cosyntropin and Adrenal-Gland-Diseases

A central feature of the endocrine pathophysiology of septic shock is thought to be the existence of adrenal dysfunction. Based on changes in glucocorticoid secretion and responsiveness, protein binding, and activity. These changes have been described by the terms "Relative Adrenal Insufficiency" (RAI), or "Critical Illness Related Corticosteroid Insufficiency" (CIRCI), and form part of the rationale for trials of glucocorticoid treatment in septic shock. Diagnostic criteria for these conditions have been based on plasma cortisol profiles and have proven notoriously difficult to establish. The uncertainty in this area arises from the inability of current tests to clearly identify who is truly glucocorticoid "deficient" at a cellular level, and hence who requires supplemental glucocorticoid administration. Emerging data suggest that there may be abnormalities in the tissue activity of glucocorticoids in patients with severe sepsis and plasma profiles may not be reliable indicators of tissue glucocorticoid activity, We put forward an alternative point of view, that is the spectrum of adrenocortical dysfunction in sepsis - plasma and tissue, can be grouped under the umbrella of a "sick euadrenal syndrome" rather than an adrenocortical insufficiency.

Topics: Adrenal Cortex Function Tests; Adrenal Gland Diseases; Adrenal Glands; Animals; Cosyntropin; Critical Care; Humans; Shock, Septic

The diagnostic value of tests for detecting hypothalamic-pituitary adrenal insufficiency (HPAI) is controversial.. Our objective was to compare standard-dose and low-dose corticotropin tests for diagnosing HPAI.. We searched the PubMed database from 1966-2006 for studies reporting diagnostic value of standard-dose or low-dose corticotropin tests, with patient-level data obtained from original investigators.. Eligible studies had more than 10 patients. All subjects were evaluated because of suspicion for chronic HPAI, and patient-level data were available. We excluded studies with no accepted reference standard for HPAI (insulin hypoglycemia or metyrapone test) if test subjects were in the intensive care unit or if only normal healthy subjects were used as controls.. We constructed receiver operator characteristic (ROC) curves using patient-level data from each study and then merged results to create summary ROC curves, adjusting for study size and cortisol assay method. Diagnostic value of tests was measured by calculating area under the ROC curve (AUC) and likelihood ratios.. Patient-level data from 13 of 23 studies (57%; 679 subjects) were included in the metaanalysis. The AUC were as follows: low-dose corticotropin test, 0.92 (95% confidence interval 0.89-0.94), and standard-dose corticotropin test, 0.79 (95% confidence interval 0.74-0.84). Among patients with paired data (seven studies, 254 subjects), diagnostic value of low-dose corticotropin test was superior to standard-dose test (AUC 0.94 and 0.85, respectively; P<0.001).. Low-dose corticotropin test was superior to standard-dose test for diagnosing chronic HPAI, although it has technical limitations.

Topics: Adrenal Gland Diseases; Adrenocorticotropic Hormone; Adult; Child; Cosyntropin; Fasting; Glucocorticoids; Humans; Hydrocortisone; Hypothalamic Diseases; Hypothalamo-Hypophyseal System; Pituitary Diseases; Reproducibility of Results; ROC Curve

Recent work has taught us that our conventional approach to corticosteroid replacement therapy requires review. Specifically, the doses of hydrocortisone we have used are probably too high for the majority, and should ideally be administered in three or more doses through the day. Nevertheless, there is not much hard evidence that excessive glucocorticoid replacement per se will lead to adverse effects such as osteoporosis, even though it may exacerbate any tendency in those who are predisposed to it for other reasons. As such, there is no compelling need for using determinations of either UFC excretion or of the serum cortisol profile in the routine management of patients on replacement therapy. Nevertheless, such measures may be considered in those thought to be at particular risk of osteoporosis, and in whom it is felt that special effort should be made to ensure that they are receiving the minimum dose possible. In such circumstances, a cortisol day curve is likely to be of more value than measurement of UFC.

