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Martel-Duguech L, Poirier J, Bourdeau I, Lacroix A. Diagnosis and management of secondary adrenal crisis. Rev Endocr Metab Disord 2024; 25:619-637. [PMID: 38411891 DOI: 10.1007/s11154-024-09877-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2024] [Indexed: 02/28/2024]
Abstract
Adrenal crisis (AC) is a life threatening acute adrenal insufficiency (AI) episode which can occur in patients with primary AI but also secondary AI (SAI), tertiary AI (TAI) and iatrogenic AI (IAI). In SAI, TAI and IAI, AC may develop when the HPA axis is unable to mount an adequate glucocorticoid response to severe stress due to pituitary or hypothalamic disruption. It manifests as an acute deterioration in multi-organ homeostasis that, if untreated, leads to shock and death. Despite the availability of effective preventive strategies, its prevalence is increasing in patients with SAI, TAI and IAI due to more frequent exogenous steroid administration, pituitary immune-related effects of immune checkpoint inhibitors and opioid use in pain management. The delayed diagnosis of acute AI which remains infrequently suspected increases the risk of AC. Its main precipitating factors are infections, emotional distress, surgery, cessation or reduction in GC doses, pituitary infarction or surgical cure of endogenous Cushing's syndrome. In patients not known previously to have SAI/TAI/IAI, recognition of its symptoms, signs, and biochemical abnormalities can be challenging and cause delay in proper diagnosis and therapy. Effective therapy of AC is rapid intravenous administration of hydrocortisone (initial bolus of 100 mg followed by 200 mg/24 h as continuous infusion or bolus of 50 mg every 6 h) and 0.9% saline. In diagnosed patients, preventive education in sick-day rules adjustment of glucocorticoid replacement and hydrocortisone parenteral self-administration must be performed repeatedly by trained health care providers. Strategies to improve the adequate preventive education in patients at risk for secondary AI should be promoted in collaboration with various medical specialist societies and patients support associations.
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Affiliation(s)
- Luciana Martel-Duguech
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Jonathan Poirier
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada.
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[Hypoxic and hypoglycemic brain damage as a result of an adrenal cortex crisis-An important differential diagnosis in cases of unspecific symptoms]. Anaesthesist 2022; 71:462-466. [PMID: 35226122 DOI: 10.1007/s00101-022-01088-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 12/16/2021] [Accepted: 12/30/2021] [Indexed: 11/26/2022]
Abstract
Acute adrenal cortex insufficiency is a rare disease, which is hard to diagnose because of its diffuse symptoms. Symptoms, such as general weakness, nausea or vomiting, fatigue, hyponatremia, hyperkalemia, hypoglycemia and pronounced hypotension up to shock can be crucial in the diagnosis of an adrenal cortex crisis. The underlying disease of adrenal cortex insufficiency is also characterized by not always obvious symptoms, which are differently expressed depending on whether it is the primary or secondary type.After the diagnosis is made it is important to educate the patients, determine the optimal dosage of the substitution and ensure the compliance of the patients to optimize the further process and avoid an adrenal crisis. An adrenal crisis is one of the reasons for a higher mortality of these patients, which is well-described in the current literature. Descriptions of fatal courses and their reasons are rare; however, knowledge of the disease and the importance of rapid intervention is very important, especially for physicians who work in the emergency room or intensive care unit (ICU).This article reports about a female patient with a known secondary adrenal cortex insufficiency who developed the complete picture of an adrenal crisis. Despite rapid diagnosis and initiation of treatment massive brain damage could not be averted due to hypoxia and hypoglycemia. This case report demonstrates the potential symptoms, in particular a massive hypoglycemia and an initial shock refractory to catecholamine. It also shows the severity of that disease and the importance of rapid treatment even though it is difficult to make the diagnosis.
