MENS: Multiple Endocrine Neoplasia Syndromes

It looks like we've made this young lady kind of famous the way this picture has brought traffic to this blog.  So this article is about a very special young lady and her struggle with a very different disease which virtually mirrors Cushing's Syndrome, MENS, or Multiple Endocrine Neoplasia Syndromes.  Her name is Brandi Fouche, and she and her mother graciously gave me permission to use this photograph of this young lady when she posted it to a private forum for people with Cushing's syndrome because she was essentially the poster girl for the disease.  It took some courage in my book for a teenager in her shape to pose for a picture in a bikini to show a forum she had the classical look of Cushing's, much less to let me expose her to public view to help those seeking information about their own health problems.

A few months ago her mother, Nancy, informed us that testing had revealed Brandi suffered form a form of MENS instead of Cushing's.  Because of what it does MENS often raises the cortisol levels just like Cushing's Disease/Syndrome with the same predictable results.  However, MENS is a more serious disease.

That's because Neoplasias are tumors that form in two or more endocrine glands at the same time and can have multiple affects..  As we found out in exchanges with Nancy they can spread to the lymphatic system, which is an ugly scenario any way one look sat it.  When the tumors grow in the glands they affect whatever hormones are produced for the worse.  So when they take up residence in the Adrenal glands watch out for both Cushing's and intractable hypertension pretty much at the same time.  MENS comes in two types with the second type in two variations

MENS Type I

This is from the Merck Online Manual:

People with multiple endocrine neoplasia type 1 develop tumors, or excessive growth and activity, of two or more of the following glands:

• The parathyroid glands (the small glands located next to the thyroid gland in the base of the neck)
• The pancreas
• The pituitary gland
• The thyroid gland (less often affected)
• The adrenal glands (less often affected)

Depending on which glands are tumors and where those with MENS I will have multiple problems.  One could see a combination of any of the following:

Low blood sugar.

Intractable high blood pressure

Gigantism

Cushing's Disease

Menstrual abnormalities and breast secretions while not nursing (in women).

Peptic ulcers

Decreased sexual desire and erectile dysfunction (in men)

It appears that MENS I will have a familial history, though, with the relatively recent recognition of the disorder and difficulty recognizing the Syndrome that history may not be known.

MENS Type IIa

 Once again from the Online Merck Manual:

People with multiple endocrine neoplasia type 2A develop tumors or excessive growth and activity in two or three of the following glands:

• The thyroid gland
• The adrenal glands
• The parathyroid glands  

People with this disease often develop thyroid cancer.  They'll often have intractable high blood pressure.  They can also develop kidney stones.  Once again there does seem to be some family association with this form of MENS.

MENS Type IIb

Lastly, from the same Online Merck Manual:

Multiple endocrine neoplasia type 2B can consist of

• Medullary thyroid cancer
• Pheochromocytomas
• Growths around nerves (neuromas)

This is the scary kind because of its association with cancers.  It is not considered familiar instead being a genetic mutation.  Because of that it can show up as early as three months of age.  There are also often other abnormalities associated with it.  The link i provided to the Merck Manual has more detail on these and other things associated with the other types of MENS as well.

Diagnosis

There are DNA test for this disease.  A doctor may also order a nuclear scan of the body to detect the tumors.  The test is done by injecting a special nuclear die which will concentrate in areas of high blood usage and then a scan is done with a detector which maps out the areas of concentration.   Other testing, such as hormonal tests may lead a doctor to suspect and test for this condition.

Treatment

The treatment is to go in surgically and get the tumors out.  It may require the complete removal of the thyroid or one or both of the Adrenal glands.  So treatment can be a rather expensive proposition.  

I've missed the latest of my friend, Brandi, and i don't have the link I'd planned on including to help her and her family out on the medical expenses.  When I get it I will come back and edit this article to include it and send it back out for folks to see.  Brandi has a rough road and this has affected her health and some of her familial relationships.  Her mother is in her corner for sure and so am I.

So, How's That Treatment Going?

Since it's been awhile since we talked about our treatment we thought our online friends might want to know how things are going.  We went to the doctor just last Friday, 01/30/2015.  I'll get to what we found out in a minute, but first a review of the treatment we started.

Back in October of 2014 we reported among a number of things that we began a course of treatment with a medication of the same class as one which is being evaluated to treat Cushing's, that is Cabergoline.  Specifically it is not cabergoline used in my case, but another D9 agonist which is also a wider acting drug.  a couple of years back we underwent surgery to remove a tumor we hoped might be the culprit for our Cushing's though it is sited in a place more typical for a Cushing's like disease known as MENS, or Multiple Endocrine Neoplasia.  MENS is a Disease in which the victim presents with multiple tumors which secrete excessive amounts of hormones, cortisols being the most common.  It's not a nice disease to contemplate having as in many cases the tumors are cancers.