Topics: 17-alpha-Hydroxyprogesterone; Addison Disease; Adrenal Cortex Hormones; Adrenal Gland Diseases; Adrenal Hyperplasia, Congenital; Adrenocorticotropic Hormone; Adult; Corticotropin-Releasing Hormone; Cosyntropin; Cushing Syndrome; Glucocorticoids; Humans; Hydrocortisone; Hypoglycemia; Osteoporosis; Risk

We describe a case of a 42 year old male who presented with Addison's disease resulting from primary lymphoma of the adrenals. Our case and a review of the literature indicates that this distinct entity has some unique clinical and radiologic features. In this entity, the lymphoma tends to be extranodal and have a poor prognosis. In addition, the computed tomography (CT) images have the unique appearance of enlargement of the adrenal gland with maintenance of the adreniform shape. We suggest that primary adrenal lymphoma is a distinct clinical entity and should be considered in patients with an elevated serum lactate dehydrogenase, characteristic CT findings and Addison's disease.

Topics: Addison Disease; Adrenal Cortex Neoplasms; Adrenal Gland Diseases; Adult; Antineoplastic Combined Chemotherapy Protocols; Biomarkers, Tumor; Cosyntropin; Cyclophosphamide; Dexamethasone; Diagnosis, Differential; Doxorubicin; Etoposide; Eye Neoplasms; Fatal Outcome; Humans; Hydrocortisone; Hyperkalemia; Ifosfamide; L-Lactate Dehydrogenase; Lymphoma, T-Cell; Male; Methotrexate; Neoplasm Proteins; Oculomotor Muscles; Prednisone; Tomography, X-Ray Computed; Tuberculosis, Endocrine; Vincristine

We investigated: (i) the association between severity of cirrhosis and serum levels of free cortisol (SFC) and total cortisol (STC), measured before and 30 min after (T(30)) the low-dose 1-µg short synacthen test (LD-SST); and (ii) the prognostic value of SFC and STC.. Consecutive, hemodynamically stable, cirrhotic patients (34 Child-Pugh class A, 29B, and 32C) underwent the LD-SST. Patients were followed for at least 12 months to assess non-transplant-related mortality.. Child-Pugh class C patients had significantly higher basal levels of SFC than Child-Pugh class A or B patients. Prevalence of suspected adrenal dysfunction ranged between 7.4% (T(0) STC < 138 nmol/L) and 49.4% (change in STC < 250 nmol/L) according to the threshold used. In receiver-operator curve analysis, the area-under-the-curve values were 0.67 for T(30) SFC (0.51-0.79), 0.81 for Child-Pugh score (0.70-0.88), and 0.79 for albumin level (0.63-0.88). During the follow-up period, 16 patients with high T(30) SFC (≥ 78.9 nmol/L) (26.2%) and one patient with low T(30) SFC (< 78.9 nmol/L) (3.4%) died (P = 0.027 for high vs low T(30) SFC, log-rank test). Albeit not statistically significant, the risk of death for patients with T(30) SFC ≥ 78.9 nmol/L was fivefold higher than for patients with lower levels after adjusting for cirrhosis severity and level of albumin.. One-year, non-transplant-related mortality is high among patients with T(30) levels of SFC ≥ 78.9 nmol/L (26.2%). These findings might result from latent inflammatory stress in hemodynamically stable cirrhotic patients, detected by adrenal testing.

Topics: Adrenal Cortex Function Tests; Adrenal Gland Diseases; Adult; Aged; Biomarkers; Cosyntropin; Female; Hemodynamics; Humans; Hydrocortisone; Kaplan-Meier Estimate; Liver Cirrhosis; Male; Middle Aged; Predictive Value of Tests; Prevalence; Prognosis; Proportional Hazards Models; Prospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Time Factors; Up-Regulation

Many spontaneous adrenal hematomas have been observed in patients being treated by Synacthène. The purpose of this study is to define how to take those patients in charge on a short-, mid- and long-term.. From January 2000 to December 2008, five patients (four males and one female), mean age 47, were taken in charge in our service for spontaneous adrenal hematomas. All those patients had been treated with Synacthène for a mid-sciatic pain for 72 hours. We associated a clinical, endocrine and radiologic staging to treat those patients.. Four patients underwent a watchful waiting, only one patient needed surgery. No adrenal tumor was ever found during the mean two years follow-up (one to four). Two patients suffered of the condition of the antiphospholipid syndrome.. Spontaneous adrenal hematomas are a most uncommon pathology. The clinical attitude has thus to be defined clearly. The patient must be under close clinical evaluation. Biological and morphological parameters have to be often repeated. An adrenal tumor has to be excluded by the evaluation, as that tumor could be secreting or could not be secreting. Antiphospholipid syndrome must also be excluded.