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Lousada LM, Mendonca BB, Bachega TASS. Adrenal crisis and mortality rate in adrenal insufficiency and congenital adrenal hyperplasia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:488-494. [PMID: 34283908 PMCID: PMC10522175 DOI: 10.20945/2359-3997000000392] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/18/2021] [Indexed: 11/23/2022]
Abstract
Primary adrenal insufficiency (PAI) is characterized by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids. Addison's disease (AD) and congenital adrenal hyperplasia (CAH) are the most frequent disorders in adults and children, respectively. Despite the diagnostic advances and the availability of glucocorticoid and mineralocorticoid replacements, adrenal crisis (AC) is still a potentially lethal condition contributing to the increased mortality, not only during the first year of life, but also throughout life. Failure in increasing glucocorticoid doses during acute stress, when greater amounts of glucocorticoids are required, can lead to AC and an increase morbimortality rate of PAI. Considering a mortality rate of 0.5 per 100 patient years, up to 1,500 deaths from AC are expected in Brazil in the coming decade, which represents an alarming situation. The major clinical features are hypotension and volume depletion. Nonspecific symptoms such as fatigue, lack of energy, anorexia, nausea, vomiting, and abdominal pain are common. The main precipitating factors are gastrointestinal diseases, other infectious disease, stressful events (e.g., major pain, surgery, strenuous physical activity, heat, and pregnancy), and withdrawal of glucocorticoid therapy. Suspected AC requires immediate therapeutic action with intravenous (iv) hydrocortisone, fluid infusion, monitoring support, and antibiotics if necessary. AC is best prevented through patient education, precocious identification and by adjusting the glucocorticoid dosage in stressor situations. The emergency card, warning about acute glucocorticoid replacement, has high value in reducing the morbidity and mortality of AC.
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Affiliation(s)
- Lia Mesquita Lousada
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Tania A S S Bachega
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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Cruz-Flores S. Neurological Complications of Endocrine Emergencies. Curr Neurol Neurosci Rep 2021; 21:21. [PMID: 33709163 DOI: 10.1007/s11910-021-01105-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Endocrine disorders are the result of insufficient or excessive hormonal production. The clinical course is long, and the manifestations are nonspecific due to the systemic effect of hormones across many organs and systems including the nervous system. This is a narrative review of the recent evidence of the diagnosis and treatment approach of these medical and neurological emergencies. RECENT FINDINGS With the possible exception of diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia, endocrinological emergencies are complex, uncommon yet life-threatening conditions with protean and often nonspecific early clinical signs. They frequently are the first manifestation of the endocrine derangement. The systemic effects of hormones extend to the nervous system and as such, these conditions can present with neurological complications manifested, in most cases, by a diffuse dysfunction of the brain in the form of encephalopathy, delirium, seizures, and coma; or specific and peculiar syndromes such as hemichorea, hemiballism, and epilepsia partialis continua. The severity of these conditions often necessitates management in the intensive care unit requiring substantial supportive care in addition to specific targeted therapy to correct the hormonal metabolic abnormalities while at the same time blocking hormonal activity, in cases of excessive function, or supplementing hormonal deficiencies. Endocrine emergencies and their neurological complications are infrequent. The major challenge for most is early recognition. Their morbidity and mortality are high and their diagnosis requires high index of suspicion. The neurological complication most often improves with the correction of the metabolic derangement and their acuity and severity require admission to the intensive care unit.
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Affiliation(s)
- Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA.
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Critical Illness Associated Fatal Hypoglycemia in a Nondiabetic Male. Case Rep Crit Care 2019; 2019:4790320. [PMID: 31263604 PMCID: PMC6556287 DOI: 10.1155/2019/4790320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/15/2019] [Indexed: 11/18/2022] Open
Abstract
We present here the case of a 55-year-old male who presented to the emergency department with severe abdominal pain and respiratory distress secondary to mesenteric ischemia. His critical illness on preexisting chronic kidney disease, previously undiagnosed alcoholic cirrhosis, and congestive heart failure led to a rare yet fatal consequence of refractory hypoglycemia. Critical illness associated hypoglycemia generally occurs as a result of high metabolic consumption with relative insulin excess and insufficient nutritional intake that is seen frequently in critically ill patients. This, along with reduced hepatic and renal gluconeogenesis seen in preexisting liver and renal disease, can cumulate to life-threatening hypoglycemia and is seen as a poor prognostic factor in the ICU setting.
