound-iodine thyroxin-bindingindex
0-56 pg/ml (0-150 pg/m\) 2.5-6.0 J..Ig/100 ml (5.0-25 J..Ig/ml) 6.4-8.0 mg/24 hr (5-15 mg/24 hr) 3.5-4.1 mg/24 hr (6-16 mg/24 hr) 3.7-4.2 J..Ig/100 ml (3.5-8.0 J..Ig/100 ml) 1.06-1.08 (0.9-1.2)
plasma-ACTH pg/ml ±SEM
x
ACTH pg/ml
Table 4. Plasma-ACTH and -cortisol values in patients with primary adrenal insufficiency. Plasma was obtained two hours after ingestion of the morning dose (25.0 mg cortisone-acetate, total daily dose 37.5 mg and 0.1 mg 9-a-f1uorohydrocortisone) or after withdrawal of replacement therapy for 24 hours.
cortisol ~g/100 ml
51.U. LYP I.v.
300
200
40
100 20
plasma-cortisol J..Ig/100 ml ±SEM
N
x
Addison's disease without treatment
2073 ± 458
2.7 ± 2.0
10
Addison's disease with treatment
1073 ± 204
12.9 ± 1.9
13
Normal controls
55.6±17
1\.3 ± 1.5
12
of LH and FSH were grossly elevated since the patient was menopausal for two years. To test the pituitary adrenotropic function, LVP was administered because CRF is not available for clinical studies. With this stimulus a clearcut rise in plasma-ACTH was observed with a maximum of 235 pg/ml after 60 minutes. This rise in ACTH was followed 30 minutes later by a rise in plasma-cortisol from 5.6 to 12.5 Ilg per 100 ml.(Fig. 1). In our hands in normal persons the maximal ACTH value during LVP-testing is observed after 30 minutes with a mean of 215 ± 30 pg/ml. Thus, the ACTH response to LVP in this patient appeared to be normal in increment but delayed in time.
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472
In general the adrenal insufficiency in this patient apparently cannot be explained by a c.Jefect in pituitary function. On the basis of evidence now availo o able, a deficiency in hypothalamic CRF synthesis and/or release would best explain the defect ob· served. As all parameters of thyroid function, gonadal function and GH release were within the normal range, Fig. 1. Immunoreactive plasma-ACTH and plasma-cortisol le· vels during the simultaneous pituitary stimulation test. LVP an isolated insufficiency of CRF secretion must be was used to stimulate ACTH release. The shadowed area repostulated. One might object, that the suppression presents the 95% confidence limits of the normal reaction of of the hypothalamic-pituitary-adrenal system is posACTH as reported previously (Voigt, Fehm, Reck and Pfeiffer 1974). The ACTH response to LVP in our patient appeared sibly due to long-term administration of prednisone. Therefore we examined the effect of the usual reto be normal in increment but delayed in time. Surprisingly, there was a small rise in plasma-cortisol also, demonstrating placement therapy (37.5 mg cortisone-acetate in 2 that total atrophy of the adrenal glands had not occurred. doses equivalent to 7.5 mg prednisone and 0.1 mg to hypopituitarism. This diagnosis was confirmed by 9-a-flurohydrocortisone) on ACTH hypersecretion in patients with Addison's disease. Table 4 demonstrates radioimmunologic measurement of plasma-ACTH. that with this regimen elevated ACTH-levels deWhereas in primary adrenal insufficiency ACTH vacreased but did not fall into the normal range delues are excessively elevated (Table 4), in this paspite normalization of plasma-cortisol values and detient plasma-ACTH levels were not measurable four spite relief of all complaints. According to this fact times and one time it was found in the low normal range (Table 3). Mostly, secondary adrenal insufficien- - which in itsclf is difficult to explain - one can cy occurs within the syndrome of panhypopituitarism. rule out that an average dose of prednisone less than 2.5 mg daily, as in our patient, may induce almost Careful examination of the pituitary function by complete suppression of ACTH-secretion. means of a simultaneous pituitary stimulation test however, demonstrated normal somatotropic, thyreo- In the his tory of our patient there are no indications tropic and gonadotropic function. Basal plasma levels for a hypothalamic disease such as neoplasma, trau-
CRF Insufficiency
473
sufficiency, hemaehromatosis, increased amounts of gonadal steroids, infections and neoplastic diseases. In this patient ACTH-hypersecretion could be excluded and a thorough clinical examination revealed no evidenee for non-endocrine causes of hyperpigmentation. Therefore the most obvious assumption would be that hyperpigmentation was due to hypersecretion of MSH although MSH has not been meaRecently, the concept that printary pituitary and pri- sured. If it should prove out that MSH levels were elevated, there are at least 2 different mechanisms mary hypothalamic deficits can be differentiated by which could account for this: examining the response of the pituitary gland to hy1. Aeeording to Abe, Nicholson, Liddie, Orth and pothalamic re leasing hormones, has been questioned seriously. Patel and Burger (1973) demonstrated that Island (1969) a deficiency in adrenal steroids stimulates ß-MSH secretion as weIl as ACTH-secretion. the TSH reserve is usually normal in hypothalamic and pituitary hypothyroidism and TRH responsiveThis would suggest that eaeh ease of adrenal insufness cannot adequately differentiate between the two fieiency secondary to monohormonal ACTH or CRF conditions. Similar conflicting results were obtained insufficiency is aecompanied by hyperpigmentation. with LHRH in patients with hypogonadotrophie hy- However, the only patient described in the literature pogonadism (Mortimer, Besser, McNeilly, MarshalI, who was thought to have hyperpigmentation in the Harsoulis, Turnbridge, Gomez-Pan and Hall 1973). presence of monohormonal ACTH insufficiency is Finally, the value of vasopressin in the diagnostic that of Steinberg, Shechter and Segal (1954), whereevaluation of pituitary and hypothalamic function as all other patients with this diagnosis were dehas been criticized also (Toft, Buus and Nielson scribed as pale. 1971). However, in our experiences as weIl as in the 2. Another assumption would be that the hypothalaliterature there was never a patient observed with a mie disorder in our patient pertains not only to CRF normal response in LVP-testing in the presenee of but also to MSH release-inhibiting hormone (MRIH). proven adrenal insufficiency due to a pituitary disHowever, though MRIH has been found in the huorder, whereas negative results may occur in otherman hypothalamus (Kastin and Schally 1967), the wise normal persons. physiologie significance of MRIH in man is not estaAn enigmatic feature in this patient was that hyperpigmentation of the skin existed which was very suggestive or primary adrenal insufficiency. There are many causes of hyperpigmentation beside hypersecretion of ACTH and/or MSH, e.g. advanced hepatic in-
blished till now. Acknowledgements The authors wish to acknowledge the skillful technical assistance of Mrs. U. Winkler and Mrs. Ch. Nierle.
