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ACTH Deficiency

NORD is very grateful to Andrew A. Bremer, MD, PhD, Department of Pediatrics, Division of Endocrinology, Vanderbilt University School of Medicine, for assistance in the preparation of this report.

Synonyms of ACTH Deficiency

  • adrenocorticotropic hormone deficiency, isolated

Disorder Subdivisions

  • No subdivisions found.

General Discussion

ACTH deficiency arises as a result of decreased or absent production of adrenocorticotropic hormone (ACTH) by the pituitary gland. A decline in the concentration of ACTH in the blood leads to a reduction in the secretion of adrenal hormones, resulting in adrenal insufficiency (hypoadrenalism). Adrenal insufficiency leads to weight loss, lack of appetite (anorexia), weakness, nausea, vomiting, and low blood pressure (hypotension). Because these symptoms are so general, the diagnosis is sometimes delayed or missed
entirely. For that reason, some clinicians believe the disorder to be more common than
previously thought.

Symptoms

ACTH deficiency can either be congenital or acquired, and its manifestations are clinically indistinguishable from those of glucocorticoid deficiency. Symptoms include weight loss, lack of appetite (anorexia), muscle weakness, nausea and vomiting, and low blood pressure (hypotension). Low blood levels of sugar and dilutional hyponatremia (low blood sodium levels) may occur; however, blood potassium levels are typically normal as affected patients are deficient in glucocorticoids and not mineralocorticoids due to their intact renin-angiotensin-aldosterone system. The pituitary hormone ACTH may be undetectable in blood tests, and the level of the adrenal hormone cortisol is abnormally low. Concentrations of 17-hydroxycorticosteroids and 17-ketosteroids, produced from the adrenal cortex, are also abnormally low in the urine. Some adrenal hormones that are decreased are precursors of male sex hormones and are also known as "pre-androgens".

Although males with this disorder usually have a normal hair pattern, females may have very little pubic and underarm (axillary) hair. In contrast to Addison's disease, skin
pigmentation usually remains normal. Emotional symptoms may range from depression to psychosis.

Causes

The exact cause(s) of ACTH deficiency remain unknown. A defect in the brain's hypothalamus or in the pituitary gland may cause the deficiency. Also, there is a congenital (present at birth) form of ACTH deficiency that has been tracked to mutations of the T-box 19 (TBX19) gene (also referred to as TPIT) on the long arm of chromosome one (1q23-q24) and the corticotropin releasing hormone (CRH) gene on the long arm of chromosome eight (8q13). The inheritance pattern is thought to be autosomal recessive.

Chromosomes, which are present in the nucleus of human cells, carry the genetic information for each individual. Human body cells normally have 46 chromosomes. Pairs of human chromosomes are numbered from 1 through 22 and the sex chromosomes are designated X and Y. Males have one X and one Y chromosome and females have two X chromosomes. Each chromosome has a short arm designated "p" and a long arm designated "q". Chromosomes are further sub-divided into many bands that are numbered. For example, chromosome 1q23-q24 refers to a region on the long arm of chromosome 1 between bands 23 and 24. Similarly chromosome 8q13 refers to the band numbered 13 on the long arm of chromosome 8. The numbered bands specify the location of the thousands of genes that are present on each chromosome.

Genetic diseases are determined by the combination of genes for a particular trait that are
on the chromosomes received from the father and the mother.

Recessive genetic disorders occur when an individual inherits the same abnormal gene for the same trait from each parent. If an individual receives one normal gene and one gene for the disease, the person will be a carrier for the disease, but usually will not show symptoms.

The risk for two carrier parents to both pass the defective gene and, therefore, have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier like the parents is 50% with each pregnancy. The chance for a child to receive normal genes from both parents and be genetically normal for that particular trait is 25%. The risk is the same for males and females.

All individuals carry 4-5 abnormal genes. Parents who are close relatives (consanguineous) have a higher chance than unrelated parents to both carry the same abnormal gene, which increases the risk to have children with a recessive genetic disorder.

Dominant genetic disorders occur when only a single copy of an abnormal gene is necessary for the appearance of the disease. The abnormal gene can be inherited from either parent, or can be the result of a new mutation (gene change) in the affected individual. The risk of passing the abnormal gene from affected parent to offspring is 50% for each pregnancy regardless of the sex of the resulting child.

Affected Populations

Symptoms of ACTH deficiency most often occur in adults, but the disorder may also be diagnosed in infancy. The disorder affects males and females in equal numbers.

Related Disorders

Symptoms of the following disorders may be similar to those of ACTH Deficiency. Comparisons may be useful for a differential diagnosis:

Congenital adrenal hyperplasia (CAH) is a group of disorders resulting from defective synthesis of the corticosteroid hormones of the adrenal gland. The adrenal gland becomes
enlarged. In certain forms of CAH, the adrenal gland produces excessive amounts of "male" sex hormones ("pre-androgens") in both males and females. The external genitals of some females with this disorder become masculinized to various degrees. Lack of glucocorticoids, especially cortisol, causes various metabolic problems. Lack of mineralocorticoids, primarily aldosterone, causes salt and water imbalances which may be life threatening. (For more information on this disorder, choose "Congenital Adrenal Hyperplasia" as your search term in the Rare Disease Database.)

