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Butt MI, Alzuhayri N, Amer L, Riazuddin M, Aljamei H, Khan MS, Abufarhaneh M, Alrajhi E, Alnassar A, Alahmed R, Aljayar DMA, Abothenain FF, De Vol E. Comparing the utility of 30- and 60-minute cortisol levels after the standard short synacthen test to determine adrenal insufficiency: A retrospective cross-sectional study. Medicine (Baltimore) 2020; 99:e22621. [PMID: 33120750 PMCID: PMC7581130 DOI: 10.1097/md.0000000000022621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Short Synacthen test (SST) involves measuring the baseline, 30-, and 60-minute serum cortisol levels, after injecting 250 μg of synthetic adrenocorticotropic hormone or Synacthen (ACTH). This study aimed to review the current clinical practice of performing SST to establish a standardized test protocol and to additionally test the hypothesis regarding performing the 60-minute cortisol test alone and the dependence of overall SST result on baseline cortisol level.Patients >14 years who underwent SST from January 2010 to December 2017 were included. Pearson's chi-square cross-tabulation was used to identify individuals with inconsistent 30- and 60-minute serum cortisol test results. Logistic regression analysis was performed to predict normal responses based on the baseline cortisol value.Of the 965 patients identified from pharmacy, medical, and laboratory records, 849 were included. Mean baseline, 30-, and 60-minute cortisol levels after ACTH injection were 394 ± 286.58, 722 ± 327.11, and 827 ± 369.30 nmol/L, respectively. Overall, 715 (84%) and 134 (16%) patients had normal and abnormal responses, respectively. Primary and secondary adrenal insufficiency was diagnosed in 10% and 35%, respectively, while ACTH levels were not measured in 55% of the patients. Overall, 9.49% (n = 72) of the patients had a suboptimal response at 30 minutes, but reached the threshold value of 550 nmol/L at 60 minutes. This particular subgroup's mean change (240 nmol/L) in cortisol level from baseline to 30-minute was higher than that observed in patients with abnormal response at both time-points (mean change, 152 nmol/L). No patient with 30-minute optimal responses had 60-minute suboptimal responses. The baseline serum cortisol threshold of ≥226 nmol/L had 80% sensitivity, 71% specificity, and 93% positive predictive value for detecting a normal SST (P-value < .0001).Relying on a 60-minute cortisol level can identify all normal and abnormal responses, while relying on 30-minute cortisol level alone may produce false-positives. Additionally, a baseline cortisol level of ≥226 nmol/L is a reliable threshold for determining adequate adrenal function, particularly with a low pretest hypoadrenalism probability.
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Affiliation(s)
- Muhammad Imran Butt
- King Faisal Specialist Hospital & Research Centre, Zahrawi St, Al Maather
- Al Faisal University, Al Zahrawi Street, Riyadh, Kingdom of Saudi Arabia
| | - Nouf Alzuhayri
- King Faisal Specialist Hospital & Research Centre, Zahrawi St, Al Maather
| | - Lama Amer
- King Faisal Specialist Hospital & Research Centre, Zahrawi St, Al Maather
| | - Muhammad Riazuddin
- King Faisal Specialist Hospital & Research Centre, Zahrawi St, Al Maather
- Al Faisal University, Al Zahrawi Street, Riyadh, Kingdom of Saudi Arabia
| | - Hadeel Aljamei
- King Faisal Specialist Hospital & Research Centre, Zahrawi St, Al Maather
| | | | | | - Eman Alrajhi
- King Faisal Specialist Hospital & Research Centre, Zahrawi St, Al Maather
| | - Anhar Alnassar
- King Faisal Specialist Hospital & Research Centre, Zahrawi St, Al Maather
| | - Reem Alahmed
- King Faisal Specialist Hospital & Research Centre, Zahrawi St, Al Maather
| | | | | | - Edward De Vol
- King Faisal Specialist Hospital & Research Centre, Zahrawi St, Al Maather
