scholarly journals Persistent Fatigue After Pregnancy: A Case Report

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A147-A147
Author(s):  
Sowjanya Naha ◽  
Joseph Theressa Nehu Parimi ◽  
Rajani Gundluru ◽  
John Chen Liu ◽  
Hasan Syed ◽  
...  
Keyword(s):  
Postpartum Period ◽  
Past History ◽  
Serum Cortisol ◽  
Dehydroepiandrosterone Sulfate ◽  
Serum Cortisol Level ◽  
Postural Orthostatic Tachycardia Syndrome ◽  
Endocrine Disorders ◽  
Acth Stimulation ◽  
Persistent Fatigue ◽  
Autoimmune Adrenalitis

Abstract Background: Pregnancy is characterized by physiologic immunosuppression and the postpartum period is often associated with rebound autoimmunity leading to unmasking of latent autoimmune disorders. Clinical Case: A thirty-one-year-old Caucasian female presented with generalized fatigue, myalgias and arthralgias that started three months after the birth of her first child. She was seen at a local hospital on multiple occasions and was treated symptomatically. She was noted to have orthostatic hypotension during these visits and was initiated on midodrine and fludrocortisone for presumed postural orthostatic tachycardia syndrome. When her symptoms did not abate, she was referred to our center for further care. At the time that we saw her, she reported nausea and vomiting in addition to the aforementioned symptoms. On careful questioning she also admitted to salt craving and unintentional weight loss of about 20 lbs over the past three months. She did not have a past history of autoimmune or endocrine disorders, but family history was positive for Grave’s disease and celiac disease in her aunt and mother respectively. Physical examination revealed hyperpigmentation of the face, knuckles, toes and abdominal scars. Random serum cortisol level was low (1.06 mcg/dL) with no perceptible response to ACTH stimulation (1.10 mcg/dL and 1.04 mcg/dL at 30 and 60 mins respectively). Serum aldosterone was undetectable (<4 ng/dL) and dehydroepiandrosterone sulfate level was low (19 mcg/dL, n: 45–295 mcg/dL). The patient was immediately initiated on corticosteroid replacement therapy. Her symptoms rapidly resolved and she was discharged on maintenance dosing of hydrocortisone and fludrocortisone. ACTH was grossly elevated (577 pg/mL) and 21-Hydroxylase antibodies were positive, confirming a diagnosis of autoimmune adrenalitis. Conclusion: Symptoms of adrenal insufficiency are often non-specific and can overlap with physiological symptoms of pregnancy. Persistence of these symptoms after delivery should raise concerns for autoimmune adrenalitis precipitated by immune reconstitution in the postpartum period.

scholarly journals MON-LB038 Isolated Hypoaldosteronism Due to Autoimmune Adrenalitis in a Patient With Autoimmune Polyglandular Syndrome

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Dheera Grover ◽  
Chenxiang Cao ◽  
Sarika Rao
Keyword(s):  
Adrenal Insufficiency ◽  
Adrenal Cortex ◽  
Time Course ◽  
Serum Cortisol ◽  
Diabetes Mellitus Type 1 ◽  
Normal Serum ◽  
Serum Cortisol Level ◽  
Autoimmune Polyglandular Syndrome ◽  
Loss Of Appetite ◽  
Autoimmune Adrenalitis