Addison's disease (primary adrenal insufficiency) usually develops later in life. It is characterized by chronic diminished adrenocortical function. The resulting deficiencies of
glucocorticoids and mineralocorticoids cause weakness, low resistance to physiological
stress, metabolic abnormalities, and circulatory insufficiency. Many Addison's patients
have sufficient levels of these corticosteroids to permit adequate functioning under normal circumstances. Even mild physiologic stress, however, can precipitate an Addisonian crisis consisting of circulatory collapse and, if untreated, death. With replacement of the essential adrenal hormones, Addison's patients can lead a normal life. (For more information on this disorder, choose "Addison" as your search term in the Rare Disease Database.)

Secondary adrenal insufficiency results from insufficient production or release of the
pituitary hormone ACTH. It may be caused by prolonged corticosteroid therapy. ACTH
production doesn't return to normal for several months after completion of the therapy. Central nervous system tumors affecting the pituitary gland, granulomatous disease, and death (necrosis) of the pituitary gland after a pregnancy (Sheehan's syndrome) also may cause secondary adrenal insufficiency.

Standard Therapies

Diagnosis
When ACTH deficiency is suspected, blood samples are taken for analysis, especially of the level of cortisol in the blood. Cortisol is the name of one of the hormones produced by the outer portion (cortex) of the adrenal glands. If the concentration of cortisol is low, it typically indicates a low concentration of ACTH. On occasion, an ACTH stimulation test may be administered.

Treatment
Hormone replacement therapy with cortisol is the treatment of choice for this disorder. With such therapy, patients can lead a normal life.

Investigational Therapies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

For information about clinical trials sponsored by private sources, contact:
www.centerwatch.com

Contact for additional information about ACTH deficiency:

Andrew A Bremer, MD, PhD
Department of Pediatrics
Division of Endocrinology
Vanderbilt University School of Medicine
11134-A DOT 9170
2200 Children's Way
Nashville, TN 37232-9170
Tel: 615.936.1874
Fax: 615.875.7633
Email: andrew.a.bremer@vanderbilt.edu

Organizations related to ACTH Deficiency

References

TEXTBOOKS
Berkow R, ed. The Merck Manual-Home Edition.2nd ed. Whitehouse Station, NJ: Merck Research Laboratories; 2003:956-58.

Beers MH, Berkow R, eds. The Merck Manual, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999:104-05.

Bennett JC, Plum F, eds. Cecil Textbook of Medicine. 20th ed. Philadelphia, PA: W.B. Saunders Co.; 1996:1215-16

Wilson JD, Foster DW, eds. Textbook of Endocrinology. 8th ed. Philadelphia, PA: W.B. Saunders Company; 1992:249.

JOURNAL ARTICLES
Agha A, Rogers B, Sherlock M, et al. Anterior pituitary dysfunction in survivors of traumatic brain injury. J Clin Endocrinol Metab. 2004;89:4929-36.

Chikada N, Imaki T, Hotta M, et al. An assessment of bone mineral density in patients withAddison’s disease; isolated ACTH deficiency treated with glucocorticoid. Endocr J.
2004;51:355-60.

Agha A, Liew A, Finucane F, et al. Conventional glucocorticoid replacement overtreats adult
hypopituitary patients with partial ACTH deficiency. Clin Endocrinol (Oxf). 2004;60:688-93.

Selva KA, LaFranchi SH, Boston B. A novel presentation of familial gluco-corticoid
deficiency (FGD) and current literature review. J Pediatr Endocrinol Metab. 2004;17:85-92.

Hiroi N, Ichijo T, Tsuchida Y, et al. A trial of intranasal ACTH(1-24) administration to a
patient with isolated ACTH deficiency. Med Sci Monit. 2004;10:CS9-13.

Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders. Anesthesiol Clin North America. 2004;22:93-123.

Gonc EN, Kandemir N, Kinik ST. Significance of low-dose and standard-dose ACTH Tests compared to overnight metyrapone test in the diagnosis of adrenal insufficiency in childhood. Horm Res. 2003;60:191-97.

Joffe RT, Brasch JS, MacQueen GM. Psychiatric aspects of endocrine disorders in women. Psychiatr Clin North America. 2003;26:683-91.

Packham EA, Brook JD. T-box genes in human disorders. Hum Mol Genet. 2003;12 Spec No 1:R37-44.

Mody S, Brown MR, Parks JS. The spectrum of hypopituitarism caused by PROP1 mutations. Best Pract Res Clin Endocrinol Metab. 2002;16:421-31.

De Luis DA, Aller R, Romero E. Isolated ACTH deficiency. Horm Res. 1998:247-49.

INTERNET
Online Mendelian Inheritance in Man (OMIM). The Johns Hopkins University. ACTH Deficiency, Isolated; IAD. Entry No: 201400. Last Edited September 23, 2011. Available at: http://www.ncbi.nlm.nih.gov/omim/. Accessed September 19, 2012.

The information in NORD’s Rare Disease Database is for educational purposes only. It should never be used for diagnostic or treatment purposes. If you have questions regarding a medical condition, always seek the advice of your physician or other qualified health professional. NORD’s reports provide a brief overview of rare diseases. For more specific information, we encourage you to contact your personal physician or the agencies listed as “Resources” on this report.

Report last updated: 2012/09/20 00:00:00 GMT+0

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