References
Abe, K., Jtl.E. Nicholson, G. W. Liddie, D.N. Orth, D.P. Is· kmd: Normal and abnormal regulation of (}MSH in man. J.Clin.lnvest. 48: 1580-1585 (969) Abramson, E.A., R.A. Arky: Coexistant diabetes mellitus and isolated ACfH deficiency; report of a case. Metabolism 17: 492-495 (I968) Cleveland, W. W., O. C Green, Cl. Midgeon: A case of proved adrenocorticotropin deficiency. J.Pediat. 57: 376-381 (I960) Costom, B.H., M.M Grumbach, S.L. Kaplan: Effect of thyrotropin-releasing factor on serum thyroid-stimulating hormone. J.Clin.lnvest. 50: 2219·2225 (971) Fehm, HL., K.H Voigt, H.F. Pfeiffer: NebennierenrindeninsuffIzienz als Folge eines isolierten Mangels an Corticotropin-Releasing-Hormon (CRH). Dtsch.med.Wschr. 98: 2066-2069 (1973) Fehm, HL., K.H Voigt, E.f: Pfeiffer: Problems and artefacts in ACTH-assay. Horm.Metab.Res. 4: 477-485 (1972) Green, W.L., S.H Ingbar: Decreased corticotropin reserve as isolated pituitary defect. Arch.lnternat.Med. 108: 945952 (I961) Kastin, A.J., A. V. Schalty: MSH activity in pituitaries of rats treated with various animal hypothalamic extracts. Gen.Comp.Endocrinol. 8: 344-347 (1967)
Kratz, F., V. Grae!" Über einen Fall einer Gravidität bei isoliertem Ausfall von ACfH. Klin.Wschr. 51: 1062-1065 (1973) KTÜskemper, HL., W. Beisenherz, l. He"mann, H.K. Kley, G. KTÜskemper, K.D. Morgner, A. V. v. zur Mühlen, U. Zeidler: Hypothyreose mit isoliertem Mangel an Thyreotropin-Releasing-Hormon (TRH). Dtsch.med. Wschr. 97: 76-81 (1972) Mortimer, CH, G.M. Besser, A.S. McNeilly, l.C Marshalt, P. Harsoulis, W.M.G. Turnbridge, A. Gomes·Pan, R. Hall: Luteinizing hormone and follicle stimulating hormonereleasing hormone test in patients with hypothalamicpituitary-gonadal dysfunction. Brit.Med.J. 4: 73-77 (1973) Odelt, W.D.: Iso la ted deficiencies of anterior pituitary hormones. J.Amer.Med.Ass. 197: 1006-1016 (1966) OdelI, W.D., G.M. Green, R.H. Williams: Hypoadrenotropism: The isolated deficiency of adrenotropic hormone. J.Clin.Endocr. 20: 1017-1028 (1960) Odelt, W.. D., P.L. Rayford, G. T. Ross: Simple, partially automated method for radioimmunoassay of human thyroid stimulating, growth, luteinizing and follicle stimulating hormones. J.Lab.& Clin.Med. 70: 973-976 (1967) Patel, Y.c., HG. Burger: Serum thyrotropin (TSH) in pituitary and/or hypothalamic hypothyroidism: normal or
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ma or inflammation. Nevertheless, the fact that the first symptoms of adrenal insufficiency occurred during pregnancy is of interest. A case of "isolated ACTH deficiency" manifesting itself du ring pregnancy has been described by Kratz and Graef (1973). However, the ability of the pituitary to secrete ACTH upon adequate stimulation has not been tested in this patient.