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Maijers I, Kearns N, Harper J, Weatherall M, Beasley R. Oral steroid-sparing effect of high-dose inhaled corticosteroids in asthma. Eur Respir J 2020; 55:13993003.01147-2019. [PMID: 31558659 DOI: 10.1183/13993003.01147-2019] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/16/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND The proportion of the efficacy of high-dose inhaled corticosteroids (ICS) in oral corticosteroid-dependent asthma that is due to systemic effects is uncertain. This study aimed to estimate the ICS dose-response relationship for oral corticosteroid-sparing effects in oral corticosteroid-dependent asthma, and to determine the proportion of oral corticosteroid-sparing effects due to their systemic effects, based on the comparative dose-response relationship of ICS versus oral corticosteroids on adrenal suppression. METHODS Systematic review and meta-analysis of randomised controlled trials reporting oral corticosteroid-sparing effects of high-dose ICS in oral corticosteroid-dependent asthma. In addition, reports of oral corticosteroid to ICS dose-equivalence in terms of adrenal suppression were retrieved. The primary outcome was the proportion of the oral corticosteroid-sparing effect of ICS that could be attributed to systemic absorption, per 1000 µg increase of ICS, expressed as a ratio. This ratio estimates the oral corticosteroid sparing effect of ICS due to systemic effects. RESULTS 11 studies including 1283 participants reporting oral corticosteroid-sparing effects of ICS were identified. The prednisone dose decrease per 1000 µg increase in ICS varied from 2.1 mg to 4.9 mg, depending on the type of ICS. The ratio of the prednisone-sparing effect due to the systemic effects per 1000 µg of fluticasone propionate was 1.02 (95% CI 0.68-2.08) and for budesonide was 0.93 (95% CI 0.63-1.89). CONCLUSION In patients with oral corticosteroid-dependent asthma, the limited available evidence suggests that the majority of the oral corticosteroid-sparing effect of high-dose ICS is likely to be due to systemic effects.
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Affiliation(s)
- Ingrid Maijers
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nethmi Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - James Harper
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Weatherall
- Dept of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand .,School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
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Ortiz-Flores AE, Santacruz E, Jiménez-Mendiguchia L, García-Cano A, Nattero-Chávez L, Escobar-Morreale HF, Luque-Ramírez M. Role of sampling times and serum cortisol cut-off concentrations on the routine assessment of adrenal function using the standard cosyntropin test in an academic hospital from Spain: a retrospective chart review. BMJ Open 2018; 8:e019273. [PMID: 29730618 PMCID: PMC5942445 DOI: 10.1136/bmjopen-2017-019273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Aiming to validate the use of a single poststimulus sampling protocol for cosyntropin test short standard high-dose test (SST) in our institution, our primary objectives were (1) to determine the concordance between 30 and 60 min serum cortisol (SC) measurements during SST; and (2) to evaluate the diagnostic agreement between both sampling times when using classic or assay-specific and sex-specific SC cut-off values. The secondary objectives included (1) estimating the specificity and positive predictive value of 30 and 60 min sampling times while considering the suspected origin of adrenal insufficiency (AI); and (2) obtaining assay-specific cut-off values for SC after SST in a group of subjects with normal hypothalamic-pituitary-adrenal (HPA) axis. DESIGN AND SETTING This is a retrospective chart review study conducted at a Spanish academic hospital from 2011 to 2015. PARTICIPANTS AND INTERVENTIONS Two groups were evaluated: (1) a main study group including 370 patients in whom SC was measured at 30 and 60 min during SST; and (2) a confirmative group that included 150 women presenting with a normal HPA axis in whom SST was conducted to rule out late-onset congenital adrenal hyperplasia. Diagnostic agreement between both sampling times was assessed by considering both classic (500 nmol/L) and assay-specific SC cut-off concentrations. RESULTS Diagnostic agreement between both sampling times was greater when applying sex-specific and assay-specific cut-off values instead of the classic cut-off values. For suspected primary AI, 30 min SC determination was enough to establish a diagnosis in over 95% of cases, without missing any necessary treatment. When central AI is suspected, 60 min SC measurement was more specific, establishing a diagnosis in over 97% of cases. CONCLUSIONS Sex-specific and assay-specific SC cut-off values improve the diagnostic accuracy of SST. For primary disease, a subnormal SC response at 30 min is a reliable marker of adrenal dysfunction. On the contrary, when central AI is suspected, 60 min SC measurement improves the diagnostic accuracy of the test.
