scholarly journals Functional Adrenal Insufficiency among Tuberculosis-Human Immunodeficiency Virus co-infected patients: A Cross-section study in Uganda

2020 ◽  
Author(s):  
Agnes Bwanika Bwanika Naggirinya ◽  
Andrew Mujugira ◽  
David B. Meya ◽  
Irene Andia Biraro ◽  
Ezekiel Mupere ◽  
...  
Keyword(s):  
Human Immunodeficiency Virus ◽  
Adrenal Insufficiency ◽  
Multivariable Analysis ◽  
Serum Cortisol ◽  
Early Morning ◽  
Serum Cortisol Level ◽  
Drug Resistant ◽  
Immunodeficiency Virus ◽  
Morning Serum Cortisol ◽  
Cortisol Levels

Abstract Objective Tuberculosis (TB) is the leading cause of adrenal insufficiency in resource-limited settings. The adrenal gland is the most commonly affected endocrine organ in TB infection. We assessed prevalence and factors associated with functional adrenal insufficiency (FAI) among human immunodeficiency virus (HIV)-infected patients with drug-resistant and drug-susceptible TB in Uganda. Patients with drug-sensitive and -resistant TB were enrolled, examined for clinical signs and symptoms of FAI with an early morning serum cortisol level obtained. FAI was defined as early morning serum cortisol <414 nmol//L. Associations with FAI were modeled using multivariable logistic regression. Results : A total of 311 TB patients were screened, and 272 enrolled. Of these, 117 (43%) had drug-resistant TB. Median age was 32 years (IQR 18-66) and 66% were men. Prevalence of FAI was 59.8%. Mean cortisol levels were lower in participants with drug-resistant than susceptible TB (317.4 versus 488.5 nmol/L; p<0.001 ) . In multivariable analysis, drug-resistant TB (aOR 4.61; 95% CI: 2.3-9.1; p < 0.001), treatment duration > 1month (aOR 2.86 95% CI: 1.4- 5.5; p=0.002) and abdominal pain (aOR 2.06; 95% CI: 1.04-4.09; p=0.038) were significantly associated with FAI. Early morning serum cortisol levels should be quantified in TB-HIV co-infected patients.

scholarly journals Functional Adrenal Insufficiency among Tuberculosis-Human Immunodeficiency Virus co-infected patients: A Cross-section study in Uganda

2019 ◽  
Author(s):  
Agnes Bwanika Bwanika Naggirinya ◽  
Irene Andia Biraro ◽  
David B. Meya ◽  
Ezekiel Mupere ◽  
Andrew Mujugira ◽  
...  
Keyword(s):  
Human Immunodeficiency Virus ◽  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Early Morning ◽  
Drug Resistant ◽  
Drug Resistant Tuberculosis ◽  
Resistant Tuberculosis ◽  
Multi Drug Resistant Tuberculosis ◽  
Immunodeficiency Virus ◽  
Morning Serum Cortisol

Abstract Objective:Tuberculosis is the leading cause of adrenal insufficiency in resource-limited settings. The adrenal gland is the most commonly affected endocrine organ in tuberculosis infection. We assessed prevalence and factors associated with functional adrenal insufficiency among human immunodeficiency virus infected patients with multidrug-resistant and drug-susceptible tuberculosis in Uganda. Patients with drug-sensitive and resistant tuberculosis were enrolled, examined for clinical signs and symptoms of adrenal insufficiency, an early morning serum cortisol level obtained. Functional adrenal insufficiency was defined as early morning serum cortisol below 414/nmol//L. Associations with functional adrenal insufficiency were estimated using multivariable logistic regression.ResultsA total of 311 tuberculosis patients were screened, and 272 enrolled. Of these, 117 (43%) had multi-drug resistant tuberculosis. Median age was 32 years (IQR 18-66) and 66% were men. Prevalence of functional adrenal insufficiency was 59.8%. Mean cortisol levels were lower in participants with multi-drug resistant than drug-susceptible tuberculosis (317.4 versus 488.5 nmol/L; p<0.001). In multivariable analysis, multi-drug resistant tuberculosis (aOR 36.60; 95% CI 8.30-161.42; p<0.001) and skin hyperpigmentation (aOR 9.63; 95% CI: 2.83-32.8; p<0.001) were significantly associated with functional adrenal insufficiency. Early morning serum cortisol levels should be quantified in TB-HIV co-infected patients.