474
A. Cohen
elevated basal levels and paradoxical responses to thyrotropin-releasing hormone. J.Clin.EndoerinoI.Metab. 37: 190-196 (1973) Perkaf!. G. T., K. Eik·Nes, WH. Cames, F.H. Tyler: Seleetive hypopituitarism with deficiency of anterior pituitary basophils: A case report. J.Clin.Endocr. 20: 1269-1279 (1960) Piuman, J.A., E.D. Haigier, J.M. Hershman, C.S. Pittman: Hypothalarnie hypothyroidism. N.EngLJ.Med. 285: 844845 (1971) Spencer-Peet, J., J. Daly, V. Smith: A simple method for improving the specificity of the fluorometric determination of adrenal cortieosteroids in human plasma. J .Endoer. 31: 235-237 (1965) Steinberg, A., F.R. Shechter, H.l. Segal: True pituitary Addison's disease - A pituitary unitropie deficieney. J.Clin. Endocr. 14: 1519-1529 (1954)
Toft, H., O. Buus, E. Nielson: Vasopressin in the diagnostic evaluation of pituitary and hypothalamie funetion. Acta Endocr. 67: 393-400 (1971) Voigt, K.H., H.G. Dahlen, H.L. Fehm, J. Birk, K.E. Schrö· der, H.P.G. Schneider, G. Rothenbuchner, E.F. Pfeiffer: Simultaneous stimulation test for the anterior pituitary hormones. Horm.Metab.Res. 6: 436-437 (1974) Voigt, K.H., H.L. Fehm, R. Reck, E.F. Pfeiffer: Spontaneous and stimulated secretion of QUSO-extraetible immunoassayable ACfH in man. Klin. Wsehr. 52: 516-521 (1974) Woeber, K.A., R. Arky: Hypoglycemia as a result of isolated eorticotrophin-deficieney. Brit.Med.J. 11: 857-858 (1965) Yen, S.S.c., R. Rebar, G. Vandenberg, H. Judd: Hypothalamie amenorrhea and hypogonadotropism: responses to synthetic LRF. J.Clin.Endocr.Metab. 36: 811-816 (}973)
Horm. Metab. Res. 8 (}976) 474-478
© Georg Thieme Verlag Stuttgart
Adrenal and Plasma Corticosterone levels in the Pregnant, Foetal and Neonatal Rat, in the Perinatal Period A. Cohen Laboratoire de physiologie du developpement. Universite Pierre et Marle Curie. Paris. France
Summary A group of pregnant control rats was sacrifieed before parturition, in the morning, afternoon and evening of day 20 and 21 and in the morning of day 22. Another group was sacrifieed during parturition, when 2 to 8 foetuses had been expelled. The onset of parturition oecurred for the first rat in the afternoon of day 21 and for the last rat in the afternoon of day 22. Corticosterone was extraeted from maternal, foetal and neonatal adrenals and plasma, and was assayed by a fluorometric procedure. The maternal adrenal and plasma corticosterone levels, before parturition, were lower in the morning than in the afternoon exeepting day 22 when morning values were as high as those in the afternoon of day 21. Adrenal and plasma corticosterone eoncentrations were eleva ted during parturition in the mother but not the foetus. Plasma cortieosterone values were raised in the newborn eompared to their littermates in utero. Key-Words: Parturitian - Adrenal and Plasma Corticosterone - Pregnant Rat - Foetus - Newborn
Introduction Ouring late pregnancy in the rat, the foetal plasma corticosterone levels reaeh a peak value on day 19 and then fall until day 21 (Holt and Oliver 1968, Cohen 1973, lost 1973, Dupouy and Cohen 1975, Dupouy, Coffigny and Magre 1975). Received: 15 Oet. 1976
Accepted: 8 June 1976
Immediately after birth, the plasma eorticosterone coneentrations are high (Koch 1969, Kamoun 1970, Hiroshige and Sato 1971, Malinowska, Hardy and Nathanielsz 1972, Corbier and Rolli 1974) but deeline quiekly from the first or the second hour to the eighth hour of postnatal life (Malinowska, Hardy and Nathanielsz 1972, Corbier and Rolli 1974). The present study was undertaken to investigate changes in adrenocortical function in the rat in the immediate perinatal period and is an extension of the work of Cohen (1973), Cohen and Brault (1974) and Dupouy and Cohen (1975). A preliminary report of this work has been pl:lblished (Cohen 1975). Methods Pregnant Wistar rats were maintained under controlled Iighting eonditions (light period 06.00-20.00 h), at a constant temperature of 23 0 C with free aceess to food and water. Gestational age was caleulated from the time of ovulation: 01.00 A.M. (Jost and Picon 1970). Rats were eaged individually for at least 24 h before saerifice.
Group I: Contral group (Fig. 2 and Fig. 3) Animals were sacrificed on day 20 and day 21 of pregnancy at 10.00 h, 16.00 hand 22.00 hand on day 22 at 10.00 h, prior to parturition.