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Affiliation(s)
- Andrés E Ortiz-Flores
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal & Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Elisa Santacruz
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ana García-Cano
- Department of Clinical Biochemistry, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Lia Nattero-Chávez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal & Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Manuel Luque-Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal & Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
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Manji J, Singh G, Okpaleke C, Dadgostar A, Al-Asousi F, Amanian A, Macias-Valle L, Finkelstein A, Tacey M, Thamboo A, Javer A. Safety of long-term intranasal budesonide delivered via the mucosal atomization device for chronic rhinosinusitis. Int Forum Allergy Rhinol 2017; 7:488-493. [PMID: 28151588 DOI: 10.1002/alr.21910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 11/23/2016] [Accepted: 12/13/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although short-term use (≤2 months) of atomized topical nasal steroids has been shown to be safe and effective, the long-term safety has yet to be demonstrated. The aim of this study was to determine the impact of long-term topical budesonide treatment via the mucosal atomization device (MAD) on the hypothalamic-pituitary-adrenal axis (HPAA) and intraocular pressure (IOP). METHODS A cross-sectional study of patients with chronic rhinosinusitis (CRS), with or without nasal polyposis, managed with daily nasal budesonide via MAD was conducted at a tertiary rhinology center. Patients using systemic steroids within 3 months of assessment were excluded. HPAA impact was assessed using the cosyntropin stimulation test for adrenal function and a survey of relevant symptomatology. Patients also underwent tonometry to assess for elevated IOP potentially related to corticosteroid use. RESULTS A total of 100 CRS patients were recruited with a mean budesonide treatment duration of 23.5 months (range, 6-37 months). Stimulated cortisol response was diminished in 3 patients (3%). No patients with adrenal suppression had relevant symptomatology. IOP was elevated in 6 patients (6%). CONCLUSION These findings suggest that there is a risk of adrenal suppression and raised IOP associated with the long-term use of topical nasal budesonide via MAD. Otolaryngologists should consider periodic surveillance for these adverse events in this patient cohort.
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Affiliation(s)
- Jamil Manji
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Gurkaran Singh
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | | | - Anali Dadgostar
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | - Fahad Al-Asousi
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | - Ameen Amanian
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | - Luis Macias-Valle
- Hospital Español de México, Facultad Mexicana de Medicina Universidad La Salle Mexico City, Mexico
| | - Andres Finkelstein
- Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Chile
| | - Mark Tacey
- Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Thamboo
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | - Amin Javer
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
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Adrenal failure due to bilateral adrenal metastasis of rectal cancer: A case report. Int J Surg Case Rep 2016; 31:1-4. [PMID: 28073054 PMCID: PMC5222944 DOI: 10.1016/j.ijscr.2016.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 12/14/2016] [Accepted: 12/18/2016] [Indexed: 11/21/2022] Open
Abstract
Bilateral adrenal metastases can be lead to adrenal insufficiency. A rapid ACTH test is useful to diagnose adrenal insufficiency. Adrenal crisis may be fatal if not promptly recognized and treated.