scholarly journals Functional Adrenal Insufficiency among Tuberculosis-Human Immunodeficiency Virus co-infected patients: A Cross-section study in Uganda

2020 ◽  
Author(s):  
Agnes Bwanika Bwanika Naggirinya ◽  
Andrew Mujugira ◽  
David B. Meya ◽  
Irene Andia Biraro ◽  
Ezekiel Mupere ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Serum Cortisol ◽  
Early Morning ◽  
Serum Cortisol Level ◽  
Drug Resistant ◽  
Morning Serum Cortisol ◽  
Cortisol Levels ◽  
Clinical Signs And Symptoms

Abstract Objective: Tuberculosis (TB) is the leading cause of adrenal insufficiency in resource-limited settings. The adrenal gland is the most commonly affected endocrine organ in TB infection. We assessed factors associated with functional adrenal insufficiency (FAI) among TB-HIV patients with and without drug-resistance in Uganda. Patients with drug-sensitive and drug-resistant TB were enrolled and examined for clinical signs and symptoms of FAI with an early morning serum cortisol level obtained. FAI was defined as early morning serum cortisol <414 nmol//L. Associations with FAI were modeled using multivariable logistic regression.Results: We screened 311 TB patients and enrolled 272. Of these, 117 (43%) had drug-resistant TB. Median age was 32 years (IQR 18-66) and 66% were men. The proportion with FAI was 59.8%. Mean cortisol levels were lower in participants with drug-resistant than susceptible TB (317.4 versus 488.5 nmol/L; p<0.001). In multivariable analyses, drug-resistant TB (aOR 4.61; 95% CI: 2.3-9.1; p<0.001), treatment duration > 1 month (aOR 2.86; 95% CI: 1.4-5.5; p=0.002) and abdominal pain (aOR 2.06; 95% CI: 1.04-4.09; p=0.038) were significantly associated with FAI. Early morning serum cortisol levels should be quantified in TB-HIV co-infected patients with drug-resistant TB.

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.

MORNING SERUM CORTISOL LEVEL PREDICTS CENTRAL ADRENAL INSUFFICIENCY DIAGNOSED BY INSULIN TOLERANCE TEST

2021 ◽  
Author(s):  
Valentina Gasco ◽  
Chiara Bima ◽  
Alice Geranzani ◽  
Jacopo Giannelli ◽  
Lorenzo Marinelli ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Tolerance Test ◽  
Insulin Tolerance Test ◽  
Cortisol Concentration ◽  
Serum Cortisol Level ◽  
Cortisol Response ◽  
Insulin Tolerance ◽  
Morning Serum Cortisol ◽  
Serum Cortisol Concentration

Introduction According to guidelines, a morning serum cortisol level <83 nmol/L is diagnostic for central adrenal insufficiency (CAI), a value >414 nmol/L excludes CAI, while values between 83 and 414 nmol/L require stimulation tests. However, there are no currently reliable data on morning serum cortisol for prediction of cortisol response to insulin tolerance test (ITT). Objective Using the receiver operating characteristic curve analysis, the purpose of this study was to detect the morning serum cortisol cut-off with a specificity (SP) or a sensitivity (SE) above 95% that identify those patients who should not be tested with ITT. Methods We included 141 adult patients (83 males) aged 42.7+/-12.3 (mean +/- SD) years old. Based on serum cortisol response to ITT, patients have been divided in two groups: subjects with CAI (peak serum cortisol <500 nmol/L; 65 patients) and subjects with preserved adrenocortical function (peak cortisol >500 nmol/L; 76 patients). Results The best morning cortisol cut-off, in terms of SE (87.7%) and SP (46.1%), was ≤323.3 nmol/L. The cut-off of morning serum cortisol concentration that best predicted a deficient response to ITT was ≤126.4 nmol/L (SE 13.8%, SP 98.7%). The cut-off of morning serum cortisol concentration that best predicted a normal response to ITT was >444.7 nmol/L (SE 96.9%, SP 14.5%). Conclusions This is the first study that identifies a morning serum cortisol cut-off that best predict the response to ITT in order to simplify the diagnostic process in patients with suspected CAI. A new diagnostic flow chart for CAI is proposed.