Within days we entered the local emergency room with agonizing muscle spasms only to find out that though we had removed a tumor suspected of causing Cushing's and prophylactically been given some corticef to head AI off, the local ER wasn't allowed to test for AI (Adrenal Insufficiency) because it wasn't considered an emergency situation, a really dumb idea given this patient had informed the staff that the possibility was on the table because of the surgery and that AI can kill in a hurry.  So the attending doctor pumped us full of another kind of steroids and muscle relaxers until the cramping stopped.  Then we were sent home on a very high dosage of prednisone and told to see the attending surgeon in  couple of days.

On the day of our appontment with our surgeon we tested our blood sugar and the home tesotr informed us that our blood sugar was high, no figure, just too high for the machine to test.  Since the appointment was an hour away and the office in the same building as the hospital's ER, we kept the appointment.  Naturally the doctor sent us down to the ER, where we were found disoriented on the way by a nurse who was off duty on break and she rounded up a wheelchair and somebody to take us down to the ER where we were admitted with a blood sugar of 608, a deadly situation.  When our condition was stabilized we got a referral to the only local physician we trusted enough to deal with the situation though it was outside his specialty.

Because that doctor felt our neurological system had been compromised he started us on two medications to deal with the situation, Gabapentin and Ropinerole.  We are sure the Ropinerole was a good call because we'd already started having some trouble with some mild restless legs style symptoms but hadn't reported them yet.  So we were on the way there and the ER treatment just probably hurried the situation along.  That was back in 2012 and I haven't had a high cortisol test since.  I've had a couple of very low ones, but no high one.  What made that really frustrating is that during 2013 we did an evaluation with the object of putting us on one of the two new medications to teat Cushing's and all of our test results came back on the high side of normal.  What is more certain symptoms of Addison's I have increased since.  So we couldn't get the medication to treat Cushing's, yet our cortisols were not at a level low enough to begin reversl of my condition.

While a friend and I were on the phone one day looking into a personal theory he had which he felt might explain our Cushing's, we stumbled on a paper about a trial of a medication being explored to treat Cushing's, the D9 agonist used to treat Parkinson's disease, Cabergoline.  It hit us one of our new medications, Ropinerole, is also used to treat Parkinson's, along with Restless Leg's Syndrome.  So we checked and fund out it is also a D9 agonist, along with acting on some other receptors as well, which would explain why it wasn't being evaluated as well.  So we talked with our endocrinologist on our next visit who felt we might be on to something and looked into Cabergoline and the possibility that tweaking our dose of Ropinerole might be a strategy for treating our Cushing's.  As a research physician as well as a professor of endocrinology the possibility struck a note with the doctor.  After six months of research and forming a plan, our dosage was slightly increase to see if the Ropinerole was indeed suppressing our cortisols and a treatment stratagem established.  By the way, the doctor who at the time was prescribing the Ronpinerole approved of our little experiment, tomorrow I'll tell him how it is turning out.

Now for the money part of the post. The doctor who started me on the Ropinerole will probably like what I have to report.  Technically I'm still at the small dosage range, small enough that increasing the dosage as we did probably wouldn't have hurt a thing.  Yet, my endocrinologist is pleased with results.  Our cortisols are now at a level he feels comfortable with for treating the disease.  Something to remember is that we are cyclical  and our cortisols do drop far enough on their own to cause problems, and may already have done so once since treatment began.  So the doctor wants to go slow enough to avoid that problem as much as possible.  While we don't blame him, we do have a problem with patience and are willing to risk much to gain much.

Our heamogobin A1C is stabilized a 7.0 and we have a demonstratable, if slow weight loss going.  We've gone from 368 lbs, at the beginning of treatment to 358 lbs, so the weight slope is downward.  Although we are still hypertensive, and that worries the Doctor, our blood sugars are well into normal range in the mornings.  So everything points toward success at this point.

We've also improved our health in other ways.  We are now off of pain medications and getting around better.  My back Doctor would probably be pleased with that and I might want to schedule an appointment with her for a new evaluation for that.  

If we continue to improve and could get our experience into the medical literature it would add another bit of evidence for the efficacy for treating Cushing's with D9 agonists safely.  With more treatment options open for Cushies more personal stratagems for the treatment of this disease be available to personalize the treatment to what works best for the individual.  That can't but help those of us who've waited so long for this day where more treatment options open up for us.

So I just thought my friends might want to the update.  I have a few more topics cooking and will hopefully have something more for you in a bit.

