Sarin Bipan Chander, Sibia Keerat, Kukreja Sahiba
Professor and Head, Department of T.B. & Respiratory Diseases, Sri Guru Ram Das Institute of Medical Sciences & Research, Vallah, Amritsar, India.
Senior Resident, Department of T.B. & Respiratory Diseases, Sri Guru Ram Das Institute of Medical Sciences & Research, Vallah, Amritsar, India.
Indian J Tuberc. 2018 Jul;65(3):241-245. doi: 10.1016/j.ijtb.2017.08.033. Epub 2017 Oct 7.
Although subclinical adrenal insufficiency has been documented in tuberculosis but it has been neglected in mainstream management of TB due to inconclusive data on its prevalence in TB. The fact that adrenal insufficiency may result not only in poor general condition of the patient but also sudden death due to adrenal crisis, makes it all the more important to address this issue seriously. In this non-randomized interventional study comprising of 100 cases of TB, our aim was to assess the adreno-cortical functions in patients with pulmonary TB (50 cases) and extra-pulmonary TB (50 cases) in an attempt to determine if there is any compromise of adrenal function.
In this study, 100 cases of active TB were investigated for adrenal insufficiency by measuring morning fasting basal serum cortisol levels, followed by low dose ACTH stimulation test using 1μg synacthen (synthetic ACTH analog). The post-stimulation serum cortisol levels were estimated. Basal serum cortisol levels<220nmol/L or post-stimulation test serum cortisol level increment<200nmol/L or post-stimulation serum cortisol levels<500nmol/L were suggestive of adrenal insufficiency.
Basal serum cortisol level was low in 16% cases and after low dose ACTH stimulation test, cortisol response was subnormal in 76% cases. Incidence of adrenal insufficiency in pulmonary TB (74%) and extra-pulmonary TB (78%) were comparable. The number of females having adrenal insufficiency in both the groups was higher than the males (67.3% males and 83.3% females) but the difference was statistically significant only in extra-pulmonary TB group (p=0.011). On analysing the data, the sensitivity of basal serum cortisol level estimation in diagnosing adrenal insufficiency was observed to be 21.05% and its specificity was 100%. Positive predictive value was 100% and negative predictive value was 28.57%. Diagnostic accuracy of basal serum cortisol level estimation was observed to be 40%.
The incidence of subclinical adrenal insufficiency in TB cases attending chest department at a tertiary care hospital was significantly high but comparable in both pulmonary and extra-pulmonary type of TB. Females in general and particularly those with extra-pulmonary TB were observed to be at increased risk of adrenal insufficiency. The low dose ACTH stimulation test was able to identify cases with adrenal insufficiency which had normal basal serum cortisol levels. Screening all TB cases for adrenal insufficiency by measuring both morning basal serum cortisol levels and low dose ACTH stimulation test can help identify cases at risk of fatal adrenal crisis and institute timely management, thus improving disease prognosis.
虽然亚临床肾上腺功能不全在结核病中已有记载，但由于关于其在结核病中患病率的数据尚无定论，在结核病的主流治疗中一直被忽视。肾上腺功能不全不仅可能导致患者全身状况不佳，还可能因肾上腺危象导致猝死，这使得认真解决这个问题变得更加重要。在这项包含100例结核病患者的非随机干预研究中，我们的目的是评估肺结核患者（50例）和肺外结核患者（50例）的肾上腺皮质功能，以确定肾上腺功能是否存在任何损害。
在本研究中，通过测量早晨空腹基础血清皮质醇水平，对100例活动性结核病患者进行肾上腺功能不全调查，随后使用1μg 赛可同（合成促肾上腺皮质激素类似物）进行低剂量促肾上腺皮质激素刺激试验。测定刺激后血清皮质醇水平。基础血清皮质醇水平<220nmol/L或刺激后试验血清皮质醇水平增加值<200nmol/L或刺激后血清皮质醇水平<500nmol/L提示肾上腺功能不全。
16%的病例基础血清皮质醇水平较低，低剂量促肾上腺皮质激素刺激试验后，76%的病例皮质醇反应异常。肺结核（74%）和肺外结核（78%）中肾上腺功能不全的发生率相当。两组中肾上腺功能不全的女性人数均高于男性（男性67.3%，女性83.3%），但差异仅在肺外结核组具有统计学意义（p = 0.011）。分析数据时，观察到基础血清皮质醇水平估计在诊断肾上腺功能不全中的敏感性为21.05%，特异性为100%。阳性预测值为100%，阴性预测值为28.57%。基础血清皮质醇水平估计的诊断准确性为40%。
在一家三级医院胸科就诊的结核病病例中亚临床肾上腺功能不全的发生率显著较高，但在肺结核和肺外结核类型中相当。总体而言，女性，尤其是肺外结核女性，肾上腺功能不全的风险增加。低剂量促肾上腺皮质激素刺激试验能够识别基础血清皮质醇水平正常但存在肾上腺功能不全的病例。通过测量早晨基础血清皮质醇水平和低剂量促肾上腺皮质激素刺激试验对所有结核病病例进行肾上腺功能不全筛查，有助于识别有致命肾上腺危象风险的病例并及时进行治疗，从而改善疾病预后。
