Adrenal axis in critical illness / Eje adrenal en la enfermedad crítica

Abstract After a stressful event, adaptative mechanisms are carried out to support vital functions. Hypothalamic-pituitary-adrenal axis plays a key role in stress response regulating metabolism, cardiovascular function and immune system. This review addresses pathophysiological changes of the adrenal axis during critical illness, recognizing limitations of methods applied for its evaluation in this special context and defining indications for corticosteroid replacement in critically ill patients. The concept of relative adrenal insufficiency should be abandoned; cosyntropin stimulation test should not be performed for diagnosis of adrenal insufficiency in critical illness nor for establishing the need of treatment.

Resumen Diversos mecanismos adaptativos se ponen en marcha para sostener las funciones orgánicas vitales en el paciente crítico. El eje hipotálamo-hipófiso-adrenal tiene un papel clave en la respuesta al estrés al regular el metabolismo, la función cardiovascular y la respuesta inmune. Esta revisión tiene por objetivos analizar los cambios fisiopatológicos que se producen en el eje adrenal durante la enfermedad crítica, reconocer las limitaciones de los métodos diagnósticos y definir indicaciones de tratamiento de reemplazo corticoideo en este contexto. El concepto de insuficiencia adrenal relativa debe ser descartado y no se recomienda el test de estímulo con cosintropina para diagnóstico de insuficiencia adrenal durante enfermedad crítica ni para definir la necesidad de tratamiento.

Endocrinopatías por inmunoterapia oncológica / Endocrinopathies by oncological immunotherapy

La relación entre inmunidad y cáncer es compleja. Las células tumorales desarrollan mecanismos de evasión a las respuestas del sistema inmunitario. Esta capacidad permite su supervivencia y crecimiento. La inmunoterapia ha transformado el tratamiento oncológico mejorando la respuesta inmunitaria contra la célula tumoral. Esta se basa en el bloqueo de los puntos de control inmunitario mediante anticuerpos monoclonales contra la molécula inhibidora CTLA-4 (antígeno 4 del linfocito T citotóxico [CTLA-4]) y la proteína 1 de muerte celular programada y su ligando (PD-1/PD-L1). Aunque los inhibidores de los puntos de control inmunitario (ICIs) son fármacos bien tolerados, tienen un perfil de efectos adversos conocido como eventos adversos inmunorrelacionados (EAI). Estos afectan varios sistemas, incluyendo las glándulas endocrinas. Los eventos adversos endocrinos más frecuentes son la disfunción tiroidea, la insuficiencia hipofisaria, la diabetes mellitus autoinmune y la insuficiencia suprarrenal primaria. El creciente conocimiento de estos efectos adversos endocrinos ha llevado a estrategias de tratamiento efectivo con el reemplazo hormonal correspondiente. El objetivo de esta revisión es reconocer la incidencia de estas nuevas endocrinopatías, la fisiopatología, su valoración clínica y el manejo terapéutico. (AU)

The relationship between immunity and cancer is complex. Tumor cells develop evasion mechanisms to the immune system responses. This ability allows their survival and progression. Immunotherapy has transformed cancer treatment by improving the immune response against tumor cells. This is achieved by blocking immune checkpoints with monoclonal antibodies against cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and programmed cell death protein 1 and its ligand (PD-1 / PD-L1). Although the immune checkpoint inhibitors (ICIs) are well tolerated drugs, they have a profile of adverse effects known as immune-related adverse events (irAES). These involve diverse systems, including the endocrine glands. The most frequent endocrine immune-related adverse events are thyroid and pituitary dysfunction, autoimmune diabetes mellitus and primary adrenal insufficiency. The increasing knowledge of these irAES has led to effective treatment strategies with the corresponding hormonal replacement. The objective of this review is to recognize the incidence of these new endocrinopathies, the physiopathology, their clinical evaluation, and therapeutic management. (AU)

Conduct protocol in emergency: Acute adrenal insufficiency / Protocolo de condutas em emergência: insuficiência adrenal aguda