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Rushworth RL, Torpy DJ, Stratakis CA, Falhammar H. Adrenal Crises in Children: Perspectives and Research Directions. Horm Res Paediatr 2018; 89:341-351. [PMID: 29874655 DOI: 10.1159/000481660] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/20/2017] [Indexed: 11/19/2022] Open
Abstract
Adrenal crises (AC) are life-threatening physiological disturbances that occur at a rate of 5-10/100 patient years in patients with adrenal insufficiency (AI). Despite their seriousness, there is a paucity of information on the epidemiology of AC events in the paediatric population specifically, as most investigations have focused on AI and ACs in adults. Improved surveillance of AC-related morbidity and mortality should improve the delineation of AC risk overall and among different subgroups of paediatric patients with AI. Valid incidence measures are essential for this purpose and also for the evaluation of interventions aimed at reducing adverse health outcomes from ACs. However, the absence of an agreed AC definition limits the potential benefit of research and surveillance in this area. While approaches to the treatment and prevention of ACs have much in common across the lifespan, there are important differences between children and adults with regards to the physiological, psychological, and social milieu in which these events occur. Education is considered to be an essential element of AC prevention but studies have shown that ACs occur even among well-educated patients, suggesting that new strategies may be needed. In this review, we examine the current knowledge regarding AC events in children with AI; assess the existing definitions of an AC and offer a new definition for use in research and the clinic; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in the paediatric age group.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northwest Territories, Australia
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Ishii T, Adachi M, Takasawa K, Okada S, Kamasaki H, Kubota T, Kobayashi H, Sawada H, Nagasaki K, Numakura C, Harada S, Minamitani K, Sugihara S, Tajima T. Incidence and Characteristics of Adrenal Crisis in Children Younger than 7 Years with 21-Hydroxylase Deficiency: A Nationwide Survey in Japan. Horm Res Paediatr 2018; 89:166-171. [PMID: 29455197 DOI: 10.1159/000486393] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/18/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS We aimed to evaluate the incidence and characteristics of adrenal crisis in Japanese children with 21-hydroxylase deficiency (21-OHD). METHODS We conducted a retrospective nationwide survey for the councilors of the Japanese Society for Pediatric Endocrinology (JSPE) regarding adrenal crisis in children under 7 years with 21-OHD, admitted to hospitals from 2011 through 2016. We defined adrenal crisis as the acute impairment of general health due to glucocorticoid deficiency with at least two of symptoms, signs, or biochemical abnormalities. RESULTS The councilors of the JSPE in 83 institutions responded to this survey (response rate, 60.1%). Data analyses of 378 patients with 1,101.4 person-years (PYs) revealed that 67 patients (17.7%) experienced at least 1 episode of hospital admission for adrenal crisis at the median age of 2 years. The incidence of adrenal crisis was calculated as 10.9 per 100 PYs (95% confidence interval [CI] 9.6-12.2). Infections were the most common precipitating factors, while no factor was observed in 12.5%. Hypoglycemia occurred concomitantly in 27.4%. One patient died from severe hypoglycemia, resulting in a mortality rate of 0.09 per 100 PYs (95% CI 0.0-0.2). CONCLUSION Adrenal crisis is not rare and can be accompanied by disastrous hypoglycemia in children with 21-OHD.