Abstract BACKGROUND At the initial presentation of autoimmune adrenal insufficiency, most patients present with hormonal deficiencies from all three layers of adrenal cortex. However, isolated aldosterone deficiency causing a true partial adrenal insufficiency in the setting of autoimmune adrenalitis remains underrecognized. CASE REPORT A 67-year old female patient with a known history of diabetes mellitus type 1 since the age of 13 and morphea, presented with progressively worsening symptoms of confusion and hallucinations, fatigue, and loss of appetite over the past 5 years. During this time, she has had frequent and recurrent episodes of mild intermittent hyponatremia with hyperkalemia requiring intravenous fluids and ingested salt tablets, especially when she felt more symptomatic. On her initial evaluation here, she presented with hyponatremia (125 mmol/l, n: 135-145 mmol/l), low osmolality (264 mOsm/kg, n: 275-295 mOsm/kg), and normal potassium level (3.6 mmol/l, n: 3.6-5.2 mmol/l). Further investigations drawn at the same time revealed a low aldosterone (<4 ng/dL), normal renin (5.3 ng/mL/hr, ref 2.9-10.8), normal serum cortisol level (and normal response to Cortrosyn stimulation), though all in the setting of positive antibodies against 21-hydroxylase. Pan-imaging revealed no evidence of malignancy that can be causing ectopic SIADH production. Additional testing showed presence of auto antibodies contributing to pernicious anemia and thyroid disease. Treatment was started with fludrocortisone 0.1 mg tablet daily and she was advised to take the salt tablets only if she has any symptoms. The patient’s symptoms have resolved 8 months since this diagnosis, with normalized sodium and potassium levels. CONCLUSION Autoimmune primary adrenal insufficiency usually affects all three layers of the adrenal cortex, where patients present with deficiencies in cortisol and aldosterone. Isolated hypoaldosteronism has rarely been reported, however because it can cause life-threatening hyponatremia, it is an important entity to recognize. It is important to work up in such patients as they may be in the initial stages of autoimmune Addison’s disease and can progress to developing cortisol deficiency, though the time course to this progression is not well known.

scholarly journals Steroid-Induced Iatrogenic Adrenal Insufficiency in Children: A Literature Review

Endocrines ◽  
2020 ◽  
Vol 1 (2) ◽  
pp. 125-137
Author(s):  
Shogo Akahoshi ◽  
Yukihiro Hasegawa
Keyword(s):  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Early Morning ◽  
Serum Cortisol Level ◽  
Adrenal Crisis ◽  
Acth Stimulation ◽  
Morning Serum Cortisol ◽  
High Doses ◽  
Loss Of Appetite ◽  
Cortisol Suppression

The present review focuses on steroid-induced adrenal insufficiency (SIAI) in children and discusses the latest findings by surveying recent studies. SIAI is a condition involving adrenocorticotropic hormone (ACTH) and cortisol suppression due to high doses or prolonged administration of glucocorticoids. While its chronic symptoms, such as fatigue and loss of appetite, are nonspecific, exposure to physical stressors, such as infection and surgery, increases the risk of adrenal crisis development accompanied by hypoglycemia, hypotension, or shock. The low-dose ACTH stimulation test is generally used for diagnosis, and the early morning serum cortisol level has also been shown to be useful in screening for the condition. Medical management includes gradually reducing the amount of steroid treatment, continuing administration of hydrocortisone corresponding to the physiological range, and increasing the dosage when physical stressors are present.

The Incidence of Adrenal Insufficiency in Myeloma Patients Receiving Pulse-Dose Dexamethasone

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 5640-5640
Author(s):  
Aimaz Afrough ◽  
Amy Sidorski ◽  
Roberto Salvatori ◽  
Ivan Borrello
Keyword(s):  
Adrenal Insufficiency ◽  
Cortisol Level ◽  
Research Funding ◽  
Serum Cortisol ◽  
Stimulation Test ◽  
Serum Cortisol Level ◽  
Acth Stimulation Test ◽  
Acth Stimulation ◽  
Pulse Dose ◽  
Significant Difference