Summary Introduction: Acute adrenal insufficiency or addisonian crisis is a rare comorbidity in emergency; however, if not properly diagnosed and treated, it may progress unfavorably. Objective: To alert all health professionals about the diagnosis and correct treatment of this complication. Method: We performed an extensive search of the medical literature using specific search tools, retrieving 20 articles on the topic. Results: Addisonian crisis is a difficult diagnosis due to the unspecificity of its signs and symptoms. Nevertheless, it can be suspected in patients who enter the emergency room with complaints of abdominal pain, hypotension unresponsive to volume or vasopressor agents, clouding, and torpor. This situation may be associated with symptoms suggestive of chronic adrenal insufficiency such as hyperpigmentation, salt craving, and association with autoimmune diseases such as vitiligo and Hashimoto's thyroiditis. Hemodynamically stable patients may undergo more accurate diagnostic methods to confirm or rule out addisonian crisis. Delay to perform diagnostic tests should be avoided, in any circumstances, and unstable patients should be immediately medicated with intravenous glucocorticoid, even before confirmatory tests. Conclusion: Acute adrenal insufficiency is a severe disease that is difficult to diagnose. It should be part of the differential diagnosis in cases of hypotensive patient who is unresponsive to vasoactive agents. Therefore, whenever this complication is considered, health professionals should aim specifically at this pathology.

Resumo Introdução: a insuficiência adrenal aguda ou crise addisoniana é uma comorbidade rara na emergência; porém, se não diagnosticada e tratada de forma correta, pode evoluir de maneira desfavorável. Objetivo: alertar a todos os profissionais da saúde sobre o diagnóstico e tratamento corretos dessa complicação. Método: foi realizada uma ampla pesquisa na literatura médica, por meio de ferramentas específicas, sendo selecionados 20 artigos sobre o tema. Resultados: a crise addisoniana é de difícil diagnóstico pela inespecificidade de seus sinais e sintomas. No entanto, pode ser suspeitada em pacientes que chegam à emergência com queixa de dor abdominal, hipotensão não responsiva a volume ou a agentes vasopressores, obnubilação e torpor. Esse quadro pode vir associado a sintomas sugestivos de insuficiência adrenal crônica, como hiperpigmentação e avidez por sal, bem como a doenças autoimunes, como vitiligo e tireoidite de Hashimoto. Pacientes estáveis hemodinamicamente podem passar por métodos diagnósticos mais apurados para se confirmar ou descartar a crise addisoniana. Os exames diagnósticos não podem retardar, em hipótese alguma, o tratamento de pacientes instáveis, que deve ser iniciado imediatamente com glicocorticoide endovenoso, inclusive antes das provas confirmatórias. Conclusão: a insuficiência adrenal aguda é uma patologia grave e de difícil diagnóstico, que deve fazer parte do diagnóstico diferencial do médico ao atender um paciente hipotenso sem reposta à infusão de drogas vasoativas. Logo, na suspeita dessa complicação, o profissional não deve tardar a agir especificamente nessa patologia.

Hypopituitarism Presenting as Adrenal Insufficiency and Hypothyroidism in a Patient with Wilson's Disease: a Case Report

Wilson's disease typically presents symptoms associated with liver damage or neuropsychiatric disturbances, while endocrinologic abnormalities are rare. We report an unprecedented case of hypopituitarism in a patient with Wilson's disease. A 40-year-old woman presented with depression, general weakness and anorexia. Laboratory tests and imaging studies were compatible with liver cirrhosis due to Wilson's disease. Basal hormone levels and pituitary function tests indicated secondary hypothyroidism and adrenal insufficiency due to hypopituitarism. Brain MRI showed T2 hyperintense signals in both basal ganglia and midbrain but the pituitary imaging was normal. She is currently receiving chelation therapy along with thyroid hormone and steroid replacement. There may be a relationship between Wilson's disease and hypopituitarism. Copper deposition or secondary neuronal damage in the pituitary may be a possible explanation for this theory.