scholarly journals A Predictive Risk Score to Diagnose Adrenal Insufficiency in Outpatients: A 7 Year Retrospective Cohort Study

Medicines ◽  
2021 ◽  
Vol 8 (3) ◽  
pp. 13
Author(s):  
Worapaka Manosroi ◽  
Tanyong Pipanmekaporn ◽  
Jiraporn Khorana ◽  
Pichitchai Atthakomol ◽  
Mattabhorn Phimphilai
Keyword(s):  
Adrenal Insufficiency ◽  
Risk Score ◽  
Predictive Factors ◽  
Multivariable Analysis ◽  
Positive Likelihood Ratio ◽  
Serum Cortisol ◽  
Risk Level ◽  
Dynamic Tests ◽  
Cortisol Levels ◽  
Predictive Risk

Background: The diagnosis of adrenal insufficiency (AI) requires dynamic tests which may not be available in some institutions. This study aimed to develop a predictive risk score to help diagnose AI in outpatients with indeterminate serum cortisol levels. Methods: Five hundred and seven patients with intermediate serum cortisol levels (3–17.9 µg/dL) who had undergone ACTH (adrenocorticotropin) stimulation tests were included in the study. A predictive risk score was created using significant predictive factors identified by multivariable analysis using Poisson regression clustered by ACTH dose. Results: The seven predictive factors used in the development of a predictive model with their assigned scores are as follows: chronic kidney disease (9.0), Cushingoid appearance in exogenous steroid use (12.0), nausea and/or vomiting (6.0), fatigue (2.0), basal cortisol <9 µg/dL (12.5), cholesterol <150 mg/dL (2.5) and sodium <135 mEq/L (1.0). Predictive risk scores range from 0–50.0. A high risk level (scores of 19.5–50.0) indicates a higher possibility of having AI (positive likelihood ratio (LR+) = 11.75), while a low risk level (scores of <19.0) indicates a lower chance of having AI (LR+ = 0.09). The predictive performance of the scoring system was 0.82 based on the area under the curve. Conclusions: This predictive risk score can help to determine the probability of AI and can be used as a guide to determine which patients need treatment for AI and which require dynamic tests to confirm AI.

scholarly journals Morning Serum Cortisol May Be Less Accurate for Diagnosing Adrenal Insufficiency in Hospitalized Patients, Particularly Those on Opioids

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A89-A90
Author(s):  
Caitlin Ann Colling ◽  
Lisa B Nachtigall ◽  
Beverly M K Biller ◽  
Karen Klahr Miller
Keyword(s):  
Positive Predictive Value ◽  
Adrenal Insufficiency ◽  
Predictive Value ◽  
Serum Cortisol ◽  
Hospitalized Patients ◽  
Opioid Use ◽  
Morning Cortisol ◽  
Morning Serum Cortisol ◽  
Cortisol Levels ◽  
The Impact