Introduction It is rare for a patient to present with adrenal insufficiency secondary to bilateral adrenal metastases from a malignant colorectal tumor. Case presentation An 82-year-old Japanese man presented to our hospital with high fever and malaise. He was receiving oral chemotherapy for the treatment of rectal cancer with multiple metastases. Computed tomography showed new bilateral adrenal gland metastases. A rapid adrenocorticotropic hormone (ACTH) test showed adrenal insufficiency. Treatment with hydrocortisone provided immediate symptom improvement. Discussion Adrenal insufficiency secondary to bilateral adrenal metastases from rectal cancer is rare. A rapid ACTH test is useful to diagnose adrenal insufficiency. Conclusion The incidence of adrenal insufficiency may be underestimated in patients with multiple metastasis. Appropriate therapy with adrenal corticosteroid hormone supplementation may lead to a significant improvement in the patient’s symptoms and quality of life.
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Arimura H, Hashiguchi H, Yamamoto K, Shinnakasu A, Arimura A, Kikuchi A, Deguchi T, Habu M, Fujio S, Arita K, Nishio Y. Investigation of the clinical significance of the growth hormone-releasing peptide-2 test for the diagnosis of secondary adrenal failure. Endocr J 2016; 63:533-44. [PMID: 27020037 DOI: 10.1507/endocrj.ej15-0587] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to evaluate the ability of the growth hormone-releasing peptide-2 (GHRP-2) test to clinically diagnose hypothalamo-pituitary-adrenal (HPA) axis failure. We performed an insulin tolerance test (ITT), CRH stimulation test, and GHRP-2 test on 47 patients suspected of having a hypothalamo-pituitary disorder. Patients with pituitary disorders had significantly lower ACTH responses to the GHRP-2 test compared to patients with hypothalamic disorders and the control group. In contrast, peak cortisol levels in response to the GHRP-2 test were significantly lower in both hypothalamic and pituitary disorder cases compared with the control group. Assignment of a cut-off value of 11.6 μg/dL for the peak serum cortisol level demonstrated that the GHRP-2 test was able to predict secondary hypoadrenalism with 88.9% specificity and 89.7% sensitivity. The responses of ACTH and cortisol to the GHRP-2 test had no correlation to the CRH test, suggesting the involvement of a different mechanism of ACTH secretion. These results indicate that the GHRP-2 test may induce ACTH secretion from the pituitary gland through direct stimulation. Although the GHRP-2 test does not have the same predictive value as the insulin tolerance test (ITT), it has similar diagnostic potential as the CRH stimulation test for evaluating HPA axis failure.
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Affiliation(s)
- Hiroshi Arimura
- Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima 890-8520, Japan
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Thamboo A, Manji J, Szeitz A, Santos RD, Hathorn I, Gan EC, Alsaleh S, Javer AR. The safety and efficacy of short-term budesonide delivered via mucosal atomization device for chronic rhinosinusitis without nasal polyposis. Int Forum Allergy Rhinol 2014; 4:397-402. [PMID: 24449682 DOI: 10.1002/alr.21280] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 11/22/2013] [Accepted: 12/03/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Budesonide is a potent corticosteroid commonly prescribed for management of inflammation in chronic rhinosinusitis (CRS). The standard for prescribing budesonide is via impregnated nasal saline irrigation (INSI), although recently the mucosal atomization device (MAD) has emerged as a theoretically superior method of distributing medication into the sinuses. The MAD atomizes medication into small droplets and this is thought to enhance absorption and improve bioavailability. However, no studies have shown whether enhanced absorption and improved bioavailability of budesonide via MAD causes adrenal suppression. The objective of this study is to determine whether budesonide via MAD affects the hypothalamic-pituitary-adrenal (HPA) axis. METHODS Twenty CRS patients were recruited from a tertiary rhinology clinic and randomized to take budesonide (1 mg) via MAD or via INSI twice a day for 60 days. The adrenocorticotropic hormone (ACTH) stimulation test and 22-item Sinonasal Outcomes Test (SNOT-22) questionnaire were administered on days 1, 30, and 60 of the study. Plasma budesonide and cortisol levels were simultaneously quantified using a high-performance liquid chromatography-tandem mass spectrometry technique. RESULTS There was no indication of adrenal suppression in either group (n = 20) based on ACTH stimulation test results nor was there significant plasma budesonide levels detected in either group. Quality of life, as indicated by SNOT-22, did not differ between groups at 60 days (p = 0.404; 95% confidence interval [CI], -37.2 to 15.9), but SNOT-22 scores for patients using MAD did show statistically significant improvement at 60 days compared to baseline (p = 0.02). CONCLUSION The MAD is likely a safe and effective method of delivering budesonide to the sinuses in the short term.