Topics: Adrenal Gland Diseases; Adult; Aged; Cosyntropin; Decision Trees; Female; Hematoma; Hemorrhage; Hormones; Humans; Male; Middle Aged; Retrospective Studies

A primary antiphospholipid syndrome is a very rare cause of adrenal haemorrhage.. A 51 year-old man presented with a unilateral adrenal haemorrhage, enhanced by the prescription of Synacthène during the 4 days that preceded. There was no adrenal deficiency but the immunological control revealed the presence of anti-phospholipid antibodies. After 2 years of follow-up, adrenal controls have not shown any underlying tumour or endocrine insufficiency.. Adrenal involvement is described in the anti-phospholipid syndrome and may present in the form of adrenal deficiency in the case of occasionally only microscopic bilateral haemorrhages. Furthermore, Synacthène is known to induce adrenal haemorrhages although this complication remains rare. Moreover, any unilateral adrenal haemorrhage requires subsequent follow-up for several months or even years in order to eliminate any underlying tumour and to control the absence of any adrenal deficiency if the involvement is bilateral.

Topics: Adrenal Gland Diseases; Antiphospholipid Syndrome; Cosyntropin; Diagnosis, Differential; Follow-Up Studies; Hematoma; Humans; Injections, Intramuscular; Low Back Pain; Magnetic Resonance Imaging; Male; Middle Aged; Radiography, Abdominal; Time Factors; Tomography, X-Ray Computed

The short synacthen test (SST) is the gold standard investigation for the evaluation of adrenal insufficiency and is also frequently used for the evaluation of the hypothalamic-pituitary-adrenal (HPA) axis. The 0900-h serum cortisol concentration has also been evaluated as an indication of cortisol reserve, and a result > 450 nmol/L is highly suggestive of a normal serum cortisol response to the insulin tolerance test, while no patient with a 0900-h serum cortisol < 100 nmol/L had a sufficient response. The aim of this study was to determine if the number of inappropriate SSTs could be reduced if a 0900-h serum total cortisol was done prior to the dynamic function test.. Two hundred and ten SSTs were performed at 0900 h and the response at 30 min evaluated.. Of the 210 SST, 151 (71%) demonstrated a maximum response at 30 min of serum cortisol > 550 nmol/L. All the patients with a 0900-h serum cortisol > 500 nmol/L had an adequate response ( > 550 nmol/L), while no patient with a 0900-h serum cortisol of < 100 nmol/L had an adequate SST response. Twenty one per cent of patients were shown to have had an unnecessary invasive procedure.. We conclude that the SST is of little added value in patients with a 0900-h serum cortisol of less than 100 nmol/L or more than 500 nmol/L and it should be included in the appropriate protocols for endocrine investigation.

Topics: Adolescent; Adrenal Gland Diseases; Adult; Aged; Aged, 80 and over; Cosyntropin; Female; Humans; Hydrocortisone; Hypothalamo-Hypophyseal System; Male; Middle Aged; Outpatients; Pituitary-Adrenal System