Graups lIa and IIb: Groups sacrificed during parturition (Table 1)
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Requests for reprints should be addressed to: Dr. H.L. Fehm, Dept. Int. Medicine, Endocrinology and Metabolism, University of Ulm; Steinhövelstr. 9, D-79 Ulm/Donau (Germany)
© Georg Thieme Verlag Stuttgart
Adrenal Insufficiency Secondary to Hypothalamic Corticotropin Releasing Factor (CRF) Insufficiency with Hyperpigmentation: A Case Report* H.L. FehmI, K.H. Voigt 2 , R. Lang 1 , W.D. Hetzeil and E.F. Pfeiffer 1 lCenter of Internal Medicine and Pediatrics, Department of Endocrinology and Metabolism, and 2Center of Biology and Theoretical Medicine, Department of Physiology. University of Ulm, Ulm, Germany
Kley, KTÜskemper, Morgner, v. zur Mühlen and ZeidPartial adrenocortical insufficiency as a result of an insufficiency of the hypothalamic corticotropin releasing factor ler 1972, Pittman, Haigier, Hershman and Pittman (CRF) was demonstrated in a 53-year-old female patient. 1971, Yen, Rebar, Vandenberg and Judd 1973). Somatotropic, gonadotropic and thyreotropic functions of the pituitary gland were shown to be normal by a simultane- In 1973 we reported about a patient with adrenoous pituitary stimulation test. This held true especially for cortical insufficiency which was attributed to isothe adrenocorticotrophic function: administration of lysinelated CRF deficiency (Fehm, Voigt and Pfeiffer vasopressin induced anormal rise in immunoreactive plasma1973). This patient had suffered from recurrent tuACTH. Thus, a pituitary defect as primary cause of the disease could be exc\uded and evidence was provided that there bercular meningoencephalitis for many years and then was a lack in hypothalamic stimulation of ACTH-secretion. developed severe hypoglycemia caused by secondary An enigmatic feature in this patient was that in the absence adrenocortical insufficiency. Somatotropic, gonadoof elevated ACTH levels hyperpigmentation of the skin extropic and thyreotropic functions of the anterior piisted, Possible explanations are discussed. Key-Words: Adrenocortical Insufficiency - Corticotropin Releasing Factor - Lysine- Vasopressin Test
Introduction At least 13 patients are described in the literature who are thought to have a monohormonaJ ACTH insufficiency (Abramson and Arky 1968, Cleveland, Green and Midgeon 1960, Green and Ingbar 1961, Kratz and Graef 1973, OdelI, Green and Wi/liams 1960, OdelI, Rayford and Ross 1967, Perkof!. EikNes, Cames and Tyler 1960, Steinberg, Shechter and Segal 1954, Woeber and Arky 1965). However, growth hormone has been estimated only in one case (Woeber and Arky 1965) and ACTH in another singular one (Kratz and Graf 1973). One must assurne that both monohormonaJ and polyhormonaJ hypopituitarism may result from either prirnary pituitary or primary hypothalamic deficits. To differentiate between these two conditions it would be necessary to demonstrate adequate pituitary gland responses to hypothalamic releasing or inhibiting hormones. By analogy with earlier methods of examining adrenal reserve with ACTH or thyroid reserve with TSH, isolated TRH deficiency has been identified in several cases as a cause of isolated pituitary-thyroid failure and isolated LHRH deficiency as a cause of hypogonadotropic hypogonadism and of functional amenorrhea (Costom, Grumbach and *Supported by the Deutsche Forschungsgemeinschaft, Project B2 (SFB 87) Received: 5 May 1976
Accepted: 14 June 1976
tuitary gland were shown to be normal. Lysine-vasopressin (LVP) was used to stimulate ACTH secretion of the pituitary. This test initiated a pronounced rise in plasma ACTH. Thus, a pituitary defect as primary cause of the disease was excJuded. In the patients with monohormonal ACTH insufficiency mentioned above, no attempts were made to differentiate between wh at may be called prirnary and secondary ACTH insufficiency. Therefore it cannot be excJuded that at least some of them had a deficiency in CRF rather than in ACTH. We wish now to present the endocr\ne findings of another patient thought to suffer from isolated CRF deficiency. This fern ale patient is an outstanding example inasmuch as she exhibited a marked hyperpigmentation of the skin in the absence of measurable ACTH levels. Case Presentation Case history A 53-year-old menopausal woman was admitted to the hospital because of a history of fatigue, adynamia, hyperpigmentation of the skin and peripheraJ edema. 20 years before admission, during the flIst and only pregnancy (mens seven) there had been a sudden generalized increase of pigmentation, a decrease in the daily urine output and the onset of peripheral edema. There was no history of fever, hypotension, anorexia or weight loss. The delivery was normal, melanosis of the skin and peripheraJ edema persisted, however. An adrenal insufficiency was substantiated by demonstrating decreased urinary excretion of total 17-hydroxycorticosteroids and areplacement therapy of 5 mg prednisone daily was started. However, the patient took her meditation very irregularly and there had been repeated intervaJs without therapy up to aperiod of three months. Nevertheless, she feit relatively weil most of the time during the following 20 years with only an exceptional case of high fever upon contracting an ordinary infection. During this episode,