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Affiliation(s)
- Tomohiro Ishii
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Masanori Adachi
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kei Takasawa
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Okada
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hotaka Kamasaki
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takuo Kubota
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hironori Kobayashi
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Shimane University Faculty of Medicine, Shimane, Japan
| | - Hirotake Sawada
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Reproductive and Developmental Medicine, University of Miyazaki, Miyazaki, Japan
| | - Keisuke Nagasaki
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Division of Pediatrics, Department of Homeostatic Regulation and Development, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Chikahiko Numakura
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Shohei Harada
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Child Studies, Seitoku University, Matsudo, Japan
| | - Kanshi Minamitani
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Shigetaka Sugihara
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Toshihiro Tajima
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Jichi Medical University Tochigi Childrens Medical Center, Shimotsuke, Japan
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Caplan MJ. A Practical Forensic Approach to Fatal Pediatric Endocrinopathies. Acad Forensic Pathol 2016; 6:258-270. [PMID: 31239897 DOI: 10.23907/2016.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/08/2016] [Accepted: 04/30/2016] [Indexed: 11/12/2022]
Abstract
Of all of the organ systems in clinical medicine, the endocrine system is among the most difficult to master since it requires a detailed and knowledgeable integration of many of the body's separate systems. In forensic pathology, the evaluation of a sudden unexplained death can be challenging depending upon the particular disease processes and the organ systems that are affected. It is therefore not surprising that the investigation of sudden unexplained deaths involving the endocrine system can be particularly daunting. This review attempts to focus upon three of the major endocrine/metabolic conditions that may be potentially life-threatening and fatal in the pediatric population - hypoglycemia, adrenal insufficiency, and hyperthyroidism - and to provide forensic pathologists with a practical strategy for working up these cases. By adopting a more focused and selective approach to pediatric endocrine conditions rather than an exhaustive and comprehensive study of them, it is the intention of this review to make these disorders more manageable conceptually and to optimize the chance of arriving at a decisive and ultimately accurate postmortem diagnosis.
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Affiliation(s)
- Michael J Caplan
- Suffolk County Office of the Medical Examiner and Stony Brook University Health Sciences Center School of Medicine - Pathology
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Abstract
Adrenal crisis is a life-threatening emergency contributing to the excess mortality of patients with adrenal insufficiency. Studies in patients on chronic replacement therapy for adrenal insufficiency have revealed an incidence of 5-10 adrenal crises/100 patient years and suggested a mortality rate from adrenal crisis of 0.5/100 patient years. Patients with adrenal crisis typically present with profoundly impaired well-being, hypotension, nausea and vomiting, and fever responding well to parenteral hydrocortisone administration. Infections are the major precipitating causes of adrenal crisis. Lack of increased cortisol concentrations during infection enhances pro-inflammatory cytokine release and sensitivity to the toxic effects of these cytokines (e.g. tumour necrosis factor alpha). Furthermore, pro-inflammatory cytokines may impair glucocorticoid receptor function aggravating glucocorticoid deficiency. Treatment of adrenal crisis is simple and highly effective consisting of i.v. hydrocortisone (initial bolus of 100 mg followed by 200 mg over 24 h as continuous infusion) and 0.9% saline (1000 ml within the first hour). Prevention of adrenal crisis requires appropriate hydrocortisone dose adjustments to stressful medical procedures (e.g. major surgery) and other stressful events (e.g. infection). Patient education is a key for such dose adjustments but current education concepts are not sufficiently effective. Thus, improved education strategies are needed. Every patient should carry an emergency card and should be provided with an emergency kit for parenteral hydrocortisone self-administration. A hydrocortisone pen would hold a great potential to lower the current barriers to hydrocortisone self-injection. Improved patient education and measures to facilitate parenteral hydrocortisone self-administration in impending crisis are expected to significantly reduce morbidity and mortality from adrenal crisis.
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Affiliation(s)
- Bruno Allolio
- Endocrine UnitDepartment of Internal Medicine I, University Hospital WürzburgComprehensive Heart Failure CenterUniversity of Würzburg, 97080 Würzburg, Germany Endocrine UnitDepartment of Internal Medicine I, University Hospital WürzburgComprehensive Heart Failure CenterUniversity of Würzburg, 97080 Würzburg, Germany
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10
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Abstract
Psychosis is an abnormal mental state characterized by disorganization, delusions and hallucinations. Animal models have become an increasingly important research tool in the effort to understand both the underlying pathophysiology and treatment of psychosis. There are multiple animal models for psychosis, with each formed by the coupling of a manipulation and a measurement. In this manuscript we do not address the diseases of which psychosis is a prominent comorbidity. Instead, we summarize the current state of affairs and future directions for animal models of psychosis. To accomplish this, our manuscript will first discuss relevant behavioral and electrophysiological measurements. We then provide an overview of the different manipulations that are combined with these measurements to produce animal models. The strengths and limitations of each model will be addressed in order to evaluate its cross-species comparability.