Chiao!

I've Been Busy: And I have some things to report on

Hello dear friends and readers!

It has been a while since my last post, but I’m going to try and do better.  I’ve been a busy boy!

First, let me inform all of you of a couple of things I’ve come across.  First, let me say that I have a friend who came into my life by phone who is a cured Cushie and sadly discovered, to his dismay, that problems don’t just disappear when an ATCH tumor is removed.  Although we Cushies do lose all or most of that weight gain we had as Cushies, other damage still remains and if things are strained to the breaking point with friends and family sometimes those relationships just aren’t recoverable.  It was because of those things that I was brought into his life.

Well, we made a project out of researching those issues, and he made a project out of researching Cushing’s to, perhaps, gain more insight in my condition, where there is no visible tumor obviously causing my problems.  One of the things we did find out is that it is possible, though there doesn’t seem to be a proven case yet, for a problem with the HPA axis feedback systems, most likely a problem with the sensors, could be behind some cases like mine.  I will mention, though, that my diagnosis is no Cushing’s Disease and my endocrinologist thinks I have a micro tumor which is slipping between the cracks of my MRI scans, a more common happening than most folks realize.

Well, in the course of our research of the medical literature we stumbled onto one article where the doctor implied Cushing’s may be much more common than officially thought.  So I contacted the doctor, who lives in France to find out if that was his position and he sent me back what appears to be an article he has, or is going to submit for publication.  The contents astounded me!  It is a review of research which has been done in Europe on the incidence of Cushing’s in the Diabetic population, the papers he reviewed had an incident rate when averaged together of about 1.5%, which is well above the official rate on an order of magnitudes.  Now that we knew where to look, we dug up two more papers, one out of the UK and another out of Turkey, which had even higher rates.  In the case of the UK, they found a rate of 10% of Diabetics tested had Cushing’s.  The Turkish research test obese men and found a similar rate of 10%.  And all of those used the Dexamethasone suppression test as their standard for diagnosis, which misses a significant number of cases with Cushing’s!  One of the Western European papers and the Turkish paper recommended screening for Cushing’s for all of the populations studied as a matter for course.

In the course of our hunt for all things Cushing’s we stumbled across a study on the efficacy of treating Cushing’s with Cabergoline, a D9 agonist.  The study was quite favorable towards its use because it seems to be quite effective with a certain subset of Cushing’s sufferers.  That had particular significance for me since I am on a D9 agonist and my cortisols have all tested in the upper normal range with the exception of one occasion, since I’ve been on that medication.  The one occasion was when I collapsed in an intermediate care center and they called an ambulance, on that occasion I was diagnosed with adrenal failure, given Cortisef and sent home after I came out of it and they were sure I was stable.  That opens up some possibilities right there.

Also on a personal note, in early spring I had a realization hit me like a falling brick wall.  My back is still degenerating and it is become more difficult to walk.  I can only stand up for short periods of time and walk a short distance before the pain becomes overwhelming, and that even with pain medication!  Without it I can barely make it to the kitchen at the front of my home and back to get a cup of coffee, and sometimes I don’t even make it that far.  If I want to cook, say an egg, then I better take the pain medication before I try that, and anything which requires more time?  Well, I put a stool in the kitchen for that.  The realization was that I was giving in and letting it take its course without a fight.  So I decided to fight!

Earlier, last winter in fact, there’d been a discussion between some of us on a Cushing’s forum where a number of us complained that on disability we simply can’t afford quality food, that is, fresh fruits and vegetables, on what we are given to live on.  Because of that we are pretty much forced to live on pasta dishes and the like, which makes our weight gain even easier.  Well, somebody very knowledgeable on nutrition suggest that we garden.  When I realized what I was doing by giving in to my back problems and recalled that online conversation I decided it was time to go after two birds with one stone.  So with the help of my family I started a small garden this year.

We’ve left an old broken office chair outside to serve as a stool for me to use and, after some experimentation I found that container gardening is the best way for me to go.  So, we’ve only bought several packs of tomatoes since my vines of beefsteak tomatoes started bearing their fruit.  True, they aren’t that productive, but this is my first year at it and here at the late season they are popping out since I got my fertilization scheme right.  But they have pretty stably provided me enough tomatoes for my sandwiches to cut down on the food bill some.