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Kaplan 1971, KTÜskemper, Beisenherz , Hemnann,
Summary
CRF Insufficiency
471
ble 1. To test the reserve of the adenohypophysis, a simultaneous pituitary stimulation test was used as described reC/inical features cently (Voigt, Dahlen. Fehm, Birk, Schröder, Schneider, RoExamination revealed a we11-appearing woman with typical thenbuchner and' Pfeiffer 1974). In short, at one time 200 hyperpigmentation of the skin as seen in Addison's disease. 118 TRH and ~5.pg. LHR.H were injected intravenously as a Especially the exposed parts of the body (face, neck, arms bolus and an mfuslon wlth 5 I. U. Iysme-vasopressm .(~ VP) and hands), nipples, genitalia and creases of the palms showed and 0.5 g/kg I-argmme ~as started. InfusIOn of I-argmme was dlscontmued after 30 mmutes and of LVP after 6(} mmutes. exaggerated pigmentation. Distension of neck veins and lip Blood was drawn for radioimmunologic measurement of cyanosis were present as weil as pretibial and malleolar edema. No further anomalies were noted. Height 5'2", body TSH, LH, FSH, proactin, GH and ACTH at -30, 0, 15, 30, weight 56.5 kg, blood pressure 115/70 mm Hg, pulse 60,blin, 45, 60, 90 and 120 minutes. Gonadotropin radioimmunoassays were carried out according to OdelI, Rayford and Ross body temperature 36.20C. (1967). Prolactin was measured using a kit from Sero no Co. (Rome). Radioimmunoassay of ACTH was performed after Laboratory findings extraction of ACTH from plasma as described recently Sedimentation rate (Westergren) was 18 mm in one hour. (Fehm. Voigt and Pfeiffer 1972, Voigt, Fehm. Reck and Hematologic values pertaining to erythrocytes were a11 norPfeiffer 1974). In our assay system the cross reaction with mal, leucocytes 4,300, in the differential ce11 count were 39% human I}MSH was 1: 1,000. Tbe results of the simultaneous segmented neurophils, 2% eosinophils, 57% Iymphocytes and pituitary stimulation test are given in Table 2. Table 3 shows 2% monocytes. Blood glucose had been estJmated repeatedthe results of further endocrine examinations under basal ly throughout the day: the lowest value observed was 51 mg%. conditions. * On x-ray examination of the chest and of the skull there were no abnormalities. Frontal and sagittal views of the se11a turDicussion cica demonstrated normal length and depth of the pituitary fossa, no erosion or destruction of the anterior and posterior The diagnosis of incomplete adrenal insufficiency clinoids. no intrasellar or suprase11ar calcifications.
is clearly established on the basis of the following findings: decreased excretion of total 17-ketosteroids Replacement therapy with prednisone had been discontinued in urine, 10w normal values for urinary total 17-hydroxycorticosteroids, decreased levels of plasma-cor4 weeks prior to the first endocrine examination. Tbe responsiveness of the adrenal gland to ACTH was assessed by tisol and the diminished response of plasma-cortisol infusion of 0.5 mg synthetic ßI-24 ACTH (Ciba Co., Basel) du ring an 8-hr ACTH stimulation test (Tables 1 and during 8 hours. Plasma cortisol was measured f1uorometricalIy (Spencer·Peet, Daly and Smith 1965) be fore and 4, 6 and 3). The symptoms fatigue, adynamia, lymphocytosis and the tendency to hypotensive blood pressure va8 hours after beginning of the infusion. Tbis test was repeated on 4 consecutive days. Tbe results are given in Talues as weH as the tendency to hypoglycemia are weH explained by this diagnosis. The fact that most of Table I. Plasma-cortisol values during the ACTH stimulation the time the patient feit relatively weH while on the test performed on four consecutive days. 0.5 mg synthetic replacement therapy of a daily average of less than ßI-24 ACTH were infused du ring 8 hours. Normal range for plasma-cortisol 5.0 to 25 pg per 100 m!. 2.5 mg prednisone is attributed to the preservation of a certain amount of endogenous steroid secretion. Endocrine examinations
plasma cortisol pg/IOO ml day day day day
time interval hours
1 2 3 4
0
4
3.9 6.7 6.2 5.0
9.9 18.9 22.7 28.7
6
ACTH stimulation tests on four consecutive days revealed that an alm ost normal sensitivity of the adrenal glands to ACTH could be achieved. This is usually taken to indicate adrenal insufficiency secondary 11.8 8
10.8 24.0 24.8 31.7
24.6 *For measurement of so me of the various hormonal para25.5 meters in plasma and urine we would like to thank Drs. Birk 32.0 (TSH), Schröder (HGH) and Pal (corticosteroids).
Table 2. Results of the simultaneous pituitary stimulation test. At time zero, 200 pg TRH, 25 pg LHRH were injected intravenously as a bolus and an infusion with 5 LU. LVP and 0.5 g/kg I-arginine was started. Infusion of I-arginine was discontinued after 30 minutes, of LVP after 60 minutes. LH and FSH were grossly elevated since the patient was menopausal for 2 years. Basal levels of HGH, PRL and TSH were in the normal range and increased normally after stimulation. ACTH- and cortisol values are depicted in Figure 1. time min HGH ng/ml LH ng/ml FSH ng/ml PRL ng/ml TSH IlU/ml ACTHpg/ml cortisol 118/100 ml
-30
0
15
30
45
60
90
120
1.7
2.0
21.6
163
>30 >250 1280 28 6.2 235
>30
6.2 53
24.2 >250 1300 25 7.8 16
>30 >250 1350 24
0
1.3 250 1120 6 4.2 57
3
4.6 0
6.7
5.6
6.5
7.0
9.2
11.6
12.5
10.3
250 1370 6
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she was unconscious briefly, and feIt entirely debilitated.
