Crisis suprarrenal: prevención, corticoterapia y elección del fármaco, revisión de la evidencia actual y recomendaciones / Adrenal crisis: prevention, corticotherapy and choice of the drug, review of current evidence and recommendations

INTRODUCCIÓN. La crisis suprarrenal se refiere a la insuficiencia suprarrenal aguda; la cual es un trastorno en el que la corteza adrenal no produce suficientes hormonas esteroides (en especial cortisol) para satisfacer las demandas del cuerpo, de acuerdo al mecanismo fisiopatológico se la puede clasificar como primaria, secundaria y terciaria, siendo más común en pacientes con insuficiencia suprarrenal primaria. Es una emergencia potencialmente mortal que requiere tratamiento inmediato. OBJETIVO. Establecer una estrategia de prevención y tratamiento de la crisis suprarrenal, así como la farmacoterapia ideal y sus alternativas válidas. MATERIAL Y MÉTODOS. Se realizó una revisión bibliográfica en varias revistas virtuales de alto carácter científico como Cochrane Library, Cochrane Systematic Reviews Database, MEDLINE a través de PubMed y ClinicalTrial.gov. Se seleccionaron revisiones sistemáticas con o sin metaanálisis, ensayos clínicos y recomendaciones de expertos relacionados con prevención y tratamiento de crisis suprarrenal en general. RESULTADOS. Se obtuvieron 1819 resultados, de los cuales se seleccionaron 20 artículos con mayor validez y replicabilidad en el medio para establecer un protocolo unificado de actuación. CONCLUSIÓN. El objetivo de la terapia es el tratamiento de la hipotensión y reversión de las anomalías electrolíticas y de la deficiencia de cortisol. Se deben infundir por vía intravenosa grandes volúmenes (1 a 3 litros) de solución salina al 0,9% o dextrosa al 5% en solución salina al 0,9% y la administración de hidrocortisona (bolo de 100 mg), seguido de 50 mg cada 6 horas (o 200 mg / 24 horas como infusión continua durante las primeras 24 horas). Si no se dispone de hidrocortisona, las alternativas incluyen prednisolona, prednisona y dexametasona.

INTRODUCTION. Adrenal crisis refers to acute adrenal insufficiency; which is a disorder in which the adrenal cortex does not produce enough steroid hormones (especially cortisol) to meet the body's demands, according to the pathophysiological mechanism it can be classified as primary, secondary and tertiary, being more common in patients with primary adrenal insufficiency. It is a life-threatening emergency that requires immediate treatment. OBJECTIVE. To establish a strategy for the prevention and treatment of adrenal crisis, as well as the ideal pharmacotherapy and its valid alternatives. MATERIAL AND METHODS. A literature review was performed in several highly scientific virtual journals such as Cochrane Library, Cochrane Systematic Reviews Database, MEDLINE through PubMed and ClinicalTrial.gov. Systematic reviews with or without meta-analysis, clinical trials and expert recommendations related to prevention and treatment of adrenal crisis in general were selected. RESULTS. A total of 1819 results were obtained, from which 20 articles with greater validity and replicability in the setting were selected to establish a unified protocol for action. CONCLUSIONS. The aim of therapy is the treatment of hypotension and reversal of electrolyte abnormalities and cortisol deficiency. Large volumes (1 to 3 liters) of 0.9% saline or 5% dextrose in 0.9% saline and administration of hydrocortisone (100 mg bolus), followed by 50 mg every 6 hours (or 200 mg / 24 hours as a continuous infusion for the first 24 hours) should be infused intravenously. If hydrocortisone is not available, alternatives include prednisolone, prednisone, and dexamethasone.

