Evaluation of three acute tests of hypothalamic-pituitary-adrenal function

Lack of menstrual cycle effects on hypothalamic-pituitary-adrenal axis response to insulin-induced hypoglycaemia

OBJECTIVE

Limited data are available on the effects of the menstrual cycle on the hypothalamic-pituitary-adrenal axis (HPA) function. This study evaluates HPA axis reactivity to insulin-induced hypoglycaemia over the menstrual cycle.

PATIENTS

Twelve normal women were randomized to placebo and evaluated during three successive menstrual cycles. Menstrual phase was documented by menstrual diary and by oestradiol and progesterone levels at the time of each insulin tolerance test (ITT). Six normal men were included as a comparison in the statistical analysis.

MEASUREMENTS

Afternoon ITTs were performed initially on the second or third day of menses in women, then seven more ITTs followed at one or two week intervals during the next 10 weeks. Serum measurements of glucose, adrenocorticotrophin (ACTH) and cortisol were obtained.

RESULTS

The glucose and ACTH responses to the ITTs were similar between men and women. Cortisol levels at baseline and during the test were higher in men than in women, although the amount of change was similar. Glucose, ACTH and cortisol response to insulin-induced hypoglycaemia did not vary over the menstrual cycle or during repeat testing in men or women.

CONCLUSIONS

These data show that it is unnecessary to control for menstrual cycle during insulin tolerance tests performed at 1600 hours. It is, however, necessary to control for the effect of sex on cortisol levels. Repeat testing more than one week apart does not appear to influence the glucose, ACTH or cortisol response to insulin stress.

Alteration of major cytokines produced by mitogen-activated peritoneal macrophages and splenocytes in T-2 toxin-treated male CD-1 mice

Fusarium T-2 toxin has immunotoxic properties that may be related to the modulation of cytokine expression by cells of the immune system. Male CD-1 mice were used to study the effect of in vivo exposure to T-2 toxin on the alteration of interleukin (IL)-1α, tumor necrosis factor α (TNF), and IL-6 in lipopolysaccharide-stimulated peritoneal macrophages, and IL-2, IL-3, and interferon γ (IFNγ) in concanavalin A (Con A)-stimulated splenocytes. Mice were orally dosed with 0, 0.1, 0.5, and 2.5 mg T-2 toxin/kg body weight for 2 weeks on alternate days. Northern blot analysis of IL-1α, TNF, and IL-6 mRNA from activated peritoneal macrophages showed no significant differences between control and treated groups. Measurements of secreted protein by immunoassay demonstrated suppression of these cytokines in all treated groups, suggesting that T-2 toxin affects the translational or post-translational regulation of these cytokines from peritoneal macrophages. Levels of IL-2, IL-3, and IFNγ mRNA from Con A-activated splenocytes were higher in all treated groups. The increases were significant for IL-2 and IFNγ in the groups receiving low (0.1 mg/kg) and high (2.5 mg/kg) doses of T-2 toxin, and for IL-3 in the group receiving a medium (0.5 mg/kg) dose of this toxin (P ≤ 0.05). Results indicated that T-2 toxin given orally at low or medium doses induces transcription or increases mRNA stability of IL-2, IFNγ, and IL-3. Protein levels of all three cytokines were also increased, indicating that T-2 toxin also increases translational/post-translational efficiency of IFNγ, IL-2, and IL-3. Possible mechanisms in the immunosuppressive effects of T-2 toxin may involve endotoxemia resulting after the toxin administration, alteration of the stability of mRNA, or previously described effects of T-2 toxin on protein synthesis.

Increased endotoxin sensitivity following T-2 toxin treatment is associated with increased absorption of endotoxin

Oral exposure to T-2 Toxin (T-2) in experimental animals results in a syndrome similar to that observed in endotoxemia. Endotoxins are lipopolysaccharide, outer-membrane components of gram-negative bacteria which induce acute, inflammatory responses. In the present study, several aspects of endotoxin pathophysiology were investigated in mice following simultaneous exposure to T-2 and endotoxin, including mortality, hypothermia, tumor necrosis factor-alpha (TNF-alpha) and corticosterone production, and thymic weight. The disposition of endotoxin was also assessed, Acute, simultaneous exposure to T-2 (4 mg/kg, po) and endotoxin (3 micrograms/mouse, ip) resulted in increased mortality, hypothermia, TNF-alpha production, and thymic atrophy compared to treatment with either T-2 of endotoxin alone. Pretreatment of mice with endotoxin, a regime that renders the animals resistant to the effects of endotoxin, reduced many endotoxin effects in animals treated simultaneously with T-2 and endotoxin. Upon further investigation, it was observed that T-2 increased the absorption rate of endotoxin: as the peak height of serum endotoxin increased, the time-to-peak decreased, and the area under the curve was unchanged in animals treated simultaneously with T-2 and endotoxin. It was concluded that increased endotoxin absorption accounted for the increases in mortality, hypothermia, and TNF-alpha associated with T-2 exposure.

Relationship of the hypothalamic-pituitary-adrenal axis with chemically induced immunomodulation. I. Stress-like response after exposure to T-2 toxin

T-2 toxin (T-2), a trichothecene mycotoxin, produced by several members of the genus Fusarium is a cytotoxic feed contaminant and has been shown to by immunomodulatory. It is suspected that T-2 associated immunomodulation is mediated partly through the hypothalamic-pituitary-adrenal (HPA) axis. T-2, prepared in 4% ethanol/corn oil, was administered orally to male CD-1 mice. Endotoxemia was evident 24 h after a single, oral exposure to T-2. Blood levels of corticosterone, indicative of the stress-response, increased 24 h after T-2 exposure. Hypothalamic norepinephrine and serum corticosterone levels increased in a dose-related manner after 2 weeks of T-2 exposure. Endotoxin, detected in the serum of animals exposed to 2.5 mg/kg T-2 for 1 week, was not associated with bacteremia. Neither endotoxin nor bacteremia were detectable after 2 or 4 weeks of T-2 exposure. Exposure to 2.5 mg/kg T-2 also affected several organs. The forestomach was ulcerated, with lymphocytic infiltration, epithelial proliferation, and hyperkeratinization. Increased spleen weight was associated with a proliferative red pulp. No histological changes were observed in the enlarged liver. Gastritis has been associated with increased corticosteroid production; cortical depletion and reduced mass of the thymus are phenomena attributable to increased corticosteroid levels. An increased corticosteroid level has been associated with thymic involution leading potentially to decreased T-dependent antibody response, a known effect of T-2.

The assessment of abnormalities in hormonal responsiveness at multiple levels of the hypothalamic-pituitary-adrenocortical axis in depressive illness

A substantial body of data suggests that excessive cortisol secretion in depression may result from dysregulation at several sites within the hypothalamic-pituitary-adrenocortical (HPA) axis. The alterations in regulatory mechanisms are thought to result from a limbic system-hypothalamic "overdrive" of corticotropin-releasing hormone (CRH). We also have demonstrated that excessive secretion of cortisol may result from an abnormal adrenocortical responsiveness to adrenocorticotropic hormone (ACTH), and we have postulated that corticotropic cells within the pituitary mediate between excessive secretion of CRH from the hypothalamus and hypercortisolemia secondary to adrenocortical hyperplasia and enhanced sensitivity to ACTH at the adrenal cortex. The present report describes a series of clinical experiments utilizing several neuroendocrine probes, as well as computer-assisted tomography, to examine the complexities of the HPA axis dysregulation in depression. These studies support the hypothesis that a limbic system-hypothalamic disturbance results in excessive CRH secretion as well as enhanced adrenocortical activity, and that these factors contribute to excessive cortisol secretion in patients with depression. These data further support the hypothesis that endogenous affective disorders are best characterized in the framework of a generalized biological disturbance of HPA axis function which involves both central and peripheral endocrine sites.

Cushing's syndrome: a review of diagnostic tests

This review presents an analysis and interpretation of the published experimental data that form the basis for laboratory tests commonly used for screening, definitive diagnosis, and differential diagnosis in Cushing's syndrome. The single-dose overnight dexamethasone suppression test is excellent for screening outpatients since this test has a very low incidence of false-negative results (1.9% of 154 patients with Cushing's syndrome). The definitive diagnosis of Cushing's syndrome is best established by combining basal state measurements of the daily urine-free cortisol excretion and late evening plasma cortisol levels with the 2-mg low-dose dexamethasone suppression test. The etiology of Cushing's syndrome is best determined by combining measurements of basal state plasma adrenocorticotropin (ACTH) levels with the 8-mg high-dose dexamethasone suppression test. Under certain conditions, the basal state daily urine excretion of 17-hydroxycorticosteroids and 17-ketogenic steroids, the insulin tolerance test, and the metyrapone test may be useful in the definitive or differential diagnosis of Cushing's syndrome.

Reactive hypoglycemia

The hypoglycemoses include a large category of distinctly unique entities. Guidelines for a clinical, physiological approach to these disorders is presented. Within this diagnostic spectrum of hypoglycemia lies the reactive hypoglycemic disorders that are characterized by their postprandial onset, adrenergic mediated symptoms, and relatively benign causes. The spectrum of reactive hypoglycemia includes early alimentary-reactive hypoglycemia, late diabetic-reactive hypoglycemia, hormonal deficiency states, and idiopathic hypoglycemia. A new postprandial hypoglycemic disorder, fructose 1-6 diphosphatase, can be added to this list. The frequent sampling of blood-glucose values in the postprandial state will frequently lead to the finding of a biochemically low blood-glucose value of below 50 ml/100 ml, and these individuals show no hypothalamic-pituitary-adrenal stress to the low blood sugar and do not manifest adrenergic symptoms. Their low blood-glucose value simply reflects the transition in intermediary metabolism between the fed and fasting state and provides a biochemical marker of this event. We refer to this asymptomatic biochemical event as transitional low blood-glucose state. It has no clinical implication and may frequently be confused with the bona fide reactive hypoglycemic disorders. Using a symptomatic, counter-regulatory model to define hypoglycemia as a bona fide disorder, findings are presented in patients with the varying types of reactive hypoglycemia, and their results are compared to normal controls and to a weight-matched and disease patient controls. Abnormalities in insulin secretion are discussed as relating to the pathophysiology causal in the hypoglycemia. An approach to therapy is presented based upon the classification of the patient as to the type of hypoglycemia and their abnormalities in insulin secretion.

The effects of morphine and nalorphine on the plasma 11-hydroxycorticosteroid response to insulin-induced hypoglycaemia in patients with rheumatoid arthritis

Morphine in therapeutic dosage has been shown to impair the plasma 11-hydroxycorticosteroid response to the stress of insulin-induced hypoglycaemia. Nalorphoine in similar dosage produced no impairment of the response to hypoglycaemia.

Comparison of corticotrophin and corticosteroid response to lysine vasopressin, insulin, and pyrogen in man

Plasma corticotrophin (ACTH) and corticosteroid levels in response to lysine vasopressin (LVP), insulin hypoglycaemia, and pyrogen have been compared in seven subjects with normal pituitary adrenal function. Intramuscular vasopressin was a weak stimulus to corticotrophin release, peak values lying within the range 49 to 141 pg/ml. Insulin hypoglycaemia consistently caused a more noticeable increase, with peak levels between 114 and 364 pg/ml, while pyrogen was the most powerful, corticotrophin levels rising to between 209 and 1,725 pg/ml. Peak plasma corticosteroid levels showed less pronounced differences between the three tests, and correlated poorly with peak ACTH levels. Thus, relatively small acute changes in corticotrophin levels produce near-maximal adrenal stimulation. Under these conditions, plasma corticosteroid measurements do not accurately reflect circulating corticotrophin levels. These findings help to explain the physiological basis of several observations on the corticosteroid responses to these clinical test procedures.