H.L. Fehm, K.H. Voigt, R. Lang, W.D. Hetzel and E.F. Pfeiffer
Table 3. Results of endocrine measurements under basal conditions. In case of multiple estimations the two extreme values are given. Normal range in parenthesis. immunoreactive plasma ACTH plasma-cortisol at 8 a.m. urinary total 17-hydroxycorticosteroids urinary total 17-ketosteroids protein-bound-iodine thyroxin-bindingindex
0-56 pg/ml (0-150 pg/m\) 2.5-6.0 J..Ig/100 ml (5.0-25 J..Ig/ml) 6.4-8.0 mg/24 hr (5-15 mg/24 hr) 3.5-4.1 mg/24 hr (6-16 mg/24 hr) 3.7-4.2 J..Ig/100 ml (3.5-8.0 J..Ig/100 ml) 1.06-1.08 (0.9-1.2)
plasma-ACTH pg/ml ±SEM
x
ACTH pg/ml
Table 4. Plasma-ACTH and -cortisol values in patients with primary adrenal insufficiency. Plasma was obtained two hours after ingestion of the morning dose (25.0 mg cortisone-acetate, total daily dose 37.5 mg and 0.1 mg 9-a-f1uorohydrocortisone) or after withdrawal of replacement therapy for 24 hours.
cortisol ~g/100 ml
51.U. LYP I.v.
300
200
40
100 20
plasma-cortisol J..Ig/100 ml ±SEM
N
x
Addison's disease without treatment
2073 ± 458
2.7 ± 2.0
10
Addison's disease with treatment
1073 ± 204
12.9 ± 1.9
13
Normal controls
55.6±17
1\.3 ± 1.5
12
of LH and FSH were grossly elevated since the patient was menopausal for two years. To test the pituitary adrenotropic function, LVP was administered because CRF is not available for clinical studies. With this stimulus a clearcut rise in plasma-ACTH was observed with a maximum of 235 pg/ml after 60 minutes. This rise in ACTH was followed 30 minutes later by a rise in plasma-cortisol from 5.6 to 12.5 Ilg per 100 ml.(Fig. 1). In our hands in normal persons the maximal ACTH value during LVP-testing is observed after 30 minutes with a mean of 215 ± 30 pg/ml. Thus, the ACTH response to LVP in this patient appeared to be normal in increment but delayed in time.
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472
In general the adrenal insufficiency in this patient apparently cannot be explained by a c.Jefect in pituitary function. On the basis of evidence now availo o able, a deficiency in hypothalamic CRF synthesis and/or release would best explain the defect ob· served. As all parameters of thyroid function, gonadal function and GH release were within the normal range, Fig. 1. Immunoreactive plasma-ACTH and plasma-cortisol le· vels during the simultaneous pituitary stimulation test. LVP an isolated insufficiency of CRF secretion must be was used to stimulate ACTH release. The shadowed area repostulated. One might object, that the suppression presents the 95% confidence limits of the normal reaction of of the hypothalamic-pituitary-adrenal system is posACTH as reported previously (Voigt, Fehm, Reck and Pfeiffer 1974). The ACTH response to LVP in our patient appeared sibly due to long-term administration of prednisone. Therefore we examined the effect of the usual reto be normal in increment but delayed in time. Surprisingly, there was a small rise in plasma-cortisol also, demonstrating placement therapy (37.5 mg cortisone-acetate in 2 that total atrophy of the adrenal glands had not occurred. doses equivalent to 7.5 mg prednisone and 0.1 mg to hypopituitarism. This diagnosis was confirmed by 9-a-flurohydrocortisone) on ACTH hypersecretion in patients with Addison's disease. Table 4 demonstrates radioimmunologic measurement of plasma-ACTH. that with this regimen elevated ACTH-levels deWhereas in primary adrenal insufficiency ACTH vacreased but did not fall into the normal range delues are excessively elevated (Table 4), in this paspite normalization of plasma-cortisol values and detient plasma-ACTH levels were not measurable four spite relief of all complaints. According to this fact times and one time it was found in the low normal range (Table 3). Mostly, secondary adrenal insufficien- - which in itsclf is difficult to explain - one can cy occurs within the syndrome of panhypopituitarism. rule out that an average dose of prednisone less than 2.5 mg daily, as in our patient, may induce almost Careful examination of the pituitary function by complete suppression of ACTH-secretion. means of a simultaneous pituitary stimulation test however, demonstrated normal somatotropic, thyreo- In the his tory of our patient there are no indications tropic and gonadotropic function. Basal plasma levels for a hypothalamic disease such as neoplasma, trau-
CRF Insufficiency
473
