Is the cosyntropin test redundant in the acutely ill patient suspected of adrenal insufficiency? A case report and literature review.
Relative adrenal insufficiency is an increasingly documented phenomenon in acute illness. Recognizing and treating such adrenal insufficiency has the potential to improve outcome. A post-cosyntropin cortisol value greater than 20 microg/dl has been recognized as consistent with normal adrenal function. While the cosyntropin test remains a superb test of primary adrenal failure, its utilityin the diagnosis of secondary adrenal failure is less clearly defined. In the setting of acute illness, a number of other criteria such as increment from basal serum cortisol have been used; however, the criteria for establishing adrenal insufficiency remains less clearly defined. We report a 44-year-old Caucasian female who presented with hypoglycemia and hypotension. The patient had a basal cortisol of 1.6 ug/dl and a peak serum cortisol of 23.3 ug/dl after 250 ug of cosyntropin. Despite this apparent normal response to cosyntropin, the patient responded to glucocorticoids with an improvement in her clinical status. Pituitary MRI revealed a 7-mm pituitary cyst. Pending the availability of free cortisol levels, it is prudent not to disregard low basal cortisol levels, even in the presence of a normal cosyntropin response. We recommend that clinicians managing acutely ill patients have a low threshold for initiating glucocorticoid replacement in the presence of hypoglycemia and shock regardless of the peak cortisol values.
James H. Quillen College of Medicine, East Tennessee State University, USA.
Nerissa
N
Licup
Alan N
AN
Peiris
D000208:Acute Disease; D000304:Adrenal Cortex Function Tests / Q000706:statistics & numerical data*; D000309:Adrenal Insufficiency / Q000175:diagnosis*; D000328:Adult; D003366:Cosyntropin; D005260:Female; D006728:Hormones; D006801:Humans; D006854:Hydrocortisone / Q000008:administration & dosage / Q000097:blood
D006728:Hormones; D003366:Cosyntropin; D006854:Hydrocortisone