Hypopituitarism Presenting as Adrenal Insufficiency and Hypothyroidism in a Patient with Wilson's Disease: a Case Report

Wilson's disease typically presents symptoms associated with liver damage or neuropsychiatric disturbances, while endocrinologic abnormalities are rare. We report an unprecedented case of hypopituitarism in a patient with Wilson's disease. A 40-year-old woman presented with depression, general weakness and anorexia. Laboratory tests and imaging studies were compatible with liver cirrhosis due to Wilson's disease. Basal hormone levels and pituitary function tests indicated secondary hypothyroidism and adrenal insufficiency due to hypopituitarism. Brain MRI showed T2 hyperintense signals in both basal ganglia and midbrain but the pituitary imaging was normal. She is currently receiving chelation therapy along with thyroid hormone and steroid replacement. There may be a relationship between Wilson's disease and hypopituitarism. Copper deposition or secondary neuronal damage in the pituitary may be a possible explanation for this theory.

Insuficiência adrenal aguda / Acute adrenal insufficiency

A insuficiência adrenal (IA) consiste em síndrome clínica rara, decorrente da deficiência de glicocorticoides e/ou mineralocorticoides, podendo ser primária. A insuficiência adrenal aguda consiste em emergência endócrina rara, resultante da diminuição súbita do cortisol circulante, ou de aumento significativo da demanda por esse hormônio em pacientes com algum grau de disfunção adrenal, ocorrendo mais frequentemente no contexto da IA primária. O prognóstico da doença depende do reconhecimento e intervenção terapêutica precoces

Adrenal insuficiency (AI) consists of a rare clinical syndrome resulting from glucocorticoids and/or mineralocorticoids deficiency. Adrenal insufficiency may be primary. The acute AI is a rare endocrine emergency resulting from sudden decrease of circulating cortisol or, elevated demand for this hormone in patients with some degree of adrenal disfunction, occuring more frequently in primary AI. The prognosis depends on early recognition and precocious therapeutic intervention

Allgrove (AAA) Syndrome.

This is the first reported case of Allgrove Syndrome in Paediatric Department, S. C. B. MCH in a six years old male child who presented with convulsion and altered sensorium. He had no tears since birth, dysphagia with regurgitation of food and later developed skin hyperpigmentation. Allgrove syndrome is a rare autosomal recessive syndrome characterized by progressive loss of cholinergic function resulting in alacrimia, achalasia cardia, addison’s disease and autonomic neuropathy. Early diagnosis will lead to significant reduction of morbidity and mortality which is usually due to unrecognized adrenal crisis.

Serum and salivary cortisol in the diagnosis of adrenal insufficiency and as a predictor of the outcome in patients with severe sepsis / Avaliação do cortisol sérico e salivar no diagnóstico da insuficiência adrenal e como parâmetro preditor da evolução de pacientes com sepse grave

OBJECTIVES: To compare salivary with serum total cortisol in patients with severe sepsis, postoperative patients and healthy controls. MATERIALS AND METHODS: Serum total cortisol was determined by chemiluminescence immunoassay; salivary cortisol was determined by enzyme immunoassay. RESULTS: In patients with severe sepsis, median concentration of salivary cortisol was 14.0 and 2.6 higher than that of postoperative patients and healthy subjects. In postoperative patients, salivary cortisol was 5.4 times higher than in control patients. Serum total cortisol was also higher in patients with severe sepsis than in controls and postoperative patients. This increment, however, was much lower (2.33 and 1.64, respectively). Patients with a salivary cortisol greater than 7.2 µg/dL had a mortality rate of 80 percent, a statistically significant result when compared with the group with lower cortisol levels (Z = 2.38 and p < 0.05). CONCLUSIONS: Salivary cortisol in critically ill patients may be a better laboratory indicator of cortisol levels than serum total cortisol.

OBJETIVOS: Comparar cortisol salivar com sérico total em pacientes com sepse grave, em pós-operatório e controles normais. MATERIAIS E MÉTODOS: Cortisol sérico total foi determinado por imunoensaio quimioluminescente e cortisol salivar por imunoensaio enzimático. RESULTADOS: Em pacientes com sepse grave, a mediana do cortisol salivar foi 14,0 e 2,6 vezes maior que dos pacientes em pós-operatório e saudáveis. Nos pacientes em pós-operatório, cortisol salivar foi 5,4 vezes maior que o controle. Cortisol sérico total também foi maior em pacientes com sepse grave que nos saudáveis e pós-operatórios, porém, esse incremento foi bem menor (2,33 e 1,64, respectivamente). Pacientes com cortisol salivar superior a 7,2 µg/dL tiveram mortalidade de 80 por cento, com significância estatística, quando comparado com os pacientes com níveis mais baixos (Z = 2,38 e p < 0,05). CONCLUSÕES: Cortisol salivar em pacientes críticos parece ser um melhor marcador da atividade glicocorticoide que o cortisol sérico total.