sufficiency, hemaehromatosis, increased amounts of gonadal steroids, infections and neoplastic diseases. In this patient ACTH-hypersecretion could be excluded and a thorough clinical examination revealed no evidenee for non-endocrine causes of hyperpigmentation. Therefore the most obvious assumption would be that hyperpigmentation was due to hypersecretion of MSH although MSH has not been meaRecently, the concept that printary pituitary and pri- sured. If it should prove out that MSH levels were elevated, there are at least 2 different mechanisms mary hypothalamic deficits can be differentiated by which could account for this: examining the response of the pituitary gland to hy1. Aeeording to Abe, Nicholson, Liddie, Orth and pothalamic re leasing hormones, has been questioned seriously. Patel and Burger (1973) demonstrated that Island (1969) a deficiency in adrenal steroids stimulates ß-MSH secretion as weIl as ACTH-secretion. the TSH reserve is usually normal in hypothalamic and pituitary hypothyroidism and TRH responsiveThis would suggest that eaeh ease of adrenal insufness cannot adequately differentiate between the two fieiency secondary to monohormonal ACTH or CRF conditions. Similar conflicting results were obtained insufficiency is aecompanied by hyperpigmentation. with LHRH in patients with hypogonadotrophie hy- However, the only patient described in the literature pogonadism (Mortimer, Besser, McNeilly, MarshalI, who was thought to have hyperpigmentation in the Harsoulis, Turnbridge, Gomez-Pan and Hall 1973). presence of monohormonal ACTH insufficiency is Finally, the value of vasopressin in the diagnostic that of Steinberg, Shechter and Segal (1954), whereevaluation of pituitary and hypothalamic function as all other patients with this diagnosis were dehas been criticized also (Toft, Buus and Nielson scribed as pale. 1971). However, in our experiences as weIl as in the 2. Another assumption would be that the hypothalaliterature there was never a patient observed with a mie disorder in our patient pertains not only to CRF normal response in LVP-testing in the presenee of but also to MSH release-inhibiting hormone (MRIH). proven adrenal insufficiency due to a pituitary disHowever, though MRIH has been found in the huorder, whereas negative results may occur in otherman hypothalamus (Kastin and Schally 1967), the wise normal persons. physiologie significance of MRIH in man is not estaAn enigmatic feature in this patient was that hyperpigmentation of the skin existed which was very suggestive or primary adrenal insufficiency. There are many causes of hyperpigmentation beside hypersecretion of ACTH and/or MSH, e.g. advanced hepatic in-
blished till now. Acknowledgements The authors wish to acknowledge the skillful technical assistance of Mrs. U. Winkler and Mrs. Ch. Nierle.
References
Abe, K., Jtl.E. Nicholson, G. W. Liddie, D.N. Orth, D.P. Is· kmd: Normal and abnormal regulation of (}MSH in man. J.Clin.lnvest. 48: 1580-1585 (969) Abramson, E.A., R.A. Arky: Coexistant diabetes mellitus and isolated ACfH deficiency; report of a case. Metabolism 17: 492-495 (I968) Cleveland, W. W., O. C Green, Cl. Midgeon: A case of proved adrenocorticotropin deficiency. J.Pediat. 57: 376-381 (I960) Costom, B.H., M.M Grumbach, S.L. Kaplan: Effect of thyrotropin-releasing factor on serum thyroid-stimulating hormone. J.Clin.lnvest. 50: 2219·2225 (971) Fehm, HL., K.H Voigt, H.F. Pfeiffer: NebennierenrindeninsuffIzienz als Folge eines isolierten Mangels an Corticotropin-Releasing-Hormon (CRH). Dtsch.med.Wschr. 98: 2066-2069 (1973) Fehm, HL., K.H Voigt, E.f: Pfeiffer: Problems and artefacts in ACTH-assay. Horm.Metab.Res. 4: 477-485 (1972) Green, W.L., S.H Ingbar: Decreased corticotropin reserve as isolated pituitary defect. Arch.lnternat.Med. 108: 945952 (I961) Kastin, A.J., A. V. Schalty: MSH activity in pituitaries of rats treated with various animal hypothalamic extracts. Gen.Comp.Endocrinol. 8: 344-347 (1967)
Kratz, F., V. Grae!" Über einen Fall einer Gravidität bei isoliertem Ausfall von ACfH. Klin.Wschr. 51: 1062-1065 (1973) KTÜskemper, HL., W. Beisenherz, l. He"mann, H.K. Kley, G. KTÜskemper, K.D. Morgner, A. V. v. zur Mühlen, U. Zeidler: Hypothyreose mit isoliertem Mangel an Thyreotropin-Releasing-Hormon (TRH). Dtsch.med. Wschr. 97: 76-81 (1972) Mortimer, CH, G.M. Besser, A.S. McNeilly, l.C Marshalt, P. Harsoulis, W.M.G. Turnbridge, A. Gomes·Pan, R. Hall: Luteinizing hormone and follicle stimulating hormonereleasing hormone test in patients with hypothalamicpituitary-gonadal dysfunction. Brit.Med.J. 4: 73-77 (1973) Odelt, W.D.: Iso la ted deficiencies of anterior pituitary hormones. J.Amer.Med.Ass. 197: 1006-1016 (1966) OdelI, W.D., G.M. Green, R.H. Williams: Hypoadrenotropism: The isolated deficiency of adrenotropic hormone. J.Clin.Endocr. 20: 1017-1028 (1960) Odelt, W.. D., P.L. Rayford, G. T. Ross: Simple, partially automated method for radioimmunoassay of human thyroid stimulating, growth, luteinizing and follicle stimulating hormones. J.Lab.& Clin.Med. 70: 973-976 (1967) Patel, Y.c., HG. Burger: Serum thyrotropin (TSH) in pituitary and/or hypothalamic hypothyroidism: normal or
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ma or inflammation. Nevertheless, the fact that the first symptoms of adrenal insufficiency occurred during pregnancy is of interest. A case of "isolated ACTH deficiency" manifesting itself du ring pregnancy has been described by Kratz and Graef (1973). However, the ability of the pituitary to secrete ACTH upon adequate stimulation has not been tested in this patient.