Bradicardia sinusal inducida por corticoesteroides en un niño con insuficiencia suprarrenal y septicemia / Corticosteroid-induced sinus bradycardia in a young boy with adrenal insufficiency and sepsis

La bibliografía no incluye frecuentemente alteraciones en el ritmo cardíaco de los pacientes que reciben corticoesteroides; se desconoce su mecanismo exacto. En este artículo, presentamos el caso de un paciente con bradicardia sinusal asociada con una dosis de estrés de corticoesteroides. Se ingresó a un niño de 9 años con antecedentes de panhipopituitarismo con gastroenteritis y neumonía y presentó choque septicémico el día de la hospitalización. El tratamiento con líquidos intravenosos, dosis de estrés de hidrocortisona y antibióticos permitió la recuperación. Sin embargo, luego se documentó bradicardia sinusal con una frecuencia cardíaca de 45 latidos por minuto. Esta se resolvió después de reducir gradualmente la hidrocortisona. La bradicardia sinusal inducida por corticoesteroides es un efecto adverso que suele resolverse tras interrumpir el tratamiento. Se debe considerar el monitoreo hemodinámico en estos casos. Este es el primer informe de bradicardia sinusal posterior al uso de hidrocortisona en niños con insuficiencia suprarrenal

The literature does not commonly describe cardiac rhythm disturbances, including bradycardia, in patients who are receiving corticosteroids, and the exact mechanism of such disturbances remains unknown. Herein, we present a case of sinus bradycardia associated with stress-dose corticosteroid therapy. A nine-year-old boy with a history of panhypopituitarism was admitted with gastroenteritis and pneumonia and developed septic shock on the day of admission. Management using intravenous fluids, stress doses of hydrocortisone, and antibiotics resulted in full recovery. However, within 24 hours following treatment, sinus bradycardia was documented, with a heart rate of 45 beats per minute (BPM). The bradycardia resolved after the dose of hydrocortisone was decreased gradually. Corticosteroidinduced sinus bradycardia is an adverse effect that usually resolves after corticosteroid treatment is discontinued. During stress-dose corticosteroid therapy, hemodynamic monitoring should be considered. To our knowledge, this is the first report of sinus bradycardia following the use of hydrocortisone in children who have adrenal insufficiency.

Treatment of hypothyroidism in special situations / Tratamiento del hipotiroidismo en situaciones especiales

Abstract The treatment of hypothyroidism is aimed at restoring the euthyroid state. In most cases, the signs and symptoms of thyroid deficiency generally resolve, which is particularly gratifying for the treating physician and mainly, for patients. However, there may be coexisting special situations that can potentially hinder or interfere with a successful treatment, as in the case of the elderly, patients suffering from heart disease, hematological diseases or dyslipidemia, hypothyroid patients who will undergo an emergency surgery, those with chronic kidney failure, or adrenal insufficiency, among others. Besides management of hypothyroidism in time of COVID-19 is also included. Some patients may experience intolerance to treatment and others persistent symptoms of hypothyroidism even under adequate replacement therapy, requiring a special approach. Being aware of these special situations will provide benefits to the patient and will also prevent treatment failure or complications.

Resumen El tratamiento del hipotiroidismo tiene como objetivo restaurar el estado eutiroideo. En la mayoría de los casos los signos y síntomas del déficit tiroideo en general se resuelven, lo cual es muy gratificante para el médico tratante y en especial para los pacientes. Sin embargo, pueden coexistir situaciones especiales que potencialmente dificulten o interfieran con un tratamiento exitoso como en el caso de los pacientes ancianos, aquellos con cardiopatías, enfermedades hematológicas o dislipemia, pacientes hipotiroideos que requieran cirugía de urgencia, aquellos con insuficiencia renal crónica, o insuficiencia adrenal, entre otras. Además, se incluye el manejo del hipotiroidismo en la era del COVID-19. Algunos pacientes pueden manifestar intolerancia al tratamiento y otros, persistencia de síntomas de hipotiroidismo aun bajo un adecuado reemplazo hormonal, lo cual requerirá un abordaje especial. Estar advertido de estas situaciones especiales redundará en el beneficio del paciente y evitará fracasos o complicaciones terapéuticas.