Abstract Introduction: The positive predictive value of a low morning serum cortisol to diagnose adrenal insufficiency (AI) is reported to be &gt;90%, which is the basis for guidelines recommending morning cortisol as the first-line test for central AI. A level &lt;3 µg/dL is considered diagnostic. However, studies that established this cut-off were conducted primarily in outpatients, not hospitalized patients in whom diurnal variation may be disrupted. Studies suggest that opioids suppress cortisol levels acutely, may disrupt diurnal cortisol rhythm, and cause adrenal insufficiency in 8–50% of chronically-exposed patients. The impact of hospitalization, particularly in the setting of opioid use, on the accuracy of diagnostics for AI is unknown. We hypothesized that low morning cortisol values in hospitalized patients, especially those prescribed opioids, do not accurately diagnose adrenal insufficiency, as determined by corticotropin stimulation test (CST) peak cortisol &lt;18 µg/dL. Methods: We performed a retrospective analysis of CSTs in hospitalized patients in the Mass General Brigham health system from 5/2015 to 9/2020. Opioid-exposed adults who underwent CST were included if they had a morning cortisol (5–9 AM) result. Control patients were matched by age, gender and race and had no opioid prescriptions within 30 days of testing. Patients were excluded if tested in the outpatient or ICU setting, had a history of cirrhosis or pituitary disease, had an elevated ACTH, were prescribed oral estrogen, or received oral, IV or intraarticular glucocorticoids within 30 days. Results: The analysis included 124 opioid-exposed and 322 control patients, mean (±SD) age 60.8±14.4 and 63.8±15.3y, and 55.6% and 45.0% female, respectively. Twenty-two (17.7%) opioid-exposed and 33 (10.2%) control patients were diagnosed with AI by CST (p=0.031). Nineteen opioid-exposed (15.3%) and 22 control (6.8%) patients had morning cortisol of &lt;3 µg/dL (p=0.005). A morning cortisol &lt;3 µg/dL had a positive predictive value of 36.8% (CI 19.1–59.0%) for AI in opioid-exposed and 50.0% (CI 30.7–69.3%) in control patients. In opioid-exposed patients with low morning cortisol levels, mean daily morphine milligram equivalent and duration of opioid exposure did not differ between those with AI confirmed by CST and those with normal CST (p=0.13 and 0.38, respectively). Conclusion: Among hospitalized patients with suspected AI, those prescribed opioids have a higher prevalence of central AI than controls. Serum morning cortisol &lt;3 µg/dL is not an accurate test for AI in hospitalized patients, including those prescribed opioids in whom low morning cortisol is more prevalent than in controls. Given the risks associated with misdiagnosis of AI, caution should be exercised in relying on morning cortisol values for the diagnosis of AI in hospitalized patients.

scholarly journals Ambient air pollutants are associated with morning serum cortisol in overweight and obese Latino youth in Los Angeles

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
C. M. Toledo-Corral ◽  
T. L. Alderete ◽  
M. M. Herting ◽  
R. Habre ◽  
A. K. Peterson ◽  
...  
Keyword(s):  
Hpa Axis ◽  
Air Pollutants ◽  
Latino Youth ◽  
Serum Cortisol ◽  
Ambient Air ◽  
Pubertal Status ◽  
Ambient Air Pollutants ◽  
Morning Cortisol ◽  
Morning Serum Cortisol ◽  
Cortisol Levels

Abstract Background Hypothalamic-pituitary-adrenal (HPA)-axis dysfunction has been associated with a variety of mental health and cardio-metabolic disorders. While causal models of HPA-axis dysregulation have been largely focused on either pre-existing health conditions or psychosocial stress factors, recent evidence suggests a possible role for central nervous system activation via air pollutants, such as nitrogen dioxide (NO2), ozone (O3) and particulate matter (PM). Therefore, in an observational study of Latino youth, we investigated if monthly ambient NO2, O3, and PM with aerodynamic diameter ≤ 2.5 (PM2.5) exposure were associated with morning serum cortisol levels. Methods In this cross-sectional study, morning serum cortisol level was assessed after a supervised overnight fast in 203 overweight and obese Latino children and adolescents (female/male: 88/115; mean age: 11.1 ± 1.7 years; pre-pubertal/pubertal/post-pubertal: 85/101/17; BMI z-score: 2.1 ± 0.4). Cumulative concentrations of NO2, O3 and PM2.5 were spatially interpolated at the residential addresses based on measurements from community monitors up to 12 months prior to testing. Single and multi-pollutant linear effects models were used to test the cumulative monthly lag effects of NO2, O3, and PM2.5 on morning serum cortisol levels after adjusting for age, sex, seasonality, social position, pubertal status, and body fat percent by DEXA. Results Single and multi-pollutant models showed that higher O3 exposure (derived from maximum 8-h exposure windows) in the prior 1–7 months was associated with higher serum morning cortisol (p < 0.05) and longer term PM2.5 exposure (4–10 months) was associated with lower serum morning cortisol levels (p < 0.05). Stratification by pubertal status showed associations in pre-pubertal children compared to pubertal and post-pubertal children. Single, but not multi-pollutant, models showed that higher NO2 over the 4–10 month exposure period associated with lower morning serum cortisol (p < 0.05). Conclusions Chronic ambient NO2, O3 and PM2.5 differentially associate with HPA-axis dysfunction, a mechanism that may serve as an explanatory pathway in the relationship between ambient air pollution and metabolic health of youth living in polluted urban environments. Further research that uncovers how ambient air pollutants may differentially contribute to HPA-axis dysfunction are warranted.

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