Diagnosis of adrenal failure in critically ill patients / Diagnóstico de insuficiência adrenal em pacientes críticos

In the last two decades there was important evolution on the knowledge of the function of the hypothalamic-pituitary-adrenal axis. In the last decade, the expression "relative adrenal insufficiency" (RAI) was created, and more recently "critical illness-related corticosteroid insufficiency" (CIRCI) was used to designate those patients in which cortisol production was not sufficiently increased in stress situations. Patients with CIRCI have elevated hospital morbidity and mortality. Currently, there is a wide discussion about diagnostic criteria for this dysfunction. Besides basal cortisol, some publications now study the role of other tests, such as cortrosyn test - either in low (1 μg) or high doses (250 μg); free cortisol, salivary cortisol, metyrapone test and others. With this review, we aimed at summarizing the results of the most influent papers that intended to define diagnostic criteria for CIRCI. We also suggest an approach for CIRCI diagnosis and make it clear that the decision about steroid therapy in septic shock patients is matter apart from RAI.

Nas últimas décadas, houve uma importante evolução no conhecimento sobre a função do eixo hipotálamo-pituitária-adrenal. Na última década, foi cunhada a expressão "insuficiência adrenal relativa" (IAR) e, mais recentemente, a expressão "insuficiência adrenal relacionada à doença grave" (CIRCI) foi utilizada para designar aqueles pacientes nos quais a produção de cortisol não era suficientemente elevada em situações de estresse. Pacientes com CIRCI apresentam elevada morbidade e mortalidade em hospitais. Atualmente, há uma ampla discussão sobre os critérios de diagnóstico para essa desordem. Além do cortisol basal, algumas publicações analisaram o papel de outros testes, tais como o teste de estímulo com ACTH (cortrosina), com doses baixas (1 mg) ou altas (250 mg), cortisol livre, cortisol salivar, teste da metirapona e outros. O objetivo desta revisão foi resumir os resultados dos artigos mais importantes que buscaram definir os critérios de diagnóstico para a CIRCI. Também sugerimos uma abordagem para o diagnóstico da CIRCI e deixamos claro que a decisão sobre a terapia com esteroides em pacientes em choque séptico é uma questão separada da IAR.

Pseudotumor cerebri during Cushing's disease treatment with ketoconazole / Pseudotumor cerebral durante o tratamento de doença de Cushing com cetoconazol

Benign intracranial hypertension (Pseudotumor cerebri) has been described as related to the reduction in steroid levels in Cushing's disease (CD), especially after surgical remission. Ketoconazole is a common and effective adjuvant therapy for hypercortisolism, but the major concern is liver enzyme dysfunction. We describe here the case of a 12-year old girl with CD who developed benign intracranial hypertension during treatment with ketoconazole. She presented headache, vomiting, a black spot on her right temporal visual field, and signs of elevated intracranial pressure. Pituitary image was normal on magnetic resonance image (MRI), and all symptoms improved after treatment with acetazolamide. We call attention to the diagnosis of this disorder in CD patients, especially children on ketoconazole treatment, because it could be confounded with adrenal insufficiency and lead to definitive severe visual impairment.

Hipertensão intracraniana benigna (Pseudotumor cerebral) tem sido descrita relacionada à redução dos níveis de esteroides séricos na doença de Cushing (DC), especialmente após a remissão cirúrgica. O cetoconazol é uma opção efetiva e de uso rotineiro como adjuvante na terapêutica do hipercortisolismo, tendo como paraefeito mais temido a toxicidade hepática. Relatamos o caso de uma menina com 12 anos de idade portadora de DC que desenvolveu hipertensão intracraniana benigna durante tratamento com cetoconazol. Apresentou-se com cefaleia, vômitos, comprometimento do campo visual temporal direito e sinais de hipertensão intracraniana. A ressonância magnética (RM) de hipófise era normal e todos os sinais e sintomas resolveram-se com uso de acetazolamida. Chamamos a atenção para esse diagnóstico nos pacientes com DC, especialmente crianças, em tratamento com cetoconazol, porque ele pode ser confundido com insuficiência adrenal e causar comprometimento visual severo e definitivo.