Adrenal insufficiency and glucocorticoid use during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) is an emerging pandemic challenge. Acute respiratory distress syndrome (ARDS) in COVID-19 is characterized by a severe cytokine storm. Patients undergoing glucocorticoid (GC) replacement therapy for adrenal insufficiency (AI) represent a highly vulnerable group that could develop severe complications due to the SARS-CoV-2 infection. In this review, we highlight the strategies to avoid an adrenal crisis in patients with AI and COVID-19. Adrenal crisis is a medical emergency and an important cause of death. Once patients with AI present symptoms of COVID-19, the dose of GC replacement therapy should be immediately doubled. In the presence of any emergency warning signs or inability to administer oral GC doses, we recommend that patients should immediately seek Emergency services to evaluate COVID-19 symptoms and receive 100 mg hydrocortisone by intravenous injection, followed by 50 mg hydrocortisone intravenously every 6 h or 200 mg/day by continuous intravenous infusion.

Tratamiento sustitutivo en la insuficiencia suprarrenal crónica / Replacement treatment for chronic adrenal failure

La insuficiencia suprarrenal crónica es una enfermedad que se caracteriza por el déficit de las hormonas de la corteza adrenal. Necesita tratamiento sustitutivo de por vida para lograr suplir ese déficit y así poder desarrollar una vida normal y con calidad. Para el éxito del tratamiento sustitutivo es muy importante conocer sus pautas y variantes, lo que resulta un arma en el trabajo diario de los galenos. Conocer las tendencias actuales resulta algo imprescindible, por lo que el propósito del siguiente trabajo es revisar las diferentes variantes del tratamiento que se pueden usar en este grupo de enfermos(AU)

Chronic adrenal failure is a disease characterized by shortage of adrenal cortex hormones. It requires lifelong replacement treatment to overcome this shortage in order to enjoy quality normal life. For the replacement treatment to be successful, it is very important to learn about its guidelines and variants, which is a useful tool in the daily work of physicians. Knowing the present trends is indispensable; therefore, the objective of this paper was to review the different treatment variants that may be used in this group of patients(AU)

Avaliação do eixo hipotálamo-hipófise adrenal no diagnóstico e na remissão da doença de Cushing / Assessment of the hypothalamic-pituitary-adrenal axis in Cushing's disease diagnosis and remission

A doença de Cushing (DC) permanece um desafio médico com muitas questões ainda não respondidas. O sucesso terapêutico dos pacientes com DC está ligado à correta investigação do diagnóstico síndrômico e etiológico, além da experiência e talento do neurocirurgião. A adenomectomia hipofisária transesfenoidal constitui-se no tratamento de escolha para a DC. A avaliação da remissão da doença no pós-operatório e da recorrência em longo prazo constitui um desafio ainda maior. Especial destaque deve ser dado para o cortisol sérico no pós-operatório como marcador de remissão. Adicionalmente, o uso de corticoide exógeno no pós-operatório apenas em vigência de insuficiência adrenal tem sido sugerido por alguns autores como requisito essencial para permitir a correta interpretação do cortisol sérico nesse cenário. Neste artigo, revisamos as formas de avaliação da atividade da DC e os marcadores de remissão e recidiva da DC após a realização da cirurgia transesfenoidal.

Cushing's disease (CD) remains a medical challenge, with many questions still unanswered. Successful treatment of CD patients is closely related to correct approach to syndromic and etiological diagnosis, besides the experience and talent of the neurosurgeon. Pituitary transsphenoidal adenomectomy is the treatment of choice for DC. Assessment of remission after surgery and recurrence in the long term is an even greater challenge. In this regard, special attention should be paid to the role of postoperative serum cortisol as a marker of CD remission. Additionally, the postoperative use of exogenous glucocorticoids only in cases of adrenal insufficiency has been suggested by some authors as an essential practice to enable the use of serum cortisol in this scenario. In this article, we review the forms of evaluation of DC activity, and markers of remission and relapse of CD after transsphenoidal surgery.