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Abstract
BACKGROUND The practice of glycemic control with intravenous insulin in critically ill patients has brought clinical focus on understanding the effects of hypoglycemia, especially in children. Very little is published on the impact of hypoglycemia in this population. We aimed to review the existing literature on hypoglycemia in critically ill neonates and children. METHODS We performed a systematic review of the literature up to August 2011 using PubMed, Ovid MEDLINE and ISI Web of Science using the search terms "hypoglycemia or hypoglyc*" and "critical care or intensive care or critical illness". Articles were limited to "all child (0-18 years old)" and "English". RESULTS A total of 513 articles were identified and 132 were included for review. Hypoglycemia is a significant concern among pediatric and neonatal intensivists. Its definition is complicated by the use of a biochemical measure (i.e., blood glucose) for a pathophysiologic problem (i.e., neuroglycopenia). Based on associated outcomes, we suggest defining hypoglycemia as <40-45 mg/dl in neonates and <60-65 mg/dl in children. Below the suggested threshold values, hypoglycemia is associated with worse neurological outcomes, increased intensive care unit stay, and increased mortality. Disruptions in carbohydrate metabolism increase the risk of hypoglycemia incritically ill children. Prevention of hypoglycemia, especially in the setting of intravenous insulin use, will be best accomplished by the combination of accurate measuring techniques, frequent or continuous glucose monitoring, and computerized insulin titration protocols. CONCLUSION Studies on hypoglycemia in critically ill children have focused on spontaneous hypoglycemia. With the current practice of maintaining blood glucose within a narrow range with intravenous insulin, the risk factors and outcomes associated with insulin-induced hypoglycemia should be rigorously studied to prevent hypoglycemia and potentially improve outcomes of critically ill children.
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Tanaka M, Suganuma K, Funase Y, Minami S, Shirotori K, Oguchi T, Kamijo T, Koyama T, Aizawa T. Hypoglycaemic coma due to adrenal failure in a chronic haemodialysis patient. NDT Plus 2010; 4:36-8. [PMID: 25984098 PMCID: PMC4421640 DOI: 10.1093/ndtplus/sfq188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 10/05/2010] [Indexed: 11/14/2022] Open
Abstract
A 62-year-old man, receiving chronic haemodialysis and suffering from alcoholic liver cirrhosis and chronic pancreatitis, presented with hypoglycaemic coma. Plasma cortisol was undetectable (< 5.5 nmol/L) with suppressed adrenocorticotropic hormone (ACTH), which established a diagnosis of adrenal failure due to ACTH deficiency. Twenty-five milligrams of oral hydrocortisone eradicated hypoglycaemia. Presentation of adrenal failure in this patient was atypical because he was hypertensive, serum electrolytes including sodium were normal and anaemia was unremarkable, which were all due to end-stage renal disease and its treatment with haemodialysis. As far as we are aware, this is the first case report of hypoglycaemic coma due to adrenal failure in a chronic haemodialysis patient.
