title: Relative adrenal insufficiency in post-transplant lymphoproliferative disorder.
abstract: Post-transplant lymphoproliferative disorder is treated with rapid decrement of immunosuppressive therapy. This cannot be achieved with ease in patients on long-term glucocorticoid therapy, as chronically suppressed adrenal glands may not be capable of mounting adequate response to stress. A 52-year-old Caucasian male presented with fever, orthostatic hypotension, lymphadenopathy and hyponatraemia. Serum cortisol levels were within normal levels with a sub optimal response to stimulation by ACTH. Hyponatraemia and orthostasis responded poorly to fluid restriction, saline and salt repletion but corrected after increasing the steroid dose. The normal baseline cortisol levels represented a stimulated adrenal gland, however, the ACTH stimulation had inadequate response. This sub optimal stimulation and a good response to increased steroids suggest the presence of relative or occult adrenal insufficiency. Relative adrenal insufficiency must be considered in patients who have received prolonged glucocorticoid therapy and have symptoms such as hypotension and/or hyponatraemia.
authors.affiliation: Nephrology Division, Department of Medicine, 4.200 John Sealy Annex, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555-0562, USA.
authors.forename: R D
authors.initials: RD
authors.lastname: Cinclair
authors.forename: J C
authors.initials: JC
authors.lastname: Rice
authors.forename: M
authors.initials: M
authors.lastname: Agraharkar
mesh_terms: D000309:Adrenal Insufficiency / Q000188:drug therapy / Q000209:etiology*; D000324:Adrenocorticotropic Hormone; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D005938:Glucocorticoids / Q000494:pharmacology; D006801:Humans; D007010:Hyponatremia / Q000209:etiology; D007024:Hypotension, Orthostatic / Q000209:etiology; D007166:Immunosuppressive Agents / Q000494:pharmacology; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000276:immunology; D008232:Lymphoproliferative Disorders / Q000150:complications* / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D011241:Prednisone / Q000627:therapeutic use
chemical_list: D000893:Anti-Inflammatory Agents; D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D000324:Adrenocorticotropic Hormone; D011241:Prednisone