rifampin and Adrenal-Insufficiency

Topics: Acute Disease; Addison Disease; Adrenal Insufficiency; Adult; Antibiotics, Antitubercular; Drug Therapy, Combination; Female; Humans; Rifampin; Tuberculosis, Pulmonary

A 55-year-old Indian man presented with productive cough and a large left pleural effusion. Pleural fluid culture grew Mycobacterium tuberculosis, and he was started on antituberculosis therapy. One week later, the patient presented to hospital with drowsiness, dehydration and hypotension. He was transferred to critical care and only improved after starting hydrocortisone and stopping rifampicin. His short synACTHen test subsequently confirmed primary adrenal insufficiency, and a CT of the abdomen showed bilateral adrenal enlargement. Rifampicin is known to accelerate cortisol metabolism. We report the rare case of a rifampicin-induced adrenal crisis as a first presentation of Addison's disease in a patient with tuberculous infiltration of the adrenal glands.

Topics: Adrenal Glands; Adrenal Insufficiency; Antitubercular Agents; Cough; Dehydration; Humans; Hydrocortisone; Hypotension; Male; Middle Aged; Mycobacterium tuberculosis; Pleural Effusion; Rifampin; Sleep Stages; Treatment Outcome; Tuberculosis, Pulmonary

Topics: Adrenal Insufficiency; Antibiotics, Antitubercular; Diagnosis, Differential; Humans; Hydrocortisone; Male; Middle Aged; Postoperative Nausea and Vomiting; Rifampin

Topics: Acute Disease; Adrenal Insufficiency; Antitubercular Agents; Drug Therapy, Combination; Empty Sella Syndrome; Female; Humans; Middle Aged; Mycobacterium tuberculosis; Rifampin; Tuberculosis, Lymph Node

In the developing world, early mortality within 1 month of commencing tuberculosis (TB) treatment is high, particularly with human immunodeficiency virus (HIV) co-infection. In Malawi, 40% of those who die do so in the first month of treatment. Reasons remain unclear and may include delayed diagnosis, opportunistic infections, immune restoration inflammatory syndrome (IRIS) or malnutrition. One possible contributing factor is underlying hypoadrenalism associated with TB-HIV, exacerbated by rifampicin (RMP) induction of P450 and glucocorticoid metabolism.. To assess the prevalence of hypoadrenalism in TB patients before and after commencement of TB treatment, and relationship with early mortality.. Prospective descriptive study assessing hypoadrenalism before and after anti-tuberculosis treatment, HIV status and outcome up to 3 months post-treatment.. Of 51 patients enrolled, 29 (56.9%) were female (median age 32 years, range 18-62). Of 43 patients HIV-tested, 38 (88.3%) were HIV-positive and 15.7% died within the first month. At 3 months, 11 (21.6%) were known to have died. Adequate cortisol levels were found in 49/51 (95.9%) before commencing RMP. Neither of the two with reduced response died. All 34 patients revealed adequate cortisol responses at 2 weeks.. No evidence of hypoadrenalism was found in this first study to assess adrenal function and outcome of anti-tuberculosis treatment.

Topics: Adolescent; Adrenal Insufficiency; Adult; Antibiotics, Antitubercular; Comorbidity; Female; HIV Infections; Humans; Hydrocortisone; Malawi; Male; Middle Aged; Prevalence; Prospective Studies; Rifampin; Tuberculosis, Pulmonary

Functional adrenal insufficiency (FAI) is associated with increased mortality and is defined as subnormal cortisol production during acute severe illness.. After screening 200 adult patients admitted in the medical emergency unit of Mulago Hospital, Kampala, Uganda, 113 critically ill HIV-infected adults not receiving corticosteroids were enrolled after obtaining informed consent to determine the prevalence and factors associated with FAI.. Functional adrenal insufficiency, defined in this study as morning total serum cortisol level of 3%) occurred in 52% (11 of 21) patients with FAI compared to 24% (22 of 92) patients with normal adrenal function (p= 0.01). Factors predicting FAI on multivariate analysis were use of rifampicin and eosinophilia. The mortality rate among patients with FAI (19%) was not significantly different when compared to that among patients with a normal cortisol response (33%) (p=0.221). Hyponatremia, hypoglycemia, hyperkalemia, postural hypotension and the use of ketoconazole were not associated with FAI in this study.. The diagnosis of FAI should be considered in severely ill patients with stage IV HIV disease using rifampicin or those found to have unexplained eosinophilia. Further studies to determine benefits of corticosteroids in critically ill HIV patients are needed in this setting.

Topics: Adrenal Cortex Hormones; Adrenal Insufficiency; Critical Illness; Enzyme Inhibitors; Eosinophilia; Female; HIV Infections; Humans; Longitudinal Studies; Male; Prospective Studies; Rifampin; Risk Factors; Uganda

We report the case of a 28-year-old-prostitute from Thailand with HIV infection stage B2 associated with retroperitoneal lymph node tuberculosis. 6 days after the beginning of anti-tuberculous therapy (isoniazid, rifampicin, pyrazinamid and ethambutol) the temperature rose to 40.5 degrees C, diarrhea, vomiting, and tachycardia developed and systolic blood pressure fell to 80 mm Hg. Liver function tests revealed acute hepatic failure (ALT 800 IU/l rising to 1500; serum bilirubin 89 mumol/l rising to 238.0; alkaline phosphatase 199 IU/l; glucose 1.8 mmol/l; prothrombin time 20%). Isoniazid, rifampicin, and pyrazinamid were replaced by streptomycin and PAS. A few days after withdrawal the liver profile returned to normal. Hours after the reintroduction of rifampicin total body erythema, pruritus, vomiting and severe hypotension developed, requiring saline methylprednisolone and epinephrine administration. The next reexposure to intravenous rifampicin produced a rash and was rapidly discontinued. Liver function tests remained normal. Later mild adverse reactions to streptomycin and pyrazinamid occurred, two drugs which had been well tolerated before. Subsequently the diagnosis of adrenal insufficiency was established. After initiation of steroid replacement (50 mg prednisolone) the antituberculous therapy with isoniazid, pyrazinamid and ethambutol was well tolerated. We conclude that the shock in this HIV-infected patient was either due to severe anaphylaxis to rifampicin or acute adrenal insufficiency ensuing on this drug. The reversible fulminant acute hepatic failure represents either an adverse effect of antituberculous drugs, especially hepatotoxic interactions of drug combinations, or an ischemic liver injury during hypotension caused by anaphylaxis. The case illustrates the complex nature of side effects of antituberculous drugs in HIV patients and their aggravation by adrenal insufficiency.

Topics: Adrenal Insufficiency; Adult; Anaphylaxis; Antibiotics, Antitubercular; Female; HIV Infections; Humans; Liver Failure; Prednisolone; Rifampin

Topics: Adrenal Insufficiency; Drug Interactions; Ephedrine; Half-Life; Humans; Hydrocortisone; Methylprednisolone; Phenobarbital; Phenytoin; Prednisolone; Rifampin

Topics: Adrenal Insufficiency; Humans; Rifampin; Tuberculosis

Topics: Addison Disease; Adrenal Cortex Hormones; Adrenal Insufficiency; Humans; Male; Middle Aged; Rifampin; Tuberculosis, Male Genital

Rifampicin, an antituberculous drug, causes increased hepatic metabolism of steroid hormones. We report the case of a patient with the acquired immunodeficiency syndrome treated with rifampicin who had a 'normal' screening test for adrenal insufficiency, yet had clinical evidence of adrenal failure. Diagnostic testing could not be completed due to lack of clinical response to dexamethasone. Both of these findings are due to the unique effects of rifampicin on steroid metabolism.

Topics: Acquired Immunodeficiency Syndrome; Adrenal Cortex; Adrenal Cortex Function Tests; Adrenal Insufficiency; Adult; Humans; Liver; Male; Rifampin

Topics: Addison Disease; Adrenal Insufficiency; Glucocorticoids; Humans; Male; Middle Aged; Rifampin; Tuberculosis, Renal

Topics: Adrenal Insufficiency; Aged; Humans; Hydrocortisone; Male; Rifampin; Tuberculosis, Pulmonary

Topics: Addison Disease; Adrenal Insufficiency; Drug Therapy, Combination; Female; Humans; Isoniazid; Middle Aged; Rifampin

Topics: Adrenal Insufficiency; Aged; Humans; Hydrocortisone; Male; Rifampin; Tuberculosis, Pulmonary

Topics: Adrenal Insufficiency; Humans; Male; Middle Aged; Rifampin; Tuberculosis, Pulmonary

Deviation of cortisol metabolism in favour of its 6 beta-hydroxylated derivative was demonstrated in two patients with adrenal failure receiving substitution corticosteroid therapy and rifampicin. The existence of a frank increase in the metabolic clearance antipyrin was in favour of an hepatic enzyme induction. After rifampicin treatment was stopped, the 24 hour urinary excretion of 6 beta-OH-F returned to normal, demonstrating the responsability of the drug. This enzyme induction results in a need to increase the dose of hydrocortisone substitution therapy in patients with Addison's disease treated with rifampicin.

Topics: Addison Disease; Adrenal Cortex Hormones; Adrenal Insufficiency; Adult; Aged; Antipyrine; Enzyme Induction; Humans; Hydrocortisone; Hydroxycorticosteroids; Liver; Male; Metabolic Clearance Rate; Rifampin; Steroid Hydroxylases; Tuberculosis