Pediatric ICU management
David E. Wesson, Bindi Naik-Mathuria in Pediatric Trauma, 2017
Diagnostic tests for adrenal insufficiency have several limitations. The adrenocorticotropic hormone (ACTH) stimulation test measures the ability of the adrenal gland to increase production of cortisol in response to ACTH, but it does not test the integrity of the HPA axis, the response to other stressors such as hypotension or hypoglycemia, or the adequacy of stress cortisol concentrations. It may also be poorly reproducible in patients with septic shock. Adult consensus guidelines recommend use of the high-dose ACTH stimulation test (250 μg cosyntropin) rather than the low-dose (1 μg) test due to limited data and poor reproducibility of the latter, as well as the fact that there is no premade pharmacological preparation of the low-dose solution. However, the low-dose (1 μg) test may be more physiologic and has been used in critically ill children with 100% sensitivity and 84% specificity [28]. A diagnostic approach in children can be found in Figure 11.1.
Endocrine disorders
Brice Antao, S Irish Michael, Anthony Lander, S Rothenberg MD Steven in Succeeding in Paediatric Surgery Examinations, 2017
Children with Addison’s disease have a variety of symptoms including weakness, fatigue, anorexia, weight loss, vomiting, diarrhoea and abdominal pain. Generally, there is overproduction of ACTH, which stimulates melanocytes resulting in hyper-pigmentation. The development of symptoms can be acute or chronic, but if the diagnosis is not made in a timely fashion, adrenal crisis can ensue with resulting hypotension and hypoglycaemia causing seizures. Laboratory tests reveal low serum sodium and chloride levels, whereas the potassium concentration can be elevated. Fasting glucose levels can be low, and the fasting morning cortisol level is usually low, with an elevated plasma ACTH. An ACTH stimulation test shows little or no rise in the plasma cortisol levels because the end organ, the adrenal gland, has failed or is unresponsive to stimulation.
Fixed-Dose Corticosteroid and Calcipotriene Combination Therapy
John Y. M. Koo, Ethan C. Levin, Argentina Leon, Jashin J. Wu, Mark G. Lebwohl in Mild to Moderate Psoriasis, 2014
There was one large double-blind study that assessed the long-term safety of once-daily calcipotriene/betamethasone dipropionate ointment for the treatment of psoriasis up to 52 weeks [23–25]. In this study, patients used calcipotriene/betamethasone dipropionate ointment for the first month, after which time they were randomized into one of three arms for maintenance therapy through week 52: (1) fixed-dose combination therapy, (2) alternating calcipotriene ointment with fixed-dose combination therapy every four weeks, or (3) calcipotriene ointment only. The key inclusion criterion was a PGA of at least “moderate” (i.e., 4 on a 6-point scale). The key exclusion criterion was >30% body surface area (BSA) involvement. The study enrolled 634 patients, 70% of which had “moderate” psoriasis with the rest having “severe” or “very severe” disease. All treatments were used once daily on an as-needed basis to “reflect usual clinical practice” up to a maximum of 100 g/week. Patients were assessed every four weeks for adverse events and efficacy (using a 6-point PGA scale). A subset of 19 patients had adrenal function tests [adrenocorticotropic hormone (ACTH) stimulation test and 24-hour urine cortisol] performed at baseline and after 4, 12, and 52 weeks.
Ovarian steroid cell tumor (not otherwise specified) with subsequent spontaneous pregnancy after tumor removal: a case report and literature review
Published in Gynecological Endocrinology, 2023
Phawat Matemanosak, Krantarat Peeyananjarassri, Chitkasaem Suwanrath, Saranya Wattanakumtornkul, Satit Klangsin, Ekasak Thiangphak, Kanet Kanjanapradit
Differentiating androgen-producing tumors from CAH can be challenging. Wong et al. [13] recently reviewed 21 cases of steroid cell tumor NOS with pretreatment 17-OHP results and found a prevalence of elevated 17-OHP levels of 81%. Thus, elevated 17-OHP is commonly observed in steroid cell tumor NOS, which is consistent with our patient. Among the 17 cases with elevated 17-OHP levels, five were initially diagnosed with non-classic CAH, resulting in delayed diagnosis of steroid cell tumors because of the ambiguity of diagnostic testing. For instance, a significant increase in 17-OHP after adrenocorticotropic hormone (ACTH) stimulation is typical for congenital adrenal hyperplasia, whereas the ACTH stimulation test in most patients diagnosed with steroid cell tumors resulted in no response or insignificant changes. Surprisingly, 20% of these patients demonstrated positive 17-OHP responses to ACTH stimulation owing to the presence of ACTH receptors on these tumors. Therefore, 17-OHP responsiveness to ACTH stimulation in steroid cell tumors may lead to an incorrect diagnosis of CAH. In the present case, the ACTH stimulation test was not performed, and the patient proceeded directly to surgical treatment.
Testotoxicosis without Testicular Mass: Revealed by Peripheral Precocious Puberty and Confirmed by Somatic LHCGR Gene Mutation
Published in Endocrine Research, 2020
A. Daussac, P. Barat, N. Servant, M. Yacoub, S. Missonier, F Lavran, L. Gaspari, C. Sultan, F. Paris
The child had a bone age of 8 years (a 4-year advance). Endocrinological findings are summarized in Table 1. The serum testosterone level was markedly elevated to 8.4 nmol/L (normal prepubertal level: <0.3 nmol/L). Inhibin was 121 pg/mL (N: <400 pg/mL). Basal LH and FSH levels were low (LH<0.2 UI/L; FSH<0.6 UI/L) and there was no LH response to the LHRH stimulation test, excluding central precocious puberty. IGF1 was 368 ng/ml, correlated with Tanner stage II (P2 range: 316 ± 145 ng/ml). DHEAS was low at 0.6 µmol/L (N: 0.08–2.31 µmol/L) and 17OHP was normal for age at 1.5 nmol/L (N: 0.25–1.6 nmol/l). The ACTH stimulation test and adrenal ultrasound were normal. Alpha fetoprotein (<4 ng/mL; N: <7 ng/mL) and total HCG (<2 UI/L; N: <8 UI/L) were negative. Thyroid function was normal.
Risk of osteoporosis in microscopic colitis
Published in Postgraduate Medicine, 2018
Signe Wildt, Lars K. Munck, Sabine Becker, Helle Brockstedt, Ole K. Bonderup, Mette F. Hitz
ACTH stimulation test was performed in order to evaluate the potential suppression of the adrenocortical function. Plasma cortisol was measured at baseline and 30 min after stimulation by synthetic ACTH (Synacthen ®, New Neopharm B.W.) as previously described [18]. During the study, Synacthen was in a period unavailable, as a result not all patients had ACTH stimulation test performed. Adrenal function was regarded as normal if (1) plasma cortisol before stimulation was 150 nmol/L and (2) plasma cortisol after stimulation was above 450 and/or increased by 150 nmol/L.
Related Knowledge Centers
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- Endocrinology
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- Adrenal Gland
- Drug
- Alsactide