The plasma immunoreactive adrenocorticotropin and cortisol responses to oral fenfluramine hydrochloride (1.5 mglkg body wt) or placebo were examined in 11 patients with myotonic dystrophy, 4 controls with facioscapulohumeral dystrophy, a similarly debilitating muscle wasting disease, and 14 normal controls in single-blind studies performed in mid-afternoon.Mean areas under t h e adrenocorticotropin response versus time curve were significantly greater in myotonics (2573+429 pmol.min/L) than in facioscapulohumeral dystrophy controls (6961279 pmof.min/L, P < 0.02) and normals (560f 61 pmol.min/L, P < 0.0001). Corresponding cortisol responses were significantly greater in myotonics (35757 3949 nmol.min/L) than in normals (21828f 1669 nmol.min/L, P <0.001), but not significantly greater than those in facioscapulohumeral dystrophy controls (22830k6140 nmol.min/L, P = 0.055). No stressful side-effects which could affect hormone responses, and no significant changes in blood pressure or heart rate were noted. Fenfluramine activates central serotonergic and/or noradrenergic pathways initiating secretion of corticotropin-releasing hormone and possibly arginine vasopressin. W e postulate that these fenfluramine-activated pathways a r e hyperstimulated in myotonics, leading to adrenocorticotropin and cortisol hypersecretion. This may be a manifestation of a general cell membrane defect in myotonic dystrophy. W e found a lack of correlation of a g e (and severity of disease) with adrenocorticotropin response in myotonics, and therefore, the hyperresponse may serve as a useful marker for the disease before development of other overt signs.Myotonic dystrophy (MD) is a disorder of autosomal dominant inheritance, with the genetic locus on the long arm of chromosome 19 ( I ) . I t is thc most variable in clinical presentation of the muscular dystrophies, and no primary defect or generalized abnormality has yet been identified. In preliminary studies (2) we reported hypersecretion of adrenocorticotropin (ACTH) and 8-endorphin by myotonics compared to normal controls in response to exogenous ovine corticotropin-releasing hormone (CRH) and insulin-induced hypoglycaemia. Since C R H acts directly at the corticotrope ( 3 ) , and insulin-induced hypoglycaemia causes C R H release in man (4) and increased C R H mRNA levels in rats (5), we concluded that the ACTH hypersecretion in M D is due to a defect which is elicited by CRH-corticotrope interaction.To study the hypothalamic-pituitary-adrenal axis in M D further, we examined pituitary-adrenal responses to the ACTH secretagogue, fenfluramine (fen). Fen stimulates the hypothalamic-pituitary-adrenal axis (6-8) by an incompletely understood mechanism, generally considered to be mediated by serotonin (5-HT) (9), either by a hypothalamic action to release C R H (lo), or a direct effect, regarded as less important, of 5-HT on the anterior pituitary (1 1, 12). Another interpretation suggests that the ACTH-stimulating actions of fen, while ultimately effected by C R H and/or other sec...