Many patients with acquired immune deficiency syndrome (AIDS) have symptoms consistent with adrenal insufficiency, but only a small subset of these patients meet criteria for adrenal insufficiency during a short corticotropin (ACTH) stimulation test. We hypothesized that patients with AIDS and symptoms of adrenal insufficiency who produce normal amounts of cortisol in response to administration of 0.25 mg cosyntropin may nevertheless produce lower amounts of cortisol in a course of 24 hours than comparably sick AIDS patients without symptoms of adrenal insufficiency or comparably sick patients without AIDS. We studied four groups of male patients: AIDS patients with symptoms suggestive of adrenal insufficiency but with a normal response to cosyntropin (group I), AIDS patients without symptoms suggestive of adrenal insufficiency (group II), human immunodeficiency virus (HIV)-negative patients with serious acute or chronic illness (group III), and healthy subjects (group IV). The following variables were examined: age, CD4 cell count, Acute Physiologic and Chronic Health Evaluation (APACHE) score, serum cortisol and plasma ACTH at baseline; serum cortisol at 30 and 60 minutes after intravenous administration of 0.25 mg cosyntropin; and 24-hour urinary free cortisol. The four groups had a similar mean age and baseline plasma ACTH and serum cortisol levels. However, a change in cortisol from baseline to 30 and 60 minutes after administration of cosyntropin was significantly smaller in both groups of AIDS patients than in the sick patients without AIDS and normal subjects. There were also differences noted between the two groups of AIDS patients: both baseline and stimulated levels of cortisol tended to correlate directly with ACTH levels in patients without symptoms of adrenal insufficiency, while this relationship appeared to be inverse in patients with symptoms suggestive of adrenal insufficiency (r = -.57 to -.7, P < .05 to .14). The 24-hour urinary free cortisol levels were similar among all groups, but correlated strongly with baseline and stimulated serum cortisol levels only in patients with AIDS and symptoms of adrenal insufficiency (r = .8 to .9, P < .002 to .015). We conclude that (1) AIDS patients with and without symptoms of adrenal insufficiency may have either normal adrenal function or somewhat suboptimal adrenal reserve as demonstrated by a blunted cortisol response during the short ACTH stimulation test in comparison to HIV-negative comparabl

Topics: Acquired Immunodeficiency Syndrome; Adrenal Gland Diseases; Adrenocorticotropic Hormone; Adult; Circadian Rhythm; Cosyntropin; Critical Illness; HIV Seronegativity; Humans; Hydrocortisone; Male; Reference Values

Amyloidosis is a multi-system disease. Renal involvement often leads to end-stage renal failure, which carries a poor prognosis. This paper reports the adrenal status of 22 patients with renal amyloid who were considered for or who had been commenced on renal replacement therapy. Twelve patients were considered or found to have AA amyloid and the remaining 10 had AL amyloid. Of 16 patients tested, seven demonstrated an abnormal response to a synacthen test. Four patients died at Addisonian crisis and hypo-adrenalism probably contributed to the deaths of a further two patients. Amyloid deposition was found in the adrenal glands in seven patients who died of systemic amyloidosis and renal failure. It is recommended that all patients with renal amyloid should have an assessment of adrenal function performed and if abnormal replacement steroid therapy should be commenced.

Topics: Adrenal Gland Diseases; Adrenal Glands; Adult; Aged; Amyloidosis; Cosyntropin; Female; Humans; Kidney; Kidney Diseases; Kidney Failure, Chronic; Kidney Transplantation; Liver; Male; Middle Aged; Myocardium

Topics: Adrenal Gland Diseases; Cosyntropin; Hemorrhage; Humans; Postoperative Complications; Tomography, X-Ray Computed