Abstract Introduction: Glucocorticoids (GC's) are major drugs in the treatment of multiple myeloma (MM). Chronic administration of supra-physiological doses of GC's suppresses the hypothalamus-pituitary-adrenal (HPA) axis and is associated with secondary adrenal insufficiency (AI). In MM, GC's are usually administered in weekly high dose pulses. Due to long GC-free periods in such therapy, GC-induced AI is not usually considered to be a consequence of GC therapy in MM (Krasner, AS. JAMA, 1999. 282(7): p. 671-6). Here we report on the incidence of AI in MM patients treated at our center with pulse-dose GC. Methods: This is a retrospective cross-sectional study of patients with MM treated with GC-based regimens. Patients were required to have at least a random serum cortisol or a standard 250 mcg ACTH stimulation test result available in their medical record during dexamethasone-based chemotherapy. Patients were excluded if they were on dexamethasone more than 1 day a week, were lost to follow-up, had prior use of synthetic progestational agents such as megestrol or had been on oral glucocorticoids for any other medical indication. Diagnosis of AI was established by a frankly low AM serum cortisol level (<3 ug/dL) or an inadequate cortisol response to ACTH stimulation test (Salvatori, R. JAMA, 2005. 294(19): p. 2481-8). Results: A total of 45 patients were included in this study with median age of 62 (range, 49-89). Fifteen (33.3%) of patients were diagnosed with AI. The median random cortisol level in AI group was 2.3 ug/dL (range, 0.3-7.4 ug/dL) compared to 9.9 ug/dL (range, 1.0-21.2 ug/dL) in the non-AI group. The median time between the last dexamethasone dose and the serum cortisol assay was 5 days (range, 1-21). The median number of GC-based chemotherapy cycles taken before diagnosis of AI was 15 (range, 2-60). The median cumulative dexamethasone consumption was 1280 mg (range, 180-5220 mg). There was no correlation between developing AI and dose or duration of dexamethasone treatment. We observed clinical trend between cumulative doses of ≥1500 mg (P= 0.055) or use of clarithromycin (P=0.079) and developing AI, without reaching a statistically significant difference. Conclusion: The rate of AI was 33% among patients with MM on weekly pulse-dose dexamethasone. As such, patients should be periodically evaluated for this to enable early detection and proper management. Disclosures Borrello: BMS: Honoraria, Research Funding; WindMIL Therapeutics: Equity Ownership, Patents & Royalties, Research Funding; Celgene: Honoraria, Research Funding, Speakers Bureau.

scholarly journals Predictive Factors of Adrenal Insufficiency in Outpatients with Indeterminate Serum Cortisol Levels: A Retrospective Study

Medicina ◽  
2020 ◽  
Vol 56 (1) ◽  
pp. 23
Author(s):  
Worapaka Manosroi ◽  
Mattabhorn Phimphilai ◽  
Jiraporn Khorana ◽  
Pichitchai Atthakomol ◽  
Tanyong Pipanmekaporn
Keyword(s):  
Retrospective Study ◽  
Adrenal Insufficiency ◽  
Predictive Factors ◽  
Tertiary Care ◽  
Serum Cortisol ◽  
Serum Cortisol Level ◽  
Dynamic Tests ◽  
Acth Stimulation ◽  
Tertiary Care Medical Center ◽  
Stimulation Tests

Background and Objectives: To diagnose adrenal insufficiency (AI), adrenocorticotropic hormone (ACTH) stimulation tests may need to be performed, but those tests may not be available in some institutions. In addition, they may not be necessary for some patients. The objective of this study was to identify clinical and biochemical factors that could facilitate AI diagnosis in outpatient departments and decrease the number of unnecessary dynamic tests. Materials and Methods: This seven-year retrospective study was performed in a tertiary care medical center. A total of 517 patients who had undergone ACTH stimulation tests in the outpatient department were identified. AI was described as a peak serum cortisol level of <18 µg/dL at 30 or 60 min after stimulation. The associations between clinical factors, biochemical factors, and AI were analyzed using the Poisson regression model and reported by the risk ratio (RR). Results: AI was identified in 128 patients (24.7%). Significant predictive factors for the diagnosis of AI were chronic kidney disease (RR = 2.52, p < 0.001), Cushingoid appearance (RR = 3.44, p < 0.001), nausea and/or vomiting (RR = 1.84, p = 0.003), fatigue (RR = 1.23, p < 0.001), serum basal cortisol <9 µg/dL (RR = 3.36, p < 0.001), serum cholesterol <150 mg/dL (RR = 1.26, p < 0.001), and serum sodium <135 mEq/L (RR = 1.09, p = 0.001). The predictive ability of the model was 83% based on the area under the curve. Conclusion: The easy-to-obtain clinical and biochemical factors identified may facilitate AI diagnosis and help identify patients with suspected AI. Using these factors in clinical practice may also reduce the number of nonessential dynamic tests for AI.

scholarly journals THE ICET-A SURVEY ON CURRENT CRITERIA USED BY CLINICIANS FOR THE ASSESSMENT OF CENTRAL ADRENAL INSUFFICIENCY IN THALASSEMIA: ANALYSIS OF RESULTS AND RECOMMENDATIONS

