Sharma Rajni, Madathil Shamnad, Maheshwari Vivek, Roy Kakali, Kumar Brijesh, Jain Vandana
Division of Pediatric Endocrinology, Room no.3058, Teaching Block, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India.
Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
J Pediatr Endocrinol Metab. 2019 Jan 28;32(1):57-63. doi: 10.1515/jpem-2018-0330.
Background The diagnosis of adrenal insufficiency (AI) is based on the basal and stimulated levels of serum cortisol in response to the short Synacthen test (SST). In patients with secondary AI (SAI) due to hypothalamic-pituitary-adrenal (HPA) axis defects, the SST has been validated against the insulin tolerance test (ITT), which is the gold standard. However, injection Synacthen is not easily available in some countries, and endocrinologists often use Acton-Prolongatum (intramuscular [IM] long-acting adrenocorticotropic hormone [ACTH]) in place of Synacthen. There are no studies validating the use of IM-ACTH in children with suspected AI. We evaluated the diagnostic value of the IM-ACTH test against the ITT for the diagnosis of SAI in children. Methods All children with suspected growth hormone deficiency (GHD) undergoing a routine ITT were evaluated using the IM-ACTH test within 1 week. Results Forty-eight patients (36 boys/12 girls, age range: 5-14 years) were evaluated using both the ITT and the IM-ACTH test. Twenty-eight patients had a normal cortisol response (≥18 μg/dL, 500 nmol/L) in the ITT and 20 had low values. In patients with a normal cortisol response on the ITT, the peak value obtained after the IM-ACTH test was higher than that on the ITT (28.7 μg/dL [± 8.8] vs. 23.8 μg/dL [± 4.54], respectively; p=0.0012). Compared to the ITT, the sensitivity and specificity of the IM-ACTH test for the diagnosis of SAI at cortisol cut-offs <18 μg/dL (500 nmol/L) and <22 μg/dL (600 nmol/L) were 57.1% and 92.8%, and 100% and 73.5%, respectively. Conclusions A peak cortisol value <18 μg/dL on the IM-ACTH test is highly suggestive of SAI, whereas a value >22 μg/dL rules out SAI.
肾上腺皮质功能减退症（AI）的诊断基于短程促肾上腺皮质激素试验（SST）中血清皮质醇的基础水平和刺激后水平。在因下丘脑 - 垂体 - 肾上腺（HPA）轴缺陷导致的继发性肾上腺皮质功能减退症（SAI）患者中，SST已通过与作为金标准的胰岛素耐量试验（ITT）进行验证。然而，在一些国家，注射用促肾上腺皮质激素不易获得，内分泌科医生常使用Acton - Prolongatum（肌内注射[IM]长效促肾上腺皮质激素[ACTH]）替代促肾上腺皮质激素。尚无研究验证IM - ACTH在疑似AI儿童中的应用。我们评估了IM - ACTH试验相对于ITT在儿童SAI诊断中的诊断价值。
所有接受常规ITT的疑似生长激素缺乏症（GHD）儿童在1周内使用IM - ACTH试验进行评估。
48例患者（36名男孩/12名女孩，年龄范围：5 - 14岁）同时接受了ITT和IM - ACTH试验评估。28例患者在ITT中皮质醇反应正常（≥18μg/dL，500nmol/L），20例患者皮质醇值较低。在ITT中皮质醇反应正常的患者中，IM - ACTH试验后获得的峰值高于ITT中的峰值（分别为28.7μg/dL[±8.8]和23.8μg/dL[±4.54]；p = 0.0012）。与ITT相比，IM - ACTH试验在皮质醇临界值<18μg/dL（500nmol/L）和<22μg/dL（600nmol/L）时诊断SAI的敏感性和特异性分别为57.1%和92.8%，以及100%和73.5%。
IM - ACTH试验中皮质醇峰值<18μg/dL高度提示SAI，而>22μg/dL则可排除SAI。