A Case of Steroid-induced Hyperinfective Strongyloidiasis with Bacterial Meningitis / 대한소화기학회지

Strongyloides stercoralis is a soil transmitted intestinal nematode that is endemic in the tropical and subtropical regions. In most individuals who are infected, chronic, usually asymptomatic, gastrointestinal infection persists. But, in immunocompromized hosts or in patients receiving immunosuppressive therapy, autoinfection of S. stercoralis may result in the dissemination of larvae, leading to fatal hyperinfection and increased rate of complications. We report a case of hyperinfective strongyloidiasis with bacterial meningitis in a patient receiving steroid therapy. Strongyloidiasis was diagnosed by the presence of filariform larvae of S. stercoralis in the bronchoalveolar lavage cytology and upper gastrointestinal endoscopic biopsy specimen. Her clinical symptoms had progressively aggravated and developed bacterial meningitis during treatment. She died despite aggressive antibiotic and antihelminthic therapy.

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.

Enfermedad de Addison en un niño con adrenoleucodistrofia ligada al cromosoma X / Primary adrenal failure associated to X-linked adrenoleukodystrophy: report of one case

Primary adrenal failure (PAF) can be congenital or acquired. X-linked adrenoleukodystrophy (ALD-X), produced by the mutation of the ABDC1 gene (Xq28), that leads to the plasma accumulation of very long chain fatty acids, is one of the congenital diseases associated to adrenal destruction. We report a 7 years old boy with fast progression of right strabismus and general symptoms as weariness, weakness and mucosal and skin pigmentation. A brain magnetic resonance image showed a leukoencephalopathy, characteristic of ALD-X. Low plasma cortisol, high ACTH levels and lack of response to ACTH test, confirmed the diagnosis of primary adrenal insufficiency. High plasma levels of C26:0 fatty acids, and C24/22, C26/22 ratios confirmed ALD-X.

Uso racional de corticoides en el paciente con shock séptico / Rational use of corticoids in a patient with septic shock

Introduction: Septic shock (SS) is a significant cause of mortality in NICUs. Objective: Review current knowledge on Hypothalamic-Pituitary-Adrenal Axis (HPA) and the scientific support for the use of gluco-corticoids in the use of this clinical picture. We know that the patient's ability to evolve into improvement or worsening depends upon the ability of the HPA axis to develop and sustain an adequate response to the stress provoked by SS. In some patients, due to many reasons, the prolongation of SS leads to a deficit of cortisol those results in functional acute adrenal insufficiency. Cortisol levels do not respond to ACTH stimulation test. There is no consensus among authors as to what is a normal concentration of cortisol during stress, or even if it is correlated with death among children with SS. The American College of Critical Care Medicine guidelines for SS in Pediatrics and Neonatology have made some recommendations for use of hydrocortisone.

Introducción: El shock séptico (SS) es una de las mayores causas de mortalidad en unidades de cuidados intensivos pediátricas. Objetivo: Revisar qué sabemos hasta ahora del papel que juega el eje hipotálamo-pituitaria-adrenal (HPA) en el SS y si hay evidencia científica que apoye el uso de glucocorticoides en el transcurso de este cuadro. Sabemos que de la habilidad del eje HPA para montar y sostener en el tiempo una adecuada respuesta al stress provocado por un SS dependerá si el paciente evoluciona a la mejoría o se agrava. En algunos pacientes debido a múltiples mecanismos, la prolongación del SS puede llevar a un déficit de cortisol, resultando en una insuficiencia adrenal aguda o funcional, la que se reflejaría en que los niveles de cortisol no responderían con un incremento significativo frente a una prueba de estimulo con ACTH. Entre los diversos reportes revisados, no existe consenso sobre cual sería la concentración "normal" de cortisol durante el stress y más aun no está claro si esto se correlacionaría con la mortalidad en el caso de los niños. Las guías de shock séptico en pediatría y neonatología del American College of Critical Care Medicine recomiendan en que tipo de pacientes con SS se debiera considerar tratamiento con hidrocortisona.