Disfunción suprarrenal en el paciente cirrótico, ¿síndrome hepatoadrenal o síndrome del “euadrenálico” enfermo? / Adrenal dysfunction in the cirrhotic patient, ¿hepatoadrenal syndrome or the non adrenal illness syndrome?

Adrenal insufficiency is a potentially lethal condition that is characterized by decreased production of glucocorticoids, mineralocorticoids and sex steroids. In normal conditions adrenocorticotropin and corticotrophin releasing hormone regulate cortisol production, but in critical illness other peptides and substances are produced that modulate the axis. In decompensated liver failure, there is a hemodynamic state similar to septic shock, even an increase in proinflammatory cytokines such as IL6 and TNF- alpha. In critically ill patients, a high proportion of adrenal insufficiency has been reported; therefore, some authors have argued that the same could happen in the cirrhotic patient, introducing the term hepatoadrenal syndrome. There are several reports of an increased frequency of adrenal insufficiency in the cirrhotic patient. However, these studies are heterogeneous in many aspects. There are differences in patient’s characteristics, in the criteria for the diagnosis of adrenal insufficiency, and in the laboratory tests used. Because over 90 percent of cortisol circulates bound to proteins, it is important to consider this issue in the diagnosis of adrenal insufficiency, especially in patients with hypoalbuminemia. Serum-free cortisol and salivary cortisol appear to be a good diagnostic method. Further studies need to be carried out in order to define the cut off points of these methods. These tests are not widely available.

La insuficiencia suprarrenal es una condición potencialmente letal, que se caracteriza por la disminución en la producción de glucocorticoides, mineralocorticoides y esteroides sexuales. Normalmente, la producción de cortisol es regulada por la adrenocorticotrofina y ésta por la hormona liberadora de corticotrofina, pero en estado de enfermedad, se producen otros péptidos y sustancias que modulan el eje. En la insuficiencia hepática descompensada, se produce un estado hemodinámico similar al shock séptico, incluso se produce un aumento de citoquinas proinflamatorias como IL6 y TNF- alfa. Como en el paciente crítico se ha reportado un gran porcentaje de insuficiencia adrenal, algunos autores han planteado que lo mismo podría ocurrir en el paciente cirrótico, introduciendo el término de síndrome hepatoadrenal. Varios autores han publicado que también existe un aumento en la frecuencia de insuficiencia adrenal en el paciente cirrótico. Sin embargo, en estos estudios la población analizada es heterogénea, se utilizan distintos criterios para definir insuficiencia adrenal y las pruebas de laboratorio utilizadas tienen limitaciones. Debido a que más del 90 por ciento del cortisol circula unido a proteínas, es importante considerar este factor para diagnóstico de la insuficiencia adrenal, especialmente en el paciente con hipoalbuminemia. En estos casos, el cortisol libre sérico parece ser junto al cortisol salival un buen método diagnóstico. Sin embargo, faltan estudios para definir los puntos de corte de estos exámenes y tienen la limitación que no están ampliamente disponibles.

Comparison of low dose short synacthen test [1 microgram] with standard dose short synacthen test [250 microgram] in patients of adrenal insufficiency

To determine the diagnostic accuracy of low dose 1 microg short synacthen test taking standard dose 250 microg short synacthen test as gold standard. A descriptive study. Department of Chemical Pathology and Endocrinology Armed Forces Institute of Pathology Rawalpindi from Jan 2006 to Jan 2007. Thirty patients with clinical suspicion of adrenal insufficiency and equal number of age matched healthy males and females as controls were included in the study. Relevant clinical history and physical examination was recorded on designated proforma. Short synacthen test was performed between 0800 - 1000 h by using ACTH doses of 1 microg and 250 microg with interval of 3 days in all patients and controls. Three blood samples were obtained for cortisol [basal, 30 min and 60 min after l/M ACTH injection]. Using 250 microg short synacthen test as a standard test, the 1 microg short synacthen test had sensitivity of 100%, specificity of 72%, positive predictive value of 71% and negative predictive value of 100% and 83% accuracy. The low dose 1 microg short synacthen test is as sensitive as standard dose 250 microg short synacthen test but less specific in the diagnosis of adrenal insufficiency

