Assessment of adrenal function in the initial phase of meningococcal disease.
OBJECTIVE
To determine the status of the hypothalamic-pituitary-adrenal axis in children who had meningococcal disease and were admitted to 2 regional pediatric intensive care units.


METHODS
Sixty-five children (34 boys; median age: 2.5 years; range: 0.2-15 years) had cortisol and adrenocorticotropic hormone (ACTH) levels measured on admission, then at 8 AM and 8 PM during the next 48 hours. At 48 hours, a low-dose short Synacthen test (LDST) (500 ng of 1-24 corticotropin/m2) was performed in 42 patients (19 boys). Normal ranges for 8 AM cortisol and ACTH levels in unstressed children were 140 to 500 nmol/L and 2 to 11.3 pmol/L, respectively. Adrenal insufficiency (AI) was defined as a peak cortisol <500 nmol/L on the LDST or an 8 AM cortisol value <140 nmol/L.


RESULTS
Five (7.7%) of the 65 children died, including 1 with primary AI. Cortisol levels were elevated on admission (median: 1122 mmol/L; range: 65-2110 nmol/L) with 81% of values more than the 8 AM normal range. The median ACTH level on admission was within the 8 AM normal range, but 40% of values were more than the 8 AM normal range. However, 7% and 8% of cortisol and ACTH values, respectively, were less than the normal range. Both cortisol and ACTH levels fell thereafter and showed no diurnal variation during the 48-hour profile. Six (14%) of the 42 failed the LDST. These patients had significantly lower mean 8 AM cortisol values than those with a normal peak value on the LDST. Five additional patients who did not have the LDST had 8 AM cortisol values <140 nmol/L. In the diagnosis of AI, the sensitivity of the 8 AM mean cortisol value at a cutoff of 400 nmol/L, judged against the LDST, was 83%; the specificity was 81%.


CONCLUSIONS
During the initial phase of meningococcal disease, raised cortisol and ACTH levels indicate an appropriate stress response within the hypothalamic-pituitary-adrenal axis. However, a substantial subpopulation (11 [16.9%] of 65) has evidence of adrenal dysfunction during this period. Morning cortisol values in the initial phase of meningococcal disease could be used as a potential early index of AI.
Academic Unit of Child Health, Royal Manchester Children's Hospital, Department of Clinical Biochemistry, Manchester, United Kingdom. drmpbone@hotmail.com
Mark
M
Bone
Michael
M
Diver
Andrew
A
Selby
Andrew
A
Sharples
Michael
M
Addison
Peter
P
Clayton
D000293:Adolescent; D000311:Adrenal Glands / Q000502:physiology*; D000324:Adrenocorticotropic Hormone / Q000097:blood*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D007223:Infant; D008297:Male; D008589:Meningococcal Infections / Q000097:blood / Q000175:diagnosis / Q000503:physiopathology*; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index
D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone