scholarly journals The Caveats of Corticotropin Stimulation Test in Diagnosing Secondary Adrenal Insufficiency: Case Reports and Literature Review

2016 ◽  
Vol 6 (5) ◽  
pp. 154-157
Author(s):  
Ekaterina Manuylova ◽  
Laura M. Calvi ◽  
Catherine Hastings ◽  
G. Edward Vates ◽  
Maryanne Stahlecker-Etter ◽  
...  
Keyword(s):  
Literature Review ◽  
Adrenal Insufficiency ◽  
Case Reports ◽  
Stimulation Test ◽  
Secondary Adrenal Insufficiency ◽  
Corticotropin Stimulation

scholarly journals The Prevalence of Tertiary Adrenal Insufficiency in Patients Receiving Topical Glucocorticoid Treatment for Oral Lichen Planus

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A99-A99
Author(s):  
Margret J Einarsdottir ◽  
Maria Bankvall ◽  
Jairo Robledo-Sierra ◽  
Per-Olof Rödström ◽  
Penelope Trimpou ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Lichen Planus ◽  
Oral Lichen Planus ◽  
Peak Level ◽  
Serum Cortisol ◽  
Clobetasol Propionate ◽  
Stimulation Test ◽  
Glucocorticoid Treatment ◽  
Oral Lichen ◽  
Corticotropin Stimulation

Abstract Objective: Glucocorticoid (GC) treatment suppress the hypothalamic-pituitary-adrenal axis, which may lead to tertiary adrenal insufficiency. This study aimed to investigate the prevalence of tertiary adrenal insufficiency among patients with oral lichen planus treated with topical GC (clobetasol propionate) in the oral cavity, a standard treatment option for this condition. Methods: In this cross-sectional study, we included 24 patients with oral lichen planus receiving long-term (> 6 weeks) clobetasol propionate treatment. Adrenal function was assessed by measuring serum cortisol between 8–9 AM, after a withdrawal of treatment for 48 hours. For patients with serum cortisol concentrations below 280 nmol/L (10 µg/dL), a 250 µg corticotropin stimulation test was performed. Results: Twenty patients had normal serum cortisol concentrations (range 280–621 nmol/L), whereas four patients had low serum cortisol concentrations (13, 45, 63, and 229 nmol/L, respectively). A corticotropin stimulation test revealed partial adrenal insufficiency in two patients (serum cortisol peak level 350 nmol/L and 360 nmol/L) and severe adrenal insufficiency in another two patients (serum cortisol peak level 150 nmol/L and 210 nmol/L). Conclusion: In this small study, approximately 20% of patients receiving chronic topical GCs treatment for oral lichen planus had tertiary adrenal insufficiency. It is essential to be aware of this potential risk and to inform patients about the need for GC stress-doses during an intercurrent illness episode.

scholarly journals SUN-193 A Case of Cushing’s Syndrome Caused by Epidural Corticoidsteroid Injection

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Fiorella Sotomayor Villanueva ◽  
Huong Nguyen
Keyword(s):  
Adrenal Insufficiency ◽  
Cushing’S Syndrome ◽  
Case Reports ◽  
Signs And Symptoms ◽  
Free Testosterone ◽  
Cushing's Syndrome ◽  
Stimulation Test ◽  
Patient Reported ◽  
Facial Swelling ◽  
Cosyntropin Stimulation Test

Abstract Introduction: Cushing’s syndrome (CS) is a collection of signs and symptoms caused by hypercortisolism that results from endogenous or exogenous glucocorticoid excess. It is associated with increased morbidity and mortality from musculoskeletal, metabolic, thrombotic, infectious and cardiovascular complications. The most common cause of CS today is the use of corticosteroid medications. It′s reported that more than 10 million American receive pharmacological doses of glucocorticoids each year. Case reports have shown that CS can be caused by non-systemic use of corticosteroids. Clinical case: A 53-year-old patient with past medical history of osteoarthritis who presented to outpatient endocrinology office for new onset facial swelling of 2 months. His PCP had attributed it to adverse effect of recent neck glucocorticoid injections and treated him with prednisone for 7 days without any relief. Subsequently, he was referred to Endocrinology due to concern about Cushing′s syndrome. The patient reported associated easy bruising and decreased libido. On further questioning, patient mentioned he had been receiving several epidural steroid injections in the neck, shoulders and back in the past. Per record review, from June to November 2018, he had received multiple triamcinolone and dexamethasone injections as follows: 10mg dexamethasone in each C4-5, C5-6 and C6-7 facet joints; 5mg triamcinolone injections in the right C4-5, C6-C7, left C4-5, C6 and C7, and 40mg of triamcinolone in C7-T1. The patient also reported he had multiple injections in 2019, but these records were not available. Physical exam showed hypertension, facial plethora, and scattered bilateral arm ecchymosis. Laboratory study showed hyperglycemia. Given suspicion for CS, further workup, including morning serum cortisol, ACTH, and 24-hour urine cortisol were ordered, which were 0.5 ug/dl (6.2-19.4 ug/dl), 4.3 pg/ml (7.2-63.3 pg/ml) and <2 ug/24 hours (5-64 ug/24 hours) respectively, suggesting iatrogenic CS secondary to corticoid steroid injection. Also, given that the patient reported lightheadedness, and decreased libido, cosyntropin stimulation test and free testosterone, FSH and LH were ordered to rule out adrenal insufficiency and hypogonadism respectively. Hypogonadism was ruled out, however, cosyntropin stimulation test showed peak cortisol of 12 and 16 mcg/dL at 30 and 60 minutes (>18 mcg/dL), suggesting adrenal insufficiency, due to suppression of endogenous cortisol production from exogenous glucocorticoid use. Patient was started on hydrocortisone and all glucocoirticoid injections were stopped. Conclusions: Many different non-systemic corticosteroid administrations can cause iatrogenic Cushing’s Syndrome, and therefore, physicians should be thoughtful when prescribing steroids regardless of administration form.