Uso de corticosteróides no recém-nascido com choque séptico: estado da arte / The use of corticosteroids in the newborn with sepsis shock: state of art

Objetivo: Verificar se a utilização de corticosteróide no recém-nascido com choque séptico e insuficiência adrenal tem influência na sobrevida dos pacientes. Fontes Pesquisadas: MEDLINE e LILACS no período de 1996 a 2006. Os artigos foram selecionados desde que fornecessem informações sobre a utilização de corticosteróides em recém-nascidos com choque séptico. Síntese dos Dados: A revisão foi dividida em tópicos que abordaram o recém-nascido com choque séptico, a utilização de corticosteróides neste tipo de choque e na insuficiência adrenal associada a este quadro e a relação do tratamento com a evolução dos pacientes. Conclusões: A insuficiência adrenal também ocorre no recém-nascido com choque séptico e os corticosteróides devem ser considerados, mesmo nos pré-termos, não respondentes ao tratamento convencional como expansão de volume e terapia inotrópica.

Objective: To review the use of corticosteroids in the treatment of newborns with septic shock and adrenal failure and the role in survival of the patients. Data Sources: Scientific articles were searched in the data base MEDLINE and LILLACS between 1996 and 2006. The articles were selected whether they provided information about the association of the use of corticosteroids in newborn infants with septic shock. Data Synthesis: This review is structured in topics, in which the septic shock is defined, as well the use of corticosteroids in the adrenal failure and their role in the survival of this patients. Conclusions: There are a very few studies including the use of corticosteroids in critically ill term or premature newborn infants. However, the reposition of adrenal cortex hormones must be considered in the treatment of septic shock with adrenal failure when these patients did not have a good response to the conventional treatment how volume expansion and inotropic therapy.

Enfrentamiento de la hiponatremia: Más allá de la corrección del sodio. A propósito de un caso clínico / Secondary adrenal insufficiency presenting as hyponatremia: Report of one case

Hyponatremia can be a marker of an underlying disease. We report a 52 years-old male with Diabetes Mellitus who consulted for an episode of nausea and vomiting lasting four days. His baseline serum sodium was 118 mEq/L. He had no neurological deficit. Hyponatremia was initially interpreted in context of gastrointestinal fluid loss but correction with saline solution was poor. His urine sodium was 105 mEq/L and his urine osmolality was 281 mOsm/L, so an Inappropriate Secretion of Antidiuretic Hormone Syndrome was suspected. Later, we found that the patient had a two year history of fatigue, weakness, anorexia, frequent nausea, vomiting and diarrhea, loss of libido and decreased axillary and pubic hair. Thyroid-Stimulating Hormone (TSH) was normal and serum Cortisol < 1 µg/dL. A CT scan showed a sellar mass compatible with a macroadenoma. There was also a moderately high serum prolactin and low testosterone, thyroxin and growth hormone levels. The visual fi eld exami-nation showed right temporal hemianopsia. The patient was treated with steroids with a very good clinical response and serum sodium normalization. Subsequently a transsphenoidal excision of the tumor was performed and replacement of the other hormones was started. Now the patient remains asymptomatic.

Comparison of low dose and standard dose adrenocorticotropin stimulation tests in healthy Nigerians