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Affiliation(s)
| | | | | | | | | | | | - Tsuyoshi Kamijo
- Emergency and Critical Care Center , Aizawa Hospital , Matsumoto , Japan
| | - Toru Koyama
- Emergency and Critical Care Center , Aizawa Hospital , Matsumoto , Japan
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13
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Aso K, Izawa M, Higuchi A, Kotoh S, Hasegawa Y. Stress doses of glucocorticoids cannot prevent progression of all adrenal crises. Clin Pediatr Endocrinol 2009; 18:23-7. [PMID: 24790376 PMCID: PMC4004880 DOI: 10.1297/cpe.18.23] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2008] [Accepted: 11/10/2008] [Indexed: 11/30/2022] Open
Abstract
Adrenal crises (ACs) sometimes progress rapidly and can be fatal. The aims of
the present study were to reveal whether stress doses of glucocorticoids (SDGs) can
prevent progression of severe ACs and to suggest a method of prevention, through analysis
of its clinical features. We studied 24 severe ACs (nine patients) that occurred after
diagnosis of primary or secondary adrenal insufficiency, retrospectively. The following
information was analyzed: 1) whether SDGs were given orally and/or sc; 2) duration from
the time when some symptoms started to the time when the patient came to the hospital; and
3) presence of hypoglycemia and electrolyte disturbance (hyponatremia, hyperkalemia).
Eleven crises occurred after taking SDGs. Ten crises progressed within 3 h. Six of these
ten crises progressed to severe ACs despite the fact that the patients took SDGs. Six
crises were observed in association with hypoglycemia, and five of these six crises
occurred in patients under 5 yr of age. Three of the six crises in association with
hypoglycemia progressed to ACs within 3 h. Two of the three crises progressed to severe
status within 3 h despite the fact that the patients took SDGs. Electrolyte disturbance
was observed in only one crisis. In conclusion, SDGs cannot prevent progression of all
ACs. Progression can be associated with hypoglycemia, particularly in patients under 5 yr
of age. Patients should be given guidance on an ongoing basis on how to prevent ACs and
hypoglycemia.
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Affiliation(s)
- Keiko Aso
- First Department of Pediatrics, Toho University Medical Center, Omori Hospital, Tokyo, Japan ; Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Masako Izawa
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Asako Higuchi
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Shinobu Kotoh
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Yukihiro Hasegawa
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
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14
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van Tijn DA, de Vijlder JJM, Vulsma T. Role of corticotropin-releasing hormone testing in assessment of hypothalamic-pituitary-adrenal axis function in infants with congenital central hypothyroidism. J Clin Endocrinol Metab 2008; 93:3794-803. [PMID: 18647808 DOI: 10.1210/jc.2008-0492] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The Dutch neonatal congenital hypothyroidism (CH) screening program detects infants with CH of central origin (CH-C). These infants have a high likelihood of multiple pituitary hormone deficiencies. ACTH deficiency especially poses an additional risk for brain damage and may be fatal. OBJECTIVE Our objective was to evaluate different tools for assessment of the integrity of the hypothalamus-pituitary-adrenocortex (HPA) axis in young infants, aiming for a strategy for reliable and timely diagnosis. DESIGN, SETTING This is a Dutch nationwide prospective study (enrollment 1994-1996). Patients were included if neonatal CH screening results were indicative of CH-C and HPA axis function could be tested within 6 months of birth. PATIENTS Nine male and three female infants with CH-C and four infants with false-positive screening results or transient hypothyroidism were included in the study. MAIN OUTCOME MEASURES CRH test results, multiple cortisol plasma concentrations, and cortisol excretion in 24-h urine were measured. RESULTS Six (50%) of the CH-C patients had abnormal CRH test results. Three of them had discordant test results: impaired increase of plasma cortisol in response to CRH, despite substantial increase of plasma ACTH. The other three infants, with concordant impaired responses of both ACTH and cortisol to CRH, had a very low urinary cortisol excretion in comparison with the subjects with normal CRH test results. CONCLUSIONS The CRH test proves to be a fast and reliable tool in the assessment of HPA axis (dys)function. It enables timely diagnosis in (asymptomatic) neonates at risk for serious morbidity and mortality. The discordant response type, which has not been described before, may be an early phase of HPA axis dysfunction. Alternatively, patients with this response type may constitute a separate pathogenetic subset of HPA axis-deficient patients.
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Affiliation(s)
- David A van Tijn
- Department of Pediatric Endocrinology, Academic Medical Center, University of Amsterdam, 1100 DE Amsterdam, The Netherlands.
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