PEDIATRICS Vol. 110 No. 3 September 2002, pp. 563-569
Assessment of Adrenal Function in the Initial Phase of Meningococcal Disease
* Academic Unit of Child Health, Royal Manchester Children’s Hospital, Department of Clinical Biochemistry, Manchester, United Kingdom
Royal Liverpool University Hospital, Liverpool, United Kingdom
Intensive Care Units, Alder Hey, Liverpool, United Kingdom
|| Manchester Children’s Trusts, Manchester, United Kingdom
--> Objective. To determine the status of the hypothalamic-pituitary-adrenal axis in children who had meningococcal disease and were admitted to 2 regional pediatric intensive care units.
Methods. Sixty-five children (34 boys; median age: 2.5 years; range: 0.2–15 years) had cortisol and adrenocorticotropic hormone (ACTH) levels measured on admission, then at 8 AM and 8 PM during the next 48 hours. At 48 hours, a low-dose short Synacthen test (LDST) (500 ng of 1–24 corticotropin/m2) was performed in 42 patients (19 boys). Normal ranges for 8 AM cortisol and ACTH levels in unstressed children were 140 to 500 nmol/L and 2 to 11.3 pmol/L, respectively. Adrenal insufficiency (AI) was defined as a peak cortisol <500 nmol/L on the LDST or an 8 AM cortisol value <140 nmol/L.
Results. Five (7.7%) of the 65 children died, including 1 with primary AI. Cortisol levels were elevated on admission (median: 1122 mmol/L; range: 65–2110 nmol/L) with 81% of values more than the 8 AM normal range. The median ACTH level on admission was within the 8 AM normal range, but 40% of values were more than the 8 AM normal range. However, 7% and 8% of cortisol and ACTH values, respectively, were less than the normal range. Both cortisol and ACTH levels fell thereafter and showed no diurnal variation during the 48-hour profile. Six (14%) of the 42 failed the LDST. These patients had significantly lower mean 8 AM cortisol values than those with a normal peak value on the LDST. Five additional patients who did not have the LDST had 8 AM cortisol values <140 nmol/L. In the diagnosis of AI, the sensitivity of the 8 AM mean cortisol value at a cutoff of 400 nmol/L, judged against the LDST, was 83%; the specificity was 81%.
Conclusions. During the initial phase of meningococcal disease, raised cortisol and ACTH levels indicate an appropriate stress response within the hypothalamic-pituitary-adrenal axis. However, a substantial subpopulation (11 [16.9%] of 65) has evidence of adrenal dysfunction during this period. Morning cortisol values in the initial phase of meningococcal disease could be used as a potential early index of AI.
Key Words: adrenal insufficiency • septic shock • meningococcal septicemia • low-dose ACTH test
Abbreviations: AI, adrenal insufficiency • ACTH, adrenocorticotropic hormone • HPA, hypothalamic-pituitary-adrenal (axis) • LDST, low-dose short Synacthen test • PICU, pediatric intensive care unit • GMSPS, Glasgow Meningococcal Septicemic Prognostic Score • TNF, tumor necrosis factor • IL, interleukin • SD, standard deviation
Received for publication Sep 28, 2001; Accepted May 20, 2002.
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