I’m looking to the long run, which means I’m using heirloom varieties instead of the easier to grow and cheaper hybrids.  I can save the seed from the best plants among my heirlooms and have reliable seed to plant next year, or later, if I choose to grow more varieties an my small space in the yard of the duplex I live in can really handle.  That means my seed cost will go down in the long-run as I build up a nice variety of stock I and my family can use and rely on.  It also means, since I am using containers, that my initial high cost for soil will go down in a few years and all I’ll have to do is replace some of the nutritional factors as I go along and reuse my potting soil.  By the way, although we didn’t do it this year, my plan is to use organic growing methods from now on.  I have already planned out next year’s garden and gotten most of the seeds I plan to use.

I’ve also started a New Channel on YouTube, Disabled Gardening.  I haven’t uploaded my first video yet, though I have shot most of the video footage for it, I just haven’t put it together and narrated it yet.  I intend to use it to both chronicle my gardening and to offer tips on how those of us who are disabled or otherwise disadvantaged, can grow gardens and feed ourselves, right now in an urban environment where it is wise to also make our gardens appealing in appearance as well.

So there you are.  That is what I’ve been up to.  I hope you’ve enjoyed my story.

Cushing’s And the Immune System

Greetings again my friends and readers!

Well, it has come time to talk about another aspect of Cushing’s, compromised immune system response.  Most old time zebras know well enough how vulnerable they are to opportunistic infections.  That’s one of the things long term exposure to steroids do is to make the immune system weaker and less able to ward off disease and infections.  And what is Cushing’s syndrome but long term exposure to steroids?

I was forcibly reminded of that fact this past week.  To set the stage I was having some problems with what seemed to be a stomach bug of some sort.  So I went to a clinic not far down the highway from where I live.  After seeing the doctor and being told I was suffering from “food poisoning” I waited out in the waiting room for my wife to pick me up since she’d run out to run a couple of errands real quick while I was in.  I collapsed right there in the waiting room and was rushed to the hospital where I remained until yesterday.

Although there are still some questions since I didn’t test positive for the flu or bacterial infection, it was decided that I had been brought low by a viral infection which affected more than one system and also severely dehydrated me in the process.  Right up to the last minute before release I was pumped full of antibiotics and fluids.

That is one of the things those of us who suffer from Cushing’s have to be aware of and watch out for.  Our immune systems become less able to cope with invaders over time and one can easily get into in trouble if one doesn’t stay on top of things, like I didn’t.  That means not waiting until what seems like a small problem gets out of hand.  So one has to treat almost every sniffle as something serious, don’t wait around to treat it and be ready to get help at the first sign of trouble.  I know doctors and insurers get a little bent out of shape by us “hypochondriacs,”   But let me tell you three days stuck in a hospital bed eating the low calorie diets us fat folks inevitably get put on in the vain hope we’ll lose weight is no fun.

Another thing I found while checking the net for this post was multiple reports on some research done which is another reason to be careful.  It seems there is some evidence that infections can cause the production of cortisols to go out of control in a victim of Cushing’s with fatal results.  Since all I could access were abstracts I couldn’t get down to the details.  So there’s another reason for anybody with Cushing’s to be careful, very careful.

That doesn’t mean a Cushie can’t live a reasonable life on that score.  Just exercise common sense and care.  Do that and you can generally avoid ending up in as extreme a situation as I ended up in.

Pictures: A Gallery Of Cushing's Syndrome

Welcome to my Cushing’s blog again dear readers:

Today I’m going to treat you to some pictures.  One is fairly explicit as it is of a younger Cushie who decided to do a picture of herself in a bikini so folks could see what Cushing’s has already done to her body.  I have her permission to use her picture and plan to point out a few things from it.  So here it is:

Look at her face, how round it is.  That is called a “moon face” and is one of the signs of Cushing’s syndrome and disease.  Next is the “buffalo hump” behind her neck.  Because of the color of the door in the background it doesn’t stick out that well.  But if you have the ability to zoom in and look it is there.  Note how her fat is somewhat concentrated on her torso.  In her case it’s not as extreme as some I’ve seen, myself included, but her obesity is somewhat truncal.  Lastly get a load of those stretch marks!  Those are huge and stick out prominently.  Every Cushie knows the look of those, as do pregnant women.  But then women enter a pseudo-Cushingoid state while in pregnancy and stretch marks like those are the bane of their existence aren’t they.  And look at how dark some of them are, especially those towards the back.  That isn’t just a play of light as Cushing’s stretch marks are often darker than normal, even sometimes achieving a dark purple in color.

Usually we only get to see this sort of thing from nude pictures taken by doctors.  And those aren’t the easiest pictures to get to see much less legally use.  So I’m thankful to this lady for having this picture done and even more thankful for her permission to use it.