One must consider the 17-DOS as a biosynthetic pathway with multiple regulatory factors. ACTH is its dominant regulator but in the absence of ACTH and in conditions where plasma renin activity is increased, this biosynthetic pathway maintains its sensitivity to exogenous ACTH. Suppression of the renin system delays the general recovery of aldosterone after the removal of an aldosterone producing adenoma but not of the 17-DOS: a pattern also showed after the removal of a DOC-producing adenoma. In addition to the possible role of the renin system there remain inexplicable situations in its regulation that cannot be explained by ACTH and renin. Our studies suggest that a non-renin, non-ACTH factor may influence the basal production of these steroids, and by its reduction, permits deviation of steroid substrate to cortisol production. This sequence may be operative in the "stress syndrome". Finally, one of the more interesting phenomenonologic patients who has been observed is a young male who has the biochemical findings and clinical signs of DOC excess with hypertension, hyperplasia, suppression of aldosterone and the RAS, and normal cortisol levels. All the 17-DOS are elevated and both adrenal veins have high concentrations. He represents excessive stimulation of this pathway by putative 17-deoxy regulator excess. The renin system is suppressed and ACTH levels are normal. Treatment with suppressive doses of glucocorticoid hormones diminishes the elevated 17-DOS and cortisol and ameliorates blood pressure. In summary, there seems to occur in clinical disorders and contrived experimental settings, suggestions that a non-renin, non-ACTH factor can regulate the 17-DOS, absence can explain some of the unusual conditions described (Fig. 1). The 17-DOS, while a vestigial pathway, may still cause disease, and provide clues to central organization of the adreno-cortical response to injury, stress, and disease.

Topics: Acquired Immunodeficiency Syndrome; Adrenal Cortex Hormones; Adrenal Gland Diseases; Biomarkers; Cosyntropin; Dexamethasone; Homeostasis; Humans; Hypopituitarism; Reference Values; Steroid Hydroxylases; Stress, Physiological; Zona Fasciculata

Disseminated infections with cytomegalovirus have become an increasingly important cause of morbidity and mortality in patients with the acquired immune deficiency syndrome. Herein we describe a male homosexual with the acquired immune deficiency syndrome who became severely hyponatremic during bowel preparation for colonoscopy. Biochemical evidence of adrenal insufficiency and clinical evidence for cytomegalovirus colitis was found. We propose that the patient had clinically significant cytomegalovirus adrenalitis. A random urinary sodium concentration is suggested as a potential screening test before bowel preparation in such patients.

Topics: Acquired Immunodeficiency Syndrome; Adrenal Gland Diseases; Adrenal Insufficiency; Adult; Bisacodyl; Colonoscopy; Cosyntropin; Cytomegalovirus Infections; Diet; Enema; Homosexuality; Humans; Hyponatremia; Inflammation; Male

The cosyntropin (Cortrosyn) stimulation test has been adapted for use in the postoperative period. The normal adrenal gland response to 200 micrograms of cosyntropin given intravenously has been quantified at six, 12, 24, 48 and 72 hours after extensive general surgical procedures. The value of the test in quickly and accurately diagnosing postoperative acute insufficiency of the adrenal gland remains to be established.

Topics: Adrenal Gland Diseases; Adrenal Glands; Adrenocorticotropic Hormone; Adult; Cosyntropin; Electrolytes; Evaluation Studies as Topic; Humans; Hydrocortisone; Postoperative Complications; Radioimmunoassay

Topics: Acute Disease; Adrenal Gland Diseases; Adrenal Insufficiency; Age Factors; Cosyntropin; Diagnosis, Differential; Hemorrhage; Hemorrhagic Disorders; Humans; Male; Middle Aged; Pulmonary Embolism; Spleen; Splenectomy; Subphrenic Abscess; Tomography, X-Ray Computed

A corticotropin antiserum was obtained from rabbits immunized with synthetic 1--24 corticotropin conjugated with bovine serum albumin. The antiserum did not cross react with synthetic alpha-melanotropin or with synthetic beta-endorphin and had a cross reactivity of 0.23% with human beta-lipotropin. We developed a radioimmunoassay with the antiserum obtained, in which we used polyethylene glycol in conjunction with a second precipitating antibody for fast (15-min) separation of antibody-bound and free corticotropin. The assay had a sensitivity of 16 ng/L and was validated on patients with various pituitary and adrenal diseases. From 103 normal subjects, the median value for corticotropin in specimens collected during the morning was 34 ng/L of plasma; the upper 95% confidence limit of the normal range was 98 ng/L.

Topics: Adrenal Gland Diseases; Adrenocorticotropic Hormone; Animals; Cosyntropin; Cross Reactions; Female; Humans; Hypoglycemia; Immune Sera; Insulin; Iodine Radioisotopes; Male; Neoplasms; Rabbits; Radioimmunoassay; Reference Values