Abbott M, Khoo S H, Hammer M R, Wilkins E G
Department of Genitourinary Medicine, Southport and Formby District General Hospital, UK.
J Infect. 1995 Jul;31(1):1-4. doi: 10.1016/s0163-4453(95)91116-2.
In order to determine the prevalence of cortisol deficiency in advanced HIV disease and to examine whether it may be predicted by clinical features or biochemical abnormalities, we conducted a prospective study which assessed responses to a rapid ACTH stimulation test (short-duration synthetic corticotrophin test, synacthen test) in HIV-positive patients with a CD4 count of < or = 50 x 10(6)/l. Subjective fatigue, postural drop in blood pressure, electrolyte changes, presence of concurrent opportunist infection and drug treatment were recorded. Cortisol responses were defined as 'normal' (a post stimulation cortisol level > or = 450 nmol/l), 'abnormal' (post stimulation cortisol level < 350 nmol/l) or 'impaired' (an intermediate response). Of 49 patients tested (42 male, seven female), a suboptimal response (abnormal or impaired) was found in 14 (29%) and frank insufficiency in eight (16%). Cortisol deficiency was not predicted by postural drop in blood pressure, biochemistry or symptoms of fatigue. Patients with an impaired/abnormal test were not more likely to have cytomegalovirus or mycobacterial disease but were more likely to be taking megestrol acetate (P = 0.05, Fisher's exact test). Two of three patients with initially normal tests developed impaired/abnormal cortisol responses on re-testing 6-9 months later. Cortisol deficiency is common in late stage HIV disease, but symptoms of fatigue and postural hypotension, as well as biochemical findings, are poor predictors of cortisol deficiency. We found good subjective response to therapy. Routine screening by a rapid ACTH stimulation test is recommended in HIV-positive patients with CD4 count < or = 50 x 10(6)/l. Re-testing at regular intervals may be necessary. The interaction between megestrol acetate, cortisol metabolism and synacthen testing requires further investigation.
为了确定晚期HIV疾病中皮质醇缺乏的患病率，并研究其是否可通过临床特征或生化异常进行预测，我们开展了一项前瞻性研究，评估CD4计数≤50×10⁶/l的HIV阳性患者对快速促肾上腺皮质激素刺激试验（短程合成促肾上腺皮质激素试验，辛纳科试验）的反应。记录主观疲劳、体位性血压下降、电解质变化、并发机会性感染情况及药物治疗情况。皮质醇反应被定义为“正常”（刺激后皮质醇水平≥450 nmol/l）、“异常”（刺激后皮质醇水平<350 nmol/l）或“受损”（中间反应）。在49例接受检测的患者（42例男性，7例女性）中，14例（29%）反应欠佳（异常或受损），8例（16%）存在明显不足。体位性血压下降、生化指标或疲劳症状均不能预测皮质醇缺乏。试验受损/异常的患者患巨细胞病毒或分枝杆菌疾病的可能性并不更高，但更有可能正在服用醋酸甲地孕酮（P = 0.05，Fisher精确检验）。最初试验正常的3例患者中有2例在6 - 9个月后重新检测时出现了受损/异常的皮质醇反应。皮质醇缺乏在晚期HIV疾病中很常见，但疲劳症状、体位性低血压以及生化检查结果都不能很好地预测皮质醇缺乏。我们发现治疗的主观反应良好。建议对CD4计数≤50×10⁶/l的HIV阳性患者进行快速促肾上腺皮质激素刺激试验常规筛查。可能需要定期重新检测。醋酸甲地孕酮、皮质醇代谢与辛纳科试验之间的相互作用需要进一步研究。