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.

Prueba de cosintropina en tuberculosis activa grave / Cosyntropin test in severe active tuberculosis

BACKGROUND: Frequency of adrenal insufficiency in patients with tuberculosis varies from 0 to 58%; however, all published series excluded severely ill patients. Our objective was to investigate adrenal insufficiency with the low-dose cosyntropin test in patients with severe active tuberculosis. METHOD: From two large university affiliated hospitals, 18 patients with tuberculosis and criteria of sepsis or severe sepsis according to SCCM/ACCP criteria, defined by the present authors as severe active tuberculosis, participated in the study. A low-dose ACTH test with 10 mg of ACTH was performed. After ACTH test, all patients received a stress dose of hydrocortisone (240 mg/day) during their entire hospitalization along with four antituberculous drugs. Abnormal response was considered when elevation of serum cortisol was <7 microg/dl with respect to basal level, 60 min after ACTH administration. RESULTS: Adrenal insufficiency was found in seven patients (39%); no clinical or laboratory data were associated with the presence of abnormal adrenal response. Except in one patient with HIV infection, all the signs and symptoms improved after antituberculous and hydrocortisone treatment. The increment in serum cortisol value post-ACTH test was lower in patients with hypoalbuminemia. CONCLUSIONS: Adrenal insufficiency is frequent in severe active tuberculosis. The efficacy and security of supplemental steroid treatment in severe active tuberculosis should be established by a randomized clinical trial.

Função adrenal na sepse e choque séptico / Adrenal function in sepsis and septic shock

OBJETIVO: Rever os critérios diagnósticos e o tratamento de insuficiência adrenal, em pacientes da faixa etária pediátrica, com sepse grave e choque séptico. FONTES DOS DADOS: Os artigos foram selecionados através das bases de dados MEDLINE (1966-junho 2007), Embase (1994-2007) e Cochrane Library (2000-2007). As seguintes palavras-chave foram utilizadas: choque séptico, sepse, corticosteróides, insuficiência adrenal e crianças. SÍNTESE DOS DADOS: Não existe um critério bem estabelecido e aceito para definir insuficiência adrenal em pacientes criticamente enfermos. A incidência de insuficiência adrenal varia de acordo com o critério utilizado, podendo alcançar desde valores inferiores a 15 por cento até superiores a 61 por cento. O teste rápido de estímulo com hormônio adrenocorticotrófico (ACTH) é largamente utilizado como um teste simples para a identificação de não responsividade adrenocortical, mas existe muita discussão quanto à dose de corticotropina a ser utilizada. A dose de 250 µg é a dose padrão. Recentemente, baixas doses de corticotropina (1 µg) têm sido propostas, com a sugestão de que elas possam ter uma maior sensibilidade. Dúvidas ainda persistem quanto à eficácia da reposição com baixas doses de corticosteróides em crianças com choque refratário às catecolaminas. Mais estudos são necessários para determinar se o tratamento de tais pacientes alteraria morbidade e/ou mortalidade. CONCLUSÃO: Insuficiência adrenal é comum em crianças com sepse grave e choque séptico e pode contribuir para o desenvolvimento de choque refratário às catecolaminas. Contudo, dúvidas ainda persistem em relação à eficácia da terapêutica com baixas doses de corticosteróides.