474
A. Cohen
elevated basal levels and paradoxical responses to thyrotropin-releasing hormone. J.Clin.EndoerinoI.Metab. 37: 190-196 (1973) Perkaf!. G. T., K. Eik·Nes, WH. Cames, F.H. Tyler: Seleetive hypopituitarism with deficiency of anterior pituitary basophils: A case report. J.Clin.Endocr. 20: 1269-1279 (1960) Piuman, J.A., E.D. Haigier, J.M. Hershman, C.S. Pittman: Hypothalarnie hypothyroidism. N.EngLJ.Med. 285: 844845 (1971) Spencer-Peet, J., J. Daly, V. Smith: A simple method for improving the specificity of the fluorometric determination of adrenal cortieosteroids in human plasma. J .Endoer. 31: 235-237 (1965) Steinberg, A., F.R. Shechter, H.l. Segal: True pituitary Addison's disease - A pituitary unitropie deficieney. J.Clin. Endocr. 14: 1519-1529 (1954)
Toft, H., O. Buus, E. Nielson: Vasopressin in the diagnostic evaluation of pituitary and hypothalamie funetion. Acta Endocr. 67: 393-400 (1971) Voigt, K.H., H.G. Dahlen, H.L. Fehm, J. Birk, K.E. Schrö· der, H.P.G. Schneider, G. Rothenbuchner, E.F. Pfeiffer: Simultaneous stimulation test for the anterior pituitary hormones. Horm.Metab.Res. 6: 436-437 (1974) Voigt, K.H., H.L. Fehm, R. Reck, E.F. Pfeiffer: Spontaneous and stimulated secretion of QUSO-extraetible immunoassayable ACfH in man. Klin. Wsehr. 52: 516-521 (1974) Woeber, K.A., R. Arky: Hypoglycemia as a result of isolated eorticotrophin-deficieney. Brit.Med.J. 11: 857-858 (1965) Yen, S.S.c., R. Rebar, G. Vandenberg, H. Judd: Hypothalamie amenorrhea and hypogonadotropism: responses to synthetic LRF. J.Clin.Endocr.Metab. 36: 811-816 (}973)
Horm. Metab. Res. 8 (}976) 474-478
© Georg Thieme Verlag Stuttgart
Adrenal and Plasma Corticosterone levels in the Pregnant, Foetal and Neonatal Rat, in the Perinatal Period A. Cohen Laboratoire de physiologie du developpement. Universite Pierre et Marle Curie. Paris. France
Summary A group of pregnant control rats was sacrifieed before parturition, in the morning, afternoon and evening of day 20 and 21 and in the morning of day 22. Another group was sacrifieed during parturition, when 2 to 8 foetuses had been expelled. The onset of parturition oecurred for the first rat in the afternoon of day 21 and for the last rat in the afternoon of day 22. Corticosterone was extraeted from maternal, foetal and neonatal adrenals and plasma, and was assayed by a fluorometric procedure. The maternal adrenal and plasma corticosterone levels, before parturition, were lower in the morning than in the afternoon exeepting day 22 when morning values were as high as those in the afternoon of day 21. Adrenal and plasma corticosterone eoncentrations were eleva ted during parturition in the mother but not the foetus. Plasma cortieosterone values were raised in the newborn eompared to their littermates in utero. Key-Words: Parturitian - Adrenal and Plasma Corticosterone - Pregnant Rat - Foetus - Newborn
Introduction Ouring late pregnancy in the rat, the foetal plasma corticosterone levels reaeh a peak value on day 19 and then fall until day 21 (Holt and Oliver 1968, Cohen 1973, lost 1973, Dupouy and Cohen 1975, Dupouy, Coffigny and Magre 1975). Received: 15 Oet. 1976
Accepted: 8 June 1976
Immediately after birth, the plasma eorticosterone coneentrations are high (Koch 1969, Kamoun 1970, Hiroshige and Sato 1971, Malinowska, Hardy and Nathanielsz 1972, Corbier and Rolli 1974) but deeline quiekly from the first or the second hour to the eighth hour of postnatal life (Malinowska, Hardy and Nathanielsz 1972, Corbier and Rolli 1974). The present study was undertaken to investigate changes in adrenocortical function in the rat in the immediate perinatal period and is an extension of the work of Cohen (1973), Cohen and Brault (1974) and Dupouy and Cohen (1975). A preliminary report of this work has been pl:lblished (Cohen 1975). Methods Pregnant Wistar rats were maintained under controlled Iighting eonditions (light period 06.00-20.00 h), at a constant temperature of 23 0 C with free aceess to food and water. Gestational age was caleulated from the time of ovulation: 01.00 A.M. (Jost and Picon 1970). Rats were eaged individually for at least 24 h before saerifice.
Group I: Contral group (Fig. 2 and Fig. 3) Animals were sacrificed on day 20 and day 21 of pregnancy at 10.00 h, 16.00 hand 22.00 hand on day 22 at 10.00 h, prior to parturition.
Graups lIa and IIb: Groups sacrificed during parturition (Table 1)
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Requests for reprints should be addressed to: Dr. H.L. Fehm, Dept. Int. Medicine, Endocrinology and Metabolism, University of Ulm; Steinhövelstr. 9, D-79 Ulm/Donau (Germany)
