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Kibirige D, Owarwo N, Kyazze AP, Morgan B, Olum R, Bongomin F, Andia-Biraro I. Prevalence, Clinical Features, and Predictors of Adrenal Insufficiency in Adults With Tuberculosis or HIV: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2024; 11:ofae098. [PMID: 38560601 PMCID: PMC10981394 DOI: 10.1093/ofid/ofae098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/19/2024] [Indexed: 04/04/2024] Open
Abstract
Background Despite the high frequency of adrenal insufficiency (AI) in patients with tuberculosis or HIV, its diagnosis is often missed or delayed resulting in increased mortality. This systematic review and meta-analysis aimed to document the prevalence, significant clinical features, and predictors of AI in adult patients with tuberculosis or HIV. Methods We systematically searched databases (