OBJECTIVE:To review diagnostic criteria and treatment of adrenal insufficiency in pediatric patients with severe sepsis and septic shock. SOURCES: Articles were selected using MEDLINE (1966-June 2007), Embase (1994-2007) and Cochrane Library (2000-2007) databases. following key words were utilized: septic shock, sepsis, corticosteroids, adrenal insufficiency and children. SUMMARY OF THE FINDINGS: There are no well established and accepted criteria to define adrenal insufficiency in critically ill patients. Incidence of adrenal insufficiency varies according to different criteria, and it may range between low values of 15 percent and high values of 61 percent. The rapid corticotropin stimulation test is widely used as a method to identify adrenocortical hyporesponsiveness, but controversy exists as to the corticotropin dose to be used. The 250 µg dose is the standard dose. Low doses of corticotropin (1 µg) have recently been proposed, suggesting that they may have higher sensitivity. There are still doubts as to the efficacy of low doses of corticosteroids in children with catecholamine-refractory shock. Further studies are needed to determine whether the treatment of these patients would change morbidity and/or mortality. CONCLUSION: Adrenal insufficiency is common in children with severe sepsis and septic shock and may contribute to the development of catecholamine-refractory shock. However, doubts still persist regarding the efficacy of replacement therapy with low-doses steroids.

Reversal of subclinical adrenal insufficiency through antituberculosis treatment in TB patients: a longitudinal follow up.

BACKGROUND & OBJECTIVE: Subclinical adrenal insufficiency has been shown to occur in patients with tuberculosis. Whether this insufficiency can be reversed with therapy and on long-term follow up, is not known. We studied the effect of antituberculosis treatment (ATT) with respect to reversal of the adrenal insufficiency, as assessed by response to standard dose adrenocorticotropin (ACTH) stimulation test in TB patients. METHODS: One hundred and five HIV-negative tuberculosis patients were studied. Of these, 72 patients had pulmonary and 33 had extrapulmonary forms of the disease. Baseline (pre-treatment) standard-dose ACTH stimulation test was done on all the subjects, following which, they were put on standard antituberculosis therapy, depending on the type of disease and were followed up for a period of 30 months. ACTH stimulation tests were performed at follow up, every 6 months. RESULTS: Baseline (pre-treatment) standard-dose ACTH stimulation test revealed an impaired response in 52 of 105 patients (49.5%). At 6 months, the percentage of responders had increased to 71 per cent with a gradual increasing trend noted thereafter. At 24 months, 31 of the 32 patients (97%) who were followed up demonstrated a normal response to ACTH stimulation. The percentage of responders was comparable in both pulmonary [21 of 22 patients (95%)] and extrapulmonary TB [10 of 10 patients (100%)] groups at follow up. INTERPRETATION & CONCLUSION: Our study shows that nearly half of patients with active tuberculosis had a subclinical adrenal insufficiency indicated by an impaired response to ACTH stimulation test. This insufficiency reverse with therapy in most patients on long-term follow up.

Insuficiência adrenal na criança com choque séptico / Adrenal insufficiency in children with septic shock

OBJETIVO: Revisar os critérios para o diagnóstico e o tratamento da insuficiência adrenal nos pacientes com choque séptico. FONTES DOS DADOS: Artigos publicados em revistas nacionais e internacionais, selecionados nas suas páginas eletrônicas e através do Medline, bem como referências citadas em artigos chaves. SíNTESES DOS DADOS: Nos trabalhos publicados na literatura, o achado de insuficiência adrenal em pacientes com choque séptico tem variado entre 17 por cento a 54 por cento. Os dados publicados até a presente data, na literatura consultada, revelam a inexistência de um consenso para o diagnóstico da insuficiência adrenal em pacientes com doenças críticas, particularmente naqueles com choque séptico. A presença de choque refratário a volume e resistente a catecolaminas pode ser aceito como sugestivo, enquanto que um cortisol basal inferior a 25 µg/dl é um critério diagnóstico indicativo de insuficiência adrenal. O teste de estimulação adrenal é um recurso útil na identificação dos pacientes com insuficiência adrenal relativa. Nossa opção de teste para estimulação adrenal em pediatria é a utilização de corticotropina em baixas doses (0,5 µg/ 1,73 m²). Um aumento inferior a 9 µg/dl no valor do cortisol pós-teste sugere a presença de insuficiência adrenal oculta (relativa). Nos pacientes com choque séptico apresentando insuficiência adrenal, suspeita ou confirmada, a utilização de hidrocortisona em dose de choque ou de estresse pode ser vital na sua evolução favorável. CONCLUSÕES: Os dados existentes na literatura, embora controversos, já nos permitem especular sobre quando iniciar o tratamento de reposição hormonal, sobre qual o nível sérico de cortisol aceito como adequado e em relação à escolha da dose de corticotropina, para a realização do teste de estimulação adrenal e diagnóstico de insuficiência adrenal oculta ou relativa nos pacientes com choque séptico.

