Diagnosis of adrenal insufficiency

Article Abstract:

Background: The cosyntropin stimulation test is the initial endocrine evaluation of suspected primary or secondary adrenal insufficiency. Purpose: To critically review the utility of the cosyntropin stimulation test for evaluating adrenal insufficiency. Data Sources: The MEDLINE database was searched from 1966 to 2002 for all English-language papers related to the diagnosis of adrenal insufficiency. Study Selection: Studies with fewer than 5 persons with primary or secondary adrenal insufficiency or with fewer than 10 persons as normal controls were excluded. For secondary adrenal insufficiency, only studies that stratified participants by integrated tests of adrenal function were included. Data Extraction: Summary receiver-operating characteristic (ROC) curves were generated from all studies that provided sensitivity and specificity data for 250-microg and 1-microg cosyntropin tests; these curves were then compared by using area under the curve (AUC) methods. All estimated values are given with 95% CIs. Data Synthesis: At a specificity of 95%, sensitivities were 97%, 57%, and 61% for summary ROC curves in tests for primary adrenal insufficiency (250-microg cosyntropin test), secondary adrenal insufficiency (250-microg cosyntropin test), and secondary adrenal insufficiency (1-microg cosyntropin test), respectively. The area under the curve for primary adrenal insufficiency was significantly greater than the AUC for secondary adrenal insufficiency for the high-dose cosyntropin test (P<0.001), but AUCs for the 250-microg and 1-microg cosyntropin tests did not differ significantly (P>0.5) for secondary adrenal insufficiency. At a specificity of 95%, summary ROC analysis for the 250-microg cosyntropin test yielded a positive likelihood ratio of 11.5 (95% CI, 8.7 to 14.2) and a negative likelihood ratio of 0.45 (CI, 0.30 to 0.60) for the diagnosis of secondary adrenal insufficiency. Conclusions: Cortisol response to cosyntropin varies considerably among healthy persons. The cosyntropin test performs well in patients with primary adrenal insufficiency, but the lower sensitivity in patients with secondary adrenal insufficiency necessitates use of tests involving stimulation of the hypothalamus if the pretest probability is sufficiently high. The operating characteristics of the 250-microg and 1-microg cosyntropin tests are similar.

Evaluation, Diagnosis, Medical tests, Author Abstract

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Recovery of adrenal function after failure resulting from traumatic bilateral adrenal hemorrhage

Article Abstract:

The adrenal cortex is the portion of the adrenal gland that produces steroid hormones important in metabolism, sexual function, stress, inflammation, and many other functions. Traumatic injury and other forms of damage to the adrenal glands have been reported to result in adrenal insufficiency, shock, and death caused by hemorrhage of the blood supply to the adrenals. A case is reported of a man who suffered severe bilateral adrenal hemorrhage and adrenal insufficiency, followed by complete recovery of adrenal function. A 43-year-old mildly retarded man with a history of schizophrenia and suicide attempts was hospitalized after jumping from a 60-foot building. Initial diagnosis revealed low blood pressure, increased heart rate, and several broken bones and dislocated joints. After initial treatment, the patient remained hospitalized, during which time he developed symptoms of adrenal insufficiency. Computerized tomography revealed bilateral hemorrhaging of the adrenal glands, and the patient was put on adrenal hormone replacement therapy. He was discharged from the hospital with instructions to continue taking the medication, which he did for 10 months. At that time the patient discontinued the medication contrary to medical advice. Two and a half years later, the patient was hospitalized again for treatment of foreign body aspiration (coins stuck in the trachea). Evaluation of adrenal function during this hospitalization showed complete recovery, and computerized tomography revealed normal (or slightly enlarged) adrenal glands. (Consumer Summary produced by Reliance Medical Information, Inc.)

Injuries, Suicide, Adrenal glands

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The changing clinical spectrum of adrenal insufficiency

Article Abstract:

Doctors should be alert to the possibility of adrenal insufficiency developing in conjunction with several conditions. These conditions include AIDS, brain-centered or peripheral nerve-centered adrenoleukodystrophy, autoimmune polyendocrine syndrome type I and II, or familial glucocorticoid deficiency. Adrenal insufficiency may develop in response to different factors involved with each condition including bacterial infections, stress, medications, diet, autoantibodies, or internal bleeding at the adrenal gland.

Editorial, Causes of, Adrenoleukodystrophy

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