The Performance of Serum Cortisol, Plasma Corticotropin and Serum Dehydroepiandrosterone Sulfate Levels in the Diagnosis of Hypothalamic Pituitary Adrenal Dysfunction

Authors

  • Ali Hussein Ali Alhamza
  • Abbas Ali Mansour Al-Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), Chair Diabetes, Endocrine and Metabolism Division, Department of Medicine, Basrah College of Medicine
  • Nazar S. Haddad

DOI:

https://doi.org/10.3823/1867

Keywords:

Hypothalamic pituitaryadrenal dysfunction, short cosyntropin test, dehydroepiandrosterone sulfate, corticotropin, cortisol.

Abstract

Abstract

Background:

There is no single test can identify hypothalamic-pituitary-adrenal dysfunction (HPAD) perfectly. The study aimed to assess the performance of measuring serum cortisol, serum dehydroepiandrosterone sulfate (DHEA-S) and plasma corticotropin (ACTH) in comparison with standard-dose short cosyntropin (250 µg) testing for the diagnosis of HPAD.

Methods:

This is a cross-sectional study from Al-Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC) in Basrah. For all patients with suspected HAD; baseline serum cortisol, serum dehydroepiandrosterone sulfate (DHEA-S) and plasma corticotropin (ACTH) and were measured, followed by a formal short cosyntropin test as the gold standard test.

Results:

The total number of the study participant was 169 patients. Of them, 134 (79.3%) were women. Their age ranges from 5-80 years. The cutoff serum cortisol that predicts abnormal short cosyntropin test was less than 5.31µg/dl with maximal sensitivity and specificity of 90.4 % and 92.3% respectively. The cutoff serum DHEA-S that predict abnormal short cosyntropin test was less than 31.11 µg/dl with a sensitivity of 89.2%and specificity of 62.7%.The least reliable parameter to predict the abnormal short cosyntropin was the plasma ACTH  level with a cutoff of less than 5.30 pg/ml and lowest sensitivity of 89.2% and specificity of 62.7%.

Conclusion:

To exclude HPAD, serum cortisol at 9-11 am having the highest predictive value, DHEA-S has the midway function and plasma ACTH is the least reliable for that.  Combination of serum cortisol and serum DHEA-S yield the best performance for combinations of test.

 

Keywords: Hypothalamic pituitaryadrenal dysfunction, short  cosyntropin test, dehydroepiandrosterone sulfate, corticotropin,cortisol.

 

References

-Nicolaides NC,Charmandari E, Chrousos GP, Kino T. Circadian endocrine rhythms: the hypothalamic-pituitary-adrenal axis and its actions. Ann N Y Acad Sci. 2014 May;1318:71-80. doi: 10.1111/nyas.12464.

-Charmandari E, Kino T,ChrousosGP .Neonatal and pediatric pharmacology Glucocorticoids. In Yaffe SJ, Aranda JV, 4th edn. 2010 eds.Philadelphia: Lippincott Williams and Wilkins; 760–72.

-Oelkers W. Adrenal insufficiency. N Engl J Med. 1996 Oct 17;335(16):1206-12.

-Schmidt IL, Lahner H, Mann K, PetersennS. Diagnosis of adrenalinsufficiency: Evaluation of the corticotropin-releasinghormonetest and Basalserumcortisol in comparison to the insulintolerancetest in patients with hypothalamic-pituitary-adrenaldisease. J Clin EndocrinolMetab. 2003 Sep; 88(9):4193-8.

-Al-Aridi R, Abdelmannan D, Arafah BM. Biochemical diagnosis of adrenal insufficiency: the added value of dehydroepiandrosterone sulfate measurements. EndocrPract. 2011 Mar-Apr;17(2):261-70. doi: 10.4158/EP10262.RA.

-Nasrallah MP, Arafah BM .The value of dehydroepiandrosterone sulfate measurements in the assessment of adrenal function. J ClinEndocrinolMetab; 2003 88:5293–98.

-Arafah BM. Hypothalamic pituitary adrenal function during critical illness: limitations of current assessment methods. J ClinEndocrinolMetab. 2006 Oct;91(10):3725-45.

-Kassem SL, El Sibai K, Chaiban J, Abdelmannan D, Arafah BM.Measurements of serum DHEA and DHEA sulphate levels improve the accuracy of the low-dose cosyntropin test in the diagnosis of central adrenal insufficiency. J ClinEndocrinolMetab. 2012 Oct;97(10):3655-62. doi: 10.1210/jc.2012-1806.

-Arafah BM, Kailani SH, Nekl KE, Gold RS, Selman WR.Immediate recovery of pituitary function after transsphenoidal resection of pituitary macroadenomas. J ClinEndocrinolMetab. 1994 Aug;79(2):348-54.