scholarly journals SUN-311 Adrenal Reserve Testing with the Glucagon Stimulation Test (GST) and Cosyntropin Stimulation Test (CST) in Deployed Veterans with Mild Traumatic Brain Injury

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Rama Priyanka Nagireddi ◽  
Htet Htet Win ◽  
Sarah Wagstaff ◽  
Moira Neal ◽  
Kathryn Friedman ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Adrenal Insufficiency ◽  
Mild Traumatic Brain Injury ◽  
Stimulation Test ◽  
Pituitary Hormone ◽  
Secondary Adrenal Insufficiency ◽  
Glucagon Stimulation Test ◽  
Cortisol Levels ◽  
Cosyntropin Stimulation Test

Abstract Introduction: Mild Traumatic Brain Injury (mTBI) is associated with anterior pituitary hormone dysfunction. The potential long-term effect of this injury on pituitary function in Veterans is not clear. We reviewed the utility of the fixed dose Glucagon Stimulation Test (GST) compared with the high dose Cosyntropin Stimulation test (CST) for hypothalamic-pituitary-adrenal (HPA) reserve over time in these patients with mTBI. Methods: We present an interim report of our 4-year longitudinal prospective pilot study of pituitary function in Veterans diagnosed with mTBI. Of the 34 mTBI Veterans enrolled, we have tested 28 of them (4 female, 24 male; age and BMI, 31.5±7.0 years and 30.4±6.2, mean±SD, respectively) for baseline pituitary hormone levels and cortisol response to the CST. In 22 subjects growth hormone and cortisol responses to GST were tested at baseline (Year 0). Follow-up testing was done for 18 mTBI subjects in Year 1, 13 subjects in Year 2, 10 subjects in Year 3 and 5 subjects in Year 4. The same baseline data were obtained for 14 age-, sex-, deployment- and BMI-matched control subjects without mTBI (2 female,12 male; age and BMI 34.4±6.8 years and 30.5±4.9, mean±SD, respectively). Cortisol cutoffs of <18 mcg/dL with the CST and <9.0 mcg/dL with the GST were used for the diagnosis of adrenal insufficiency. Results: Secondary adrenal insufficiency (AI), likely partial, was identified during this study on 6 occasions: 3/22 subjects at Year 0, 1/18 at Year 1, 0/13 at Year 2, 1/10 at Year 3 and 1/5 at Year 4. Two baseline subjects with AI reverted to normal in Years 1-3, one relapsed in Year 4 and a third had no further testing. Correlations of the cortisol levels from GST vs the 60-minute cortisol from CST were significant at Year 0 (n=22, r=0.553, p=0.008) and at Year 1 (n=18, r=0.802, p<0.0001). Due to decreased numbers, there were no significant correlations at Years 2 through 4. Similar correlations were obtained using the 30-minute CST values. However, the CST cortisol value predicted the low GST value in only 2/6 subjects. The mean GST cortisol levels and 60-minute CST cortisol levels for subjects at each year were not significantly different over Years 0 through 4 based on ANOVA analyses (CST: F=1.519, p= 0.206; GST: F= 0.796, p=0.532). Conclusions: Secondary adrenal insufficiency, likely partial, related to mTBI was detected by GST on 6 occasions (twice in one patient) over 4 years of observation. GST can provide useful information about HPA axis reserve, and appears to be more reliable than CST. Identification of potential secondary adrenal insufficiency using the GST in Veterans with mTBI can provide a beneficial combined test for these patients when other testing is not feasible.