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Affiliation(s)
- Andrew Thamboo
- Division of Otolaryngology, niversity of British Columbia, St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
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Zagkotsis GD, Malindretos PM, Markou MP, Koutroumbas GC, Makri PT, Kapsalas DV, Syrganis CD. Adrenal insufficiency as the presenting feature in a patient with lung cancer. J Emerg Med 2013; 46:e91-2. [PMID: 24238596 DOI: 10.1016/j.jemermed.2013.08.099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 08/18/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Georgios D Zagkotsis
- Department of Nephrology, Achillopouleion General Hospital of Volos, Volos, Greece
| | - Pavlos M Malindretos
- Department of Nephrology, Achillopouleion General Hospital of Volos, Volos, Greece
| | - Maria P Markou
- 1st Department of Internal Medicine, Achillopouleion General Hospital of Volos, Volos, Greece
| | | | - Panagiota T Makri
- Department of Nephrology, Achillopouleion General Hospital of Volos, Volos, Greece
| | - Dimitrios V Kapsalas
- 1st Department of Internal Medicine, Achillopouleion General Hospital of Volos, Volos, Greece
| | - Christos D Syrganis
- Department of Nephrology, Achillopouleion General Hospital of Volos, Volos, Greece
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Blum JA, Schmid C, Hatz C, Kazumba L, Mangoni P, Rutishauser J, la Torre A, Burri C. Sleeping glands? - The role of endocrine disorders in sleeping sickness (T.b. gambiense Human African Trypanosomiasis). Acta Trop 2007; 104:16-24. [PMID: 17767911 DOI: 10.1016/j.actatropica.2007.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2007] [Revised: 07/04/2007] [Accepted: 07/08/2007] [Indexed: 10/23/2022]
Abstract
Symptoms consistent with hypothyroidism or adrenal insufficiency, such as lethargy, anorexia, cold intolerance, weakness, hypotension or paraesthesia, are frequently reported in the literature in patients with Human African Trypanosomiasis (HAT), but an endocrine origin for these symptoms has not yet been demonstrated. Thyroid and adrenocortical function were assessed in 60 patients with late-stage HAT and compared to those in 60 age- and gender-matched healthy controls. Clinical assessment and endocrine laboratory examinations were performed on admission, within 2 days after the end of treatment and at follow-up 3 months later. Signs and symptoms of hypothyroidism, such as fatigue, cold sensation, constipation, paraesthesia, peripheral oedema and dry skin, were significantly more frequent in HAT patients than in the controls. However, these signs and symptoms could not be attributed to hypothyroidism due to the lack of supporting laboratory data, and thus empirical replacement therapy for the clinically suspected hypothyroidism was not warranted. Signs and symptoms consistent with adrenal insufficiency, such as weakness, anorexia, weight loss or hypotension, were significantly more frequent in HAT patients than in controls, but they could not be associated with an insufficiency of the adrenocortical axis. Higher basal levels of cortisol were found in HAT patients than in controls, which can be viewed as a stress response to the infection. However, a transitory adrenal insufficiency was suspected in 8% of HAT patients at admission and in 9% at discharge. All values were normal at follow-up 3 months later.
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Affiliation(s)
- Johannes A Blum
- Swiss Tropical Institute, Socinstrasse 57, CH-4002 Basel, Switzerland.
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