Now for a few before and after pictures, the first is a single picture a lady posted on Facebook showing before, while she had Cushing’s and after:

The lady is clothed in this one, of course.  However, one can clearly see what truncal obesity looks like as hers is more pronounced in the picture of her as a victim of Cushing’s.  See how skinny those arms are in comparison to the rest of her body?  That look of toothpicks stuck into a basketball is the classical look of the Cushie as the disease progresses.  Cushies both tend not to have much fat, if any, on the arms and legs and they’ll lose muscle mass as well.  Hence the distinctive profile we see here in this picture.

Next I’ll give you a picture of my mother:

That’s my young bride with her back in early 1982.  But focus on mom.  The way she’s dressed you can really see most of the symptoms we’ve discussed today on display.  You see the moon face, the buffalo hump and the pronounced truncal obesity.  Mother was almost fifty in that picture and only had about fifteen more years to live before the ravages of the disease took her.  Later in life mother developed COPD and extreme heart problems, both diseases morbidly obese people often die from.  Mother was never officially diagnosed with the disease although she had virtually all the known symptoms of the disease, including the mental health issues.  The doctors just weren’t interested in going down the road as they were thinking horses instead of zebras.

Finally, I’ll finish up with two more photos.  The first one is a “before” picture of me at age fifteen in 1971:

The next picture is my graduation picture from Waycross College in 1994 when I received my associate’s degree before moving on to a university.  I’m thirty-eight years old in that picture:

That’s quite a change, isn’t it?  I’m obviously extremely obese and have the classical moon face in that picture, more so than in my later pictures.  I was probably around 400 pounds in that picture.  That’s what Cushing’s syndrome does to a person.

Of course the picture isn’t all negative.  That last picture is on the occasion of my first graduation from a college.  I would go on to earn a Bachelor of Science degree in the same field, though I haven’t been able to get a job because of my disability.  I still have those and smaller triumphs in the face of Cushing’s syndrome and still try my best to spit in its eye.  I’m hoping that my next visit to my endocrinologist will have some good news and that I may finally get treated.

Addison's Disease

Addison’s disease is the mirror image of Cushing’s syndrome, so why write about it in a Cushing’s blog?  In my case my cortisols swing so low I’m actually Addisonian for periods of time as evidenced by a presentation in an ER in a state of adrenal crisis and some labs I have documenting cortisols in that range.  I recently met two other folks in the same situation on Facebook so there are folks out there in the Cushie community for whom this is a relevant subject.  So let’s give it a whirl.

As I mentioned in the opening, Addison’s disease is the mirror image of Cushing’s syndrome and Cushing’s disease.  It is a condition where the cortisols are too low and is lethal if left untreated.  The pathology may be autoimmune disorders and it is often associated with them, trauma, or infection.  The symptoms may include:

·        Changes in blood pressure, generally a lowering of the blood pressure.

·        Chronic diarrhea, vomiting, nausea resulting in loss of appetite and weight loss.

·        Darkening of the skin in places causing a splotchy look.

·        Paleness

·        Extreme weakness fatigue and sluggishness.

·        Mouth lesions inside the cheek.

·        Salt craving.

·        The patient may also develop vitiligo, an abnormal whitening of the skin in patches.

The lab values associated with Addison’s are:

·        Abnormally low cortisols.

·        High potassium levels

·        Low sodium levels.

The victim of Addison’s disease may also suffer from autoimmune disorders such as Hashimoto’s disease and may also suffer from pernicious anemia.  Addison’s is also more common in frequency than Cushing’s.

Sufferers of Addison’s may also go into adrenal crisis, which I wrote about here:

Adrenal Crisis 

For the person whose cortisols swing both ways this means we get the worse of both worlds.  I have pernicious anemia and the compromise to bodily healing which takes place when the cortisols are so low makes my back situation even worse.  I also suffer from a very rare manifestation of Rheumatoid Arthritis, Recurring posterior scleritis, an autoimmune disease.  As I mentioned earlier I’ve had several bouts with adrenal crisis.  I do have a little tanning going on, but it’s mild and it is splotchy.

Those with Addison’s have to be very careful because their immune responses are compromised, so they need to contact their doctors in any of the following cases:

·        Infection.

·        Stress.

·        Injury.

·        Surgery.

Their medications may need adjusting.  It goes without saying that a cyclical Cushie or Addisonian with extreme cycles needs to do the same.

Although I did mention that Addisonians are more common than Cushies, they are rare as well.  Their situation is serious and they need all the help and support they can get from family and friends.  Just as with Cushing’s, family and significant ones should become familiar with the nature of the disease.  In the case of the extreme emergency which constitutes a crisis it is especially necessary for family, friends and coworkers to know the symptoms.

Addison's Disease at Wikipedia 

Addison's Disease at PubMed Health