Secondary adrenal insufficiency after intrathecal steroid administration

1982 ◽  
Vol 56 (4) ◽  
pp. 567-570 ◽  
Author(s):  
Bart Chernow ◽  
Robert Vigersky ◽  
John T. O'Brian ◽  
Leon P. Georges
Keyword(s):  
Adrenal Insufficiency ◽  
Plasma Cortisol ◽  
Elevated Level ◽  
Delayed Response ◽  
Cortisol Response ◽  
Secondary Adrenal Insufficiency ◽  
Content Type ◽  
Steroid Administration ◽  
Adrenal Response ◽  
Corticotropin Stimulation

✓ A 38-year-old man developed secondary adrenal insufficiency as a consequence of intrathecal methylprednisolone administration. Evidence in support of this diagnosis included an absent plasma cortisol response to insulin-induced hypoglycemia, an inadequate adrenal response to exogenous corticotropin stimulation, a typical delayed response to prolonged corticotropin infusion over 3 days, and the finding of an elevated level of prednisolone in the cerebrospinal fluid a full 2 months after its administration. It is therefore recommended that patients receiving intrathecal steroids be carefully observed for the possible development of secondary adrenal insufficiency.

scholarly journals Careful Evaluation of Cosyntropin Dose in the Diagnosis of Adrenal Insufficiency

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A122-A123
Author(s):  
Clio Musurakis ◽  
Solab Chitrakar ◽  
Randa Eldin Sharag ◽  
Ekta Shrestha ◽  
Gauri Pethe ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Gold Standard ◽  
Low Dose ◽  
Treatment Plan ◽  
Stimulation Test ◽  
Diagnostic Process ◽  
High Dose ◽  
Secondary Adrenal Insufficiency ◽  
Acth Stimulation ◽  
Primary Adrenal Insufficiency

Abstract Introduction: The use of the 250μg cosyntropin dose or otherwise called high-dose ACTH test is the gold standard test for diagnosis of primary adrenal insufficiency. The 1μg dose test or the low-dose test is mostly reserved for diagnosis of secondary adrenal insufficiency. Careful consideration of the results produced during the diagnostic process is imperative to avoid mislabeling of patients with a disease that requires lifelong treatment. Case Report: This is the case of a 45-year-old female with a history of asthma and psoriasis who presented with emesis. Home medications included monthly TNF-alpha inhibitor injections for psoriasis, triamcinolone acetonide topical spray and budesonide-formoterol inhaler. On admission, she also had nausea, chills and diaphoresis, as well as palpitations, lightheadedness, and shortness of breath. When she arrived at the ER, vitals were remarkable for low blood pressure. Labs were unremarkable except for CMP concerning for anion gap metabolic acidosis, hyponatremia, and hypokalemia. A random serum cortisol was 6.4 mcg/dL, which was relatively low. ACTH was within normal range. Due to concern for adrenal insufficiency, a 1μg cosyntropin test was performed which showed a peak cortisol concentration of less than 18 mcg/dL. As the response was assessed as suboptimal, endocrinology was consulted to offer a treatment plan for steroids. However, the test was repeated using the gold standard 250μg cosyntropin dose and the patient then showed an adequate response and she was not started on steroids. Conclusions: This is a case that demonstrates how the 250 μg ACTH or high-dose stimulation test should be used for diagnosis of primary adrenal insufficiency (AI), as it is the gold standard. The 1 μg ACTH or low-dose stimulation test can be used for diagnosis of primary AI but only when the high dose test is not available. On the other hand, the 1 μg ACTH stimulation test has been shown to be more sensitive than the 250 μg test in diagnosing secondary adrenal insufficiency. When using the most appropriate test correctly, the clinician can only then offer the patient the best treatment strategies. Our patient did not require chronic replacement therapy. The steroids in this case could have harmed the patient as chronic administration could cause adrenal gland suppression.

scholarly journals Prevalence of occult adrenal insufficiency and the prognostic value of a short corticotropin stimulation test in patients with septic shock

2009 ◽  
Vol 13 (2) ◽  
pp. 85-91 ◽  
Author(s):  
Muzaffar Maqbool ◽  
Zafar Amin Shah ◽  
Fayaz Ahmad Wani ◽  
Abdul Wahid ◽  
Shaheena Parveen ◽  
...  
Keyword(s):  
Septic Shock ◽  
Adrenal Insufficiency ◽  
Prognostic Value ◽  
Stimulation Test ◽  
Corticotropin Stimulation

Isolated ACTH deficiency and primary hypothyroidism

1982 ◽  
Vol 99 (4) ◽  
pp. 573-576 ◽  
Author(s):  
Michael J. Miller ◽  
Tomm Vander Horst
Keyword(s):  
Adrenal Insufficiency ◽  
Autoimmune Thyroid Disease ◽  
Case Reports ◽  
Primary Hypothyroidism ◽  
Adrenal Failure ◽  
Secondary Adrenal Insufficiency ◽  
Isolated Acth Deficiency ◽  
Acth Deficiency ◽  
Autoimmune Thyroid ◽  
Autoimmune Aetiology

Abstract. A patient presented with severe primary hypothyroidism and secondary adrenal insufficiency due to the isolated deficiency of ACTH. The diagnostic evidence suggests that both are of an autoimmune aetiology. Acquired isolated or unitrophic ACTH deficiency is a rare but definite cause of adrenal insufficiency. Additional case reports and autopsy studies describing acquired isolated ACTH deficiency associated with autoimmune thyroid disease have appeared in the literature suggesting that the association is more than coincidental. Combined thyroid and adrenal failure should not always be considered to be the result of combined end organ failure. Unitrophic isolated ACTH deficiency may co-exist with primary hypothyroidism.

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