2016 ◽  
Vol 8 ◽  
pp. 2016034
Author(s):  
Vincenzo De Sanctis
Keyword(s):  
Adrenal Insufficiency ◽  
Predictive Value ◽  
Serum Cortisol ◽  
Stimulation Test ◽  
Serum Cortisol Level ◽  
Second Step ◽  
Acth Stimulation Test ◽  
Acth Stimulation ◽  
Basal Serum ◽  
Central Adrenal Insufficiency

Introduction: In March 2015, the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A) implemented a two-step survey on central adrenal insufficiency (CAI) assessment in TM patients and after analysis of the collected data,  recommendations for the assessment of hypothalamic-pituitary- adrenal (HPA) axis in clinical practice were defined.Methods: To ascertain the current practice for assessment of CAI in thalassemia, the Coordinator of ICET-A sent two questionnaires by email: i) The first to evaluate the current interpretation of basal serum cortisol level (first step) and ii) The second to evaluate the current usage of ACTH test and the variability in practice" (second step). Based on the surveys the core ICET-A group prepared the recommendations for the assessment of suspected CAI in thalassemia (third step).Results: A total of 19 thalassemologists/endocrinologists have participated in the first survey and 35 specialists participated in the second step questionnaire. The survey demonstrated a considerable variability in almost all aspects of relevant current criteria used for the diagnosis of CAI.  A ROC analysis using peak value > 20 μg/dl (> 550 nmol/L), after ACTH stimulation test, was performed with the aim of identifying the optimal basal serum cortisol cut-off. The optimal threshold that maximizes sensitivity plus specificity for morning basal cortisol against peak post-ACTH value >20 μg/dl (>550 nmol/L) was 10 μg/dl (275 nmol/L).,Furthermore, the values associated with highest negative predictive value (NPV) and highest, positive predictive value (PPV) were 4.20 (115 nmol/L) and 18.45 μg/dl (510 nmol/L), respectively.Surprisingly, 20 specialists in thalassemia working in blood bank, thalassemia centres (day hospital), internal medicine, hematology and onco-hematology had poor knowledge and experience in testing for CAI and stopped filling the questionnaire after the second question. In contrast, 9 endocrinologists (8 pediatricians) and 6 hematologists working in collaboration with endocrinologists completed the questionnaire.Conclusions: While waiting more extensive adequately powered and targeted studies, physicians should adopt an acceptable policy for accurate assessment of HPA in TM patients. Regular surveillance, early diagnosis, treatment and follow-up in a multi-disciplinary specialized setting are also recommended. The ICET-A recommendations are reported in order to facilitate for interested physicians the approach to successful assessment of adrenal function in thalassemia. Key words: Thalassemia, adrenal insufficiency, pitfall in the diagnosis, ACTH stimulation test, guidelines.

Nighttime serum cortisol level for diagnosis of hypercortisolism in hospitalized patients

2019 ◽  
Author(s):  
Liana Khatsimova ◽  
Uliana Tsoy ◽  
Natalia Kuritsyna ◽  
Elena Grineva ◽  
Elena Litvinenko ◽  
...  
Keyword(s):  
Cortisol Level ◽  
Serum Cortisol ◽  
Hospitalized Patients ◽  
Serum Cortisol Level

Solumedrol Treatment for Severe Sepsis in Humans with a Blunted Adrenocorticotropic Hormone-Cortisol Response: A Prospective Randomized Double-Blind Placebo-Controlled Pilot Clinical Trial

2021 ◽  
pp. 088506662110388
Author(s):  
Divya Birudaraju ◽  
Sajad Hamal ◽  
John A. Tayek
Keyword(s):  
Blood Pressure ◽  
Clinical Trial ◽  
Adrenocorticotropic Hormone ◽  
Serum Cortisol ◽  
High Dose ◽  
Cortisol Response ◽  
Acth Stimulation ◽  
Double Blind ◽  
Significant Difference ◽  
To Receive

