title: Multidrug-Resistant Tuberculosis and Its Association with Adrenal Insufficiency: Assessment with the Low-Dose ACTH Stimulation Test.
abstract: Background. Multidrug-resistant tuberculosis (MDR-TB) is a major public health care concern that affects the life of millions of people around the world. The association of tuberculosis and adrenal insufficiency is well known; however, it is thought to be less prevalent every time. A spike in TB incidence and a lack of evidence of this association in patients with MDR-TB call for reassessment of an illness (adrenal dysfunction) that if not diagnosed could seriously jeopardize patients' health. Objective. To determine the prevalence of adrenocortical insufficiency in patients with MDR-TB using the low-dose (1 μg) ACTH stimulation test at baseline and at 6-12 months of follow-up after antituberculosis treatment and culture conversion. Methods. A total of 48 men or women, aged ≥18 years (HIV-negative patients diagnosed with pulmonary MDR-TB) were included in this prospective observational study. Blood samples for serum cortisol were taken at baseline and 30 and 60 minutes after 1 μg ACTH stimulation at our tertiary level university hospital before and after antituberculosis treatment. Results. Forty-seven percent of subjects had primary MDR-TB; 43.8% had type 2 diabetes; none were HIV-positive. We found at enrollment 2 cases (4.2%) of adrenal insufficiency taking 500 nmol/L as the standard cutoff point value and 4 cases (8.3%) alternatively, using 550 nmol/L. After antituberculosis intensive phase drug-treatment and a negative mycobacterial culture (10.2 ± 3.6 months) adrenocortical function was restored in all cases. Conclusions. In patients with MDR-TB, using the low-dose ACTH stimulation test, a low prevalence of mild adrenal insufficiency was observed. After antituberculosis treatment adrenal function was restored in all cases. Given the increasing and worrying epidemic of MDR-TB these findings have important clinical implications that may help clinicians and patients make better decisions when deciding to test for adrenocortical dysfunction or treat insufficient stimulated cortisol levels in the setting of MDR-TB.
authors.affiliation: Endocrinology Division, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico; Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico; Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN 55905, USA; Division of Endocrinology, Diabetes, Metabolism & Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: René
authors.initials: R
authors.lastname: Rodríguez-Gutiérrez
authors.affiliation: Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico; Centro de Investigacion, Prevencion y Tratamiento de Infecciones Respiratorias (CIPTIR), Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico.
authors.forename: Adrian
authors.initials: A
authors.lastname: Rendon
authors.affiliation: Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico.
authors.forename: Maximiliano
authors.initials: M
authors.lastname: Barrera-Sánchez
authors.affiliation: Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico.
authors.forename: Kevin Erick Gabriel
authors.initials: KE
authors.lastname: Carlos-Reyna
authors.affiliation: Clinical Research Unit, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico.
authors.forename: Neri Alejandro
authors.initials: NA
authors.lastname: Álvarez-Villalobos
authors.affiliation: Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico.
authors.forename: Gloria
authors.initials: G
authors.lastname: González-Saldivar
authors.affiliation: Endocrinology Division, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico; Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico; Clinical Research Unit, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico.
authors.forename: José Gerardo
authors.initials: JG
authors.lastname: González-González