Acute-Onset Panhypopituitarism Nearly Missed by Initial Cosyntropin Testing

Abstract

Introduction Diagnosis of adrenal crisis and panhypopituitarism in patients with septic shock is difficult but crucial for outcome. Case A 66-year-old woman with metastasized breast cancer presented to the ED with respiratory insufficiency and septic shock after a 2-day history of the flu. After transfer to the ICU, corticosteroids were started in addition to antibiotics, as the patient was vasopressor-nonresponsive. Diabetes insipidus was diagnosed due to polyuria and treated with 4 mg desmopressin. Thereafter, norepinephrine could be tapered rapidly. On day 2, basal cortisol was 136 nmol/L with an increase to 579 nmol/L in low-dose cosyntropin testing. Polyuria had not developed again. Therefore, corticosteroids were stopped. On day 3, the patient developed again nausea, vomiting, and polyuria. Adrenal crisis and diabetes insipidus were postulated. Corticosteroids and desmopressin were restarted. Further testing confirmed panhypopituitarism. MRI showed a new sellar metastasis. After 2 weeks, stimulated cortisol in cosyntropin testing reached only 219 nmol/l, confirming adrenal insufficiency. Discussion The time course showed that the adrenal glands took 2 weeks to atrophy after loss of pituitary ACTH secretion. Therefore, a misleading result of the cosyntropin test in the initial phase with low basal cortisol and allegedly normal response to exogenous ACTH may be seen. Cosyntropin testing in the critically ill should be interpreted with caution and in the corresponding clinical setting.

Secondary adrenal insufficiency induced by long-term use of opioid analgesics

“…3 Moreover, even low-dose cosyntropin testing may not predict response to glucocorticoids 4 and thus initial cosyntropin testing may miss secondary cortisol deficiency. 5 We agree with Burgos et al 6 that the patient's clinical presentation should be considered when interpreting cosyntropin tests. We believe that glucocorticoid treatment should not be withheld on the basis of a cortisol level if the clinical presentation is consistent with hypoadrenalism.…”

Evaluation of plasma ACTH in the metyrapone test is insufficient for the diagnosis of secondary adrenal insufficiency

“…In patients with secondary adrenal insufficiency, especially in states of incomplete ACTH deficiency, the “gold standard” - Synacthen short test can give false-negative results ( 25 , 26 ). The use of 1 μg instead of 250 μg of Synacthen was initially thought to be a better procedure (more physiologic blood concentrations of 1-24ACTH ( 27 ), but some later studies have not confirmed this approach ( 28 ).…”