Relative adrenal insufficiency in post-transplant lymphoproliferative disorder.

Post-transplant lymphoproliferative disorder is treated with rapid decrement of immunosuppressive therapy. This cannot be achieved with ease in patients on long-term glucocorticoid therapy, as chronically suppressed adrenal glands may not be capable of mounting adequate response to stress. A 52-year-old Caucasian male presented with fever, orthostatic hypotension, lymphadenopathy and hyponatraemia. Serum cortisol levels were within normal levels with a sub optimal response to stimulation by ACTH. Hyponatraemia and orthostasis responded poorly to fluid restriction, saline and salt repletion but corrected after increasing the steroid dose. The normal baseline cortisol levels represented a stimulated adrenal gland, however, the ACTH stimulation had inadequate response. This sub optimal stimulation and a good response to increased steroids suggest the presence of relative or occult adrenal insufficiency. Relative adrenal insufficiency must be considered in patients who have received prolonged glucocorticoid therapy and have symptoms such as hypotension and/or hyponatraemia.

Insuficiencia supra-renal en UTI: actualización bibliográfica / Supra-renal insufficiency in the ICU: update record

La insuficiencia supra-renal en los pacientes internados en UTI no es frecuente (1-30%). Sin embargo en aquellos que cursan con hipotensión que no responde a la expansión de volumen y a las drogas vasopresoras y con hemodinamia semejante a la del shock séptico es una posibilidad diagnóstica que debe ser confirmada o descartada, ya que se trata de una condición que pone en peligro la vida. Se describen, a manera recordatoria, la prueba de estimulación rápida con ACTH sintético y las modalidades terapeúticas.

Insuficiencia adrenal idiopática: comunicación breve / Idiopatic adrenal insufficiency: short communication

Se presenta un caso de insuficiencia adrenal idiopática en un niño de cuatro años que se manifestó por crisis aguda de vómitos, dolor epigástrico, sudoración profusa, frialdad y cianosis. El laboratorio confirmó hiponatremia (Na: 110 mEq/l) hipertrotasenia (K: 7.5 mEq/1). Fué hospitalizado (Diciembre 1983) por 12 días, durante los cuales presentó cuadro neurológico caracterizado por crisis de somnolencia, excitabilidad, incordinación motora que imposibilitaba la marcha, dificultades visuales, hipotensión arterial (70/40 mm de Hg) e hipotonia muscular. Fué debido a la aparición de pigmentaciones oscuras en la piel que se pensó que podría tratarse de una insuficiencia adrenal y fué hospitalizado en Mayo de 1984 para prueba de estimulación de cortisol, con insulina/hipoglicemia. La prueba tuvo que suspenderse antes de los 30 minutos por clínica de hipoglicemia que fue documentada por el laboratorio (glicemia base de 84 mg/dl y a los 15 minutos, 31 mg/dl). El cortisol plasmático a la hora 0 fué de 1.55 ug/dl y a los treinta minutos de 2.57 ug/dl. La TAC abdominal no reveló anormalidades en las adrenales. La prueba de supresión de agua por 7 horas descartó la diabetes insípida. Las pruebas serológicas para micosis profundas y los anticuerpos antinucleares, antitiroglobulina,, y antimicrosomales tiroideos fueron negativos; al igual que la prueba de Coombs. El niño recibe acetato de cortisona y 9 alfa-fluohidrocortisona a dosis de reemplazo fisiológicas