Diagnostic studies-adrenal insufficiency

(JCEM 2016;101:364)

參考➡️ Diagnosis and treatment of primary adrenal insufficiency: an endocrine society clinical practice guideline ⬆️ Uptodate📅: Diagnosis of adrenal insufficiency in adults

Figure:

• Early a.m. serum cortisol:
  • <3 µg/dL virtually diagnostic
  • ≥18 µg/dL generally consistent with intact adrenal function, lower cutoff w/ modern specific assays (see Appendix)
• Standard (250 µg) cosyntropin stimulation test (testing ability of ACTH → ↑ cortisol) All glucocorticoids (incl creams, inh. & drops) affect test. Must know exposure to interpret.
• Other tests (w/ guidance by endocrinologist): renin, aldosterone, insulin-induced hypoglycemia (measure serum cortisol response); metyrapone
• Other lab abnormalities: hypoglycemia, eosinophilia, lymphocytosis, ± neutropenia
• ACTH: ↑ in 1°, ↓ or low-normal in 2°
• imaging studies to consider of diagnostic studies-adrenal insufficiency

Explain by ChatGPT

• Early a.m. serum cortisol:
  • A level of less than 3 micrograms per deciliter is virtually diagnostic
  • A level of 18 micrograms per deciliter or higher is generally consistent with intact adrenal function, though a lower cutoff is used with more modern specific assays
• Standard (250 microgram) cosyntropin stimulation test: This tests the ability of adrenocorticotropic hormone to increase cortisol levels A normal result is a 60-minute (or 30-minute) post-ACTH cortisol level of 18 micrograms per deciliter or higher An abnormal result may be due to primary adrenal gland disease, in which the gland is diseased and unable to give an adequate output, or chronic secondary adrenal insufficiency, in which the adrenals have atrophied and are unable to respond (Very rarely, the test may be normal in acute pituitary injury, because the adrenals are still able to respond. In this case, the early a.m. cortisol test should be used instead) All glucocorticoids, including creams, inhaled steroids, and drops, affect the test. It is important to know exposure to these substances in order to interpret the test results
• Other tests that may be conducted with guidance from an endocrinologist include renin, aldosterone, and insulin-induced hypoglycemia tests (to measure the serum cortisol response), and a metyrapone test (which blocks cortisol synthesis and therefore stimulates ACTH, allowing for measurement of plasma 11-deoxycortisol and urinary 17-hydroxycorticosteroid levels)
• Other laboratory abnormalities that may be seen include hypoglycemia, eosinophilia, lymphocytosis, and neutropenia
• ACTH levels are increased in primary adrenal insufficiency and decreased or low-normal in secondary adrenal insufficiency
• Imaging studies that may be considered include a pituitary MRI to detect anatomical abnormalities and an adrenal CT, which can show small, noncalcified adrenals in autoimmune adrenal insufficiency, enlarged adrenals in metastatic disease, hemorrhage, infection, or deposition (although they may appear normal)

窩的英文不太好

• 清晨血清皮質醇：
• 低於每分升 3 微克的水平幾乎可以診斷
• 18 微克/分升或更高的水平通常與完整的腎上腺功能一致，儘管較低的臨界值用於更現代的特異性檢測
• 標準（250 微克）促腎上腺皮質激素刺激試驗：該試驗測試促腎上腺皮質激素增加皮質醇水平的能力 正常結果是 ACTH 後 60 分鐘（或 30 分鐘）皮質醇水平為 18 微克/分升或更高 異常結果可能是由於原發性腎上腺疾病，其中腺體患病並且無法提供足夠的輸出，或慢性繼發性腎上腺功能不全，其中腎上腺已經萎縮並且無法做出反應 （極少數情況下，在急性垂體損傷時該測試可能正常，因為腎上腺仍有反應。在這種情況下，應改用早間皮質醇測試） 所有糖皮質激素，包括乳膏、吸入類固醇和滴劑，都會影響測試。了解這些物質的暴露情況對於解釋測試結果很重要
• 可在內分泌學家的指導下進行的其他測試包括腎素、醛固酮和胰島素誘導的低血糖測試（以測量血清皮質醇反應）和美替拉酮測試（阻斷皮質醇合成並因此刺激 ACTH，從而測量血漿 11-脫氧皮質醇和尿液 17-羥基皮質類固醇水平）
• 其他可能出現的實驗室異常包括低血糖、嗜酸性粒細胞增多、淋巴細胞增多和中性粒細胞減少
• ACTH 水平在原發性腎上腺功能不全中升高，在繼發性腎上腺功能不全中降低或低於正常水平
• 可以考慮的影像學檢查包括用於檢測解剖異常的垂體 MRI 和腎上腺 CT，這可以顯示自身免疫性腎上腺功能不全的小的、非鈣化的腎上腺，轉移性疾病、出血、感染或沉積的腎上腺增大（儘管它們可能看起來正常)