Hypothalamo-pituitary-adrenal (HPA) axis dysfunction is a potentially life-threatening condition. It is of paramount importance that safe; reliable diagnostic tests be available to identify patients at risk for adrenal insufficiency. The 250?g Adrenocorticotropic hormone (ACTH) stimulation test is commonly used to assess adrenocortical function. The 250?g dose is supraphysiological; therefore several investigators; over the years; have used 1?g ACTH stimulation test to assess adrenocortical function.The aim of the study was to compare the response of healthy adult Nigerian subjects to the 250?g and 1?g ACTH tests.Ten healthy subjects; five males and five females; aged between 20-60 years; (mean; 38.7 years) participated in this study. They all had normal medical histories and physical examinations; were nonsmokers; and had never received any type of glucocorticoid therapy. Serum chemistries; full blood counts; erythrocyte sedimentation rate; were all within normal limits. Both low dose ACTH test and standard dose ACTH test were performed on the 10 subjects in a randomized order on different days.There was no statistically significant difference in mean serum cortisol levels between the two test doses at 30 minutes (928.4 vs 929.8nmol/L). There was a strong correlation between 30-minute cortisol responses to 1?g and 250?g ACTH stimulation tests; r=0.999; p0.001.In agreement with other published data; our study confirms that 1?g ACTH stimulates adrenocortical secretion in normal subjects in the period 30 minutes post injection comparable to 250?g ACTH testing

Identification of Paracoccidioides brasiliensis in adrenal glands biopsies of two patients with paracoccidioidomycosis and adrenal insufficiency / Identificação do Paracoccidioides brasiliensis nas amostras de glândulas adrenais de dois doentes com paracoccidioidomicose e insuficiência adrenal

The authors report two cases of adrenal insufficiency secondary to infiltration of the adrenal glands by Paracoccidioides brasiliensis. The first patient had been treated for a chronic multifocal form of paracoccidiodomycosis 11 years ago. The diagnosis of the mycosis was done simultaneous with that of the adrenal insufficiency in the second patient. In both patients the diagnosis was done by direct visualization of fungus in adrenal biopsies. They were treated with hormonal supplements and itraconazol by 12 and six months, without relapses during the follow-up period.

Os autores apresentam dois casos de insuficiência supra-renal secundária à infiltração das adrenais pelo Paracoccidioides brasiliensis. O primeiro paciente tinha sido tratado de paracoccidioidomicose crônica multifocal 11 anos atrás. No segundo paciente, o diagnóstico da micose foi feito de forma simultânea com o da insuficiência adrenal. Em ambos os pacientes, o diagnóstico foi feito pela visualização direta do fungo nas biopsias adrenais. Eles foram tratados com suplementos hormonais com itraconazol por seis a 12 meses, sem recaídas durante o período de acompanhamento.

case of severe primary hyperthyroidism, secondary hyperparathyroidism, adrenal insufficiency and osteoporosis with multiple fractures

Osteoporosis is generally known to be one of the most serious adverse effects of long-term corticosteroid administration. Recently it was discovered that corticosteroid-induced osteoporosis occurs not only in trabecular bone but also in cortical bone, leading to the reduction in the strength of bones and subsequent fracture. We report a case of severe hyperthyroidism, secondary hyperparathyroidism, adrenal insufficiency and osteoporosis with multiple fractures [mostlikely collectively due to chronic steroid intake because of steroid dependant bronchial asthma, hyperparathyroidism and hyperthyroidism] which was treated appropriately and made an uneventful recovery

A Prospective Study on the Incidence and Predictive Factors of Relative Adrenal Insufficiency in Korean Critically-Ill Patients

This study was undertaken to evaluate the incidence and risk factors associated with relative adrenal insufficiency (RAI) in Korean critically-ill patients. All patients who were admitted to the Medical Intensive Care Unit (MICU) of Samsung Medical Center between January 1, 2006 and April 30, 2007 were prospectively evaluated using a short corticotropin stimulation test on the day of admission. RAI was defined as an increase in the serum cortisol level of <9 microgram/dL from the baseline after administration of 250 microg of corticotropin. In all, 123 patients were recruited and overall the incidence of RAI was 44% (54/123). The presence of septic shock (P=0.001), the Simplified Acute Physiology Score (SAPS) II (P=0.003), the Sequential Organ Failure Assessment (SOFA) score (P=0.001), the mean heart rate (P=0.040), lactate levels (P=0.001), arterial pH (P=0.047), treatment with vasopressors at ICU admission (P=0.004), and the 28-day mortality (P=0.041) were significantly different between patients with and without RAI. The multivariate analysis showed that the SOFA score was an independent predictor of RAI in critically-ill patients (odd ratio=1.235, P=0.032). Our data suggest that RAI is frequently found in Korean critically-ill patients and that a high SOFA score is an independent predictor of RAI in these patients.