-Kazlauskaite R, Evans AT, Villabona CV, Abdu TA, Ambrosi B, Atkinson AB, Choi CH ,et al. Consortium for Evaluation of Corticotropin Test in Hypothalamic-Pituitary Adrenal Insufficiency J ClinEndocrinolMetab. 2008 Nov;93(11):4245-53. doi: 10.1210/jc.2008-0710.

-Dorin RI, Qualls CR, Crapo LM.Diagnosis of adrenal insufficiency Ann Intern Med. 2003 Aug 5;139(3):194-204.

- Mayo Clinic is medical laboratories. Test ID: DHES. Available at attp://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/8493.Acessed at May 2, 2015.

-Mansour AA, Odaa AH, Wanoose HL.Corticosteroid nonprescription use: a cross-sectional hospital-based study in Basrah. Med PrincPract. 2010;19(3):182-7. doi: 10.1159/000285283.

-Jones SL, Trainer PJ, Perry L, Wass JA, Bessser GM, Grossman A. An audit of the insulin tolerance test in adult subjects in an acute investigation unit over one year. ClinEndocrinol (Oxf). 1994 Jul;41(1):123-8.

-Shah A, Stanhope R, Matthew D. Hazards of pharmacological tests of growth hormone secretion in childhood.BMJ. 1992 Jan 18;304(6820):173-4

-Crowley RK, Argese N, Tomlinson JW, Stewart PM. Central hypoadrenalism. J ClinEndocrinolMetab. 2014 Nov;99(11):4027-36. doi: 10.1210/jc.2014-2476.

-Broersen LH, Pereira AM, Jørgensen JO, Dekkers OM. Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis. J ClinEndocrinolMetab. 2015 Jun;100(6):2171-80. doi: 10.1210/jc.2015-1218

-Hahner S, Loeffler M, Bleicken B, Drechsler C, Milovanovic D, Fassnacht M, et al .Epidemiology of adrenal crisis in chronic adrenal insufficiency: the needfor new prevention strategies.Eur J Endocrinol. 2010 Mar;162(3):597-602. doi: 10.1530/EJE-09-0884.

-Dorsey MJ, Cohen LE, Phipatanakul W, Denufrio D, Schneider LC. Assessment of adrenal suppression in children with asthma treated with inhaled corticosteroids: use of dehydroepiandrosterone sulfate as a screening test.Ann Allergy Asthma Immunol . 2006 Aug;97(2):182-6.

-Maguire AM, Biesheuvel CJ, Ambler GR, Moore B, McLean M, Cowell CT.Evaluation of adrenal function using the human corticotrophin-releasing hormone test, low dose Synacthen test and 9am cortisol level in children and adolescents with central adrenal insufficiency. ClinEndocrinol (Oxf). 2008 May;68(5):683-91.

-Usta MB, Tuncel OK, Akbas S, Aydin B, Say GN.Decreased dehydroepiandrosterone sulphate levels in adolescents with post-traumatic stress disorder after single sexual trauma.

Nord J Psychiatry. 2015 Jul 15:1-5.

-Rothwell PM, Udwadia ZF, Lawler PG. Cortisol response to corticotropin and survival in septic shock.Lancet. 1991 Mar 9;337(8741):582-3.

-Annane D, Sébille V, Troché G, Raphaël JC, Gajdos P, Bellissant E. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin.JAMA. 2000 Feb 23;283(8):1038-45.

-Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock.JAMA. 2002 Aug 21;288(7):862-71.

-Cooper MS, Stewart PM. Corticosteroid insufficiency in acutely ill patients. N Engl J Med. 2003 Feb 20;348(8):727-34.

-Boonen E, Bornstein SR, Van den Berghe G. New insights into the controversy of adrenal function during critical illness. Lancet Diabetes Endocrinol. 2015 Jun 10. pii: S2213-8587(15)00224-7. doi: 10.1016/S2213-8587(15)00224-7.

-Ferrante E, Morelli V, Giavoli C, Mantovani G, Verrua E, Sala E, et al. Is the 250-μg ACTH test a useful tool for the diagnosis of centralhypoadrenalism in adult patients with pituitary disorders? Hormones (Athens). 2012 Oct-Dec;11(4):428-35.

-Yamaji T, Ishibashi M, Takaku F, Itabashi A, Katayama S, Ishii J. Serum dehydroepiandrosterone sulfate concentrations in secondary adrenal insufficiency.JClinEndocrinolMetab. 1987 Sep;65(3):448-51.

-Oelkers W. Dose-response aspects in the clinical assessment of the hypothalamo-pituitary-adrenal axis, and the low-dose adrenocorticotropintest.Eur J Endocrinol. 1996 Jul;135(1):27-33.

Downloads

Published

2016-01-25

Issue

Section

Endocrinology