Purpose To test the benefits of Solumedrol treatment in sepsis patients with a blunted adrenocorticotropic hormone (ACTH)-cortisol response (delta <13 µg/dL) with regard to the number of days on ventilator, days on intravenous blood pressure support, length of time in an intensive care unit (ICU), 14-day mortality, and 28-day mortality. The trial was prospective, randomized, and double-blind. As part of a larger sepsis trial, 54 patients with sepsis had an intravenous ACTH stimulation test using 250 µg of ACTH, and serum cortisol was measured at times 0, 30, and 60 min. Eleven patients failed to increase their cortisol concentration above 19.9 µg/dL and were excluded from the clinical trial as they were considered to have adrenal insufficiency. The remaining 43 patients had a baseline cortisol of 32 ± 1 µg/dL increased to 38 ± 3 µg/dL at 30 min and 40 ± 3 at 60 min. All cortisol responses were <12.9 µg/dL between time 0 and time 60, which is defined as a blunted cortisol response to intravenous ACTH administration. Twenty-one were randomized to receive 20 mg of intravenous Solumedrol and 22 were randomized to receive a matching placebo every 8 h for 7-days. There was no significant difference between the two randomized groups. Data analysis was carried out bya two-tailed test and P < .05 as significant. Results Results: The mean age was 51 ± 2 (mean ± SEM) with 61% female. Groups were well matched with regard to APACHE III score in Solumedrol versus placebo (59 ± 6 vs 59 ± 6), white blood cell count (18.8 ± 2.2 vs 18.6 ± 2.6), and incidence of bacteremia (29 vs 39%). The 28-day mortality rate was reduced in the Solumedrol treated arm (43 ± 11 vs 73 ± 10%; P < .05). There was no change in days in ICU, days on blood pressure agents, or days on ventilator. Seven days of high-dose intravenous Solumedrol treatment (20 mg every 8 h) in patients with a blunted cortisol response to ACTH was associated with an improved 28-day survival. This small study suggests that an inability to increase endogenous cortisol production in patients with sepsis who are then provided steroid treatment could improve survival.

scholarly journals Post-surgical hypocortisolism after removal of an adrenal incidentaloma: is it predictable by an accurate endocrinological work-up before surgery?

2010 ◽  
Vol 162 (1) ◽  
pp. 91-99 ◽  
Author(s):  
Cristina Eller-Vainicher ◽  
Valentina Morelli ◽  
Antonio Stefano Salcuni ◽  
Massimo Torlontano ◽  
Francesca Coletti ◽  
...  
Keyword(s):  
Hpa Axis ◽  
Adrenal Incidentaloma ◽  
Serum Cortisol ◽  
Urinary Free Cortisol ◽  
Tolerance Test ◽  
Surgical Removal ◽  
Acth Stimulation ◽  
Unilateral Adrenalectomy ◽  
Free Cortisol ◽  
Few Data

ObjectiveFew data are available regarding the need of steroid substitutive therapy after unilateral adrenalectomy for adrenal incidentaloma (AI). It is unknown whether, before surgery, the hypothalamic–pituitary–adrenal (HPA) axis secretion parameters can predict post-surgical hypocortisolism.AimThis study aimed to evaluate whether, in AI patients undergoing unilateral adrenalectomy, post-surgical hypocortisolism could be predicted by the parameters of HPA axis function.DesignProspective, multicenter.MethodsA total of 60 patients underwent surgical removal of AI (surgical indication: 29 subclinical hypercortisolism (SH); 31 AI dimension). Before surgery, SH was diagnosed in patients presenting at least three criteria out of urinary free cortisol (UFC) levels>60 μg/24 h, cortisol after 1-mg dexamethasone suppression test (1 mg-DST)>3.0 μg/dl, ACTH levels<10 pg/ml, midnight serum cortisol (MSC)>5.4 μg/dl.Two months after surgery, HPA axis function was assessed by low dose ACTH stimulation test or insulin tolerance test when needed: 39 patients were affected (Group B) and 21 were not affected (Group A) with hypocortisolism. The accuracy in predicting hypocortisolism of pre-surgical HPA axis parameters or their combinations was evaluated.ResultsThe presence of >2 alterations among 1 mg-DST>5.0 μg/dl, ACTH<10 pg/ml, elevated UFC and MSC has the highest odds ratio (OR) for predicting post-surgical hypocortisolism (OR 10.45, 95% confidence interval, CI 2.54–42.95, P=0.001). Post-surgical hypocortisolism was predicted with 100% probability by elevated UFC plus MSC levels, but not ruled out even in the presence of the normality of all HPA axis parameters.ConclusionPost-surgical hypocortisolism cannot be pre-surgically ruled out. A steroid substitutive therapy is indicated after unilateral adrenalectomy for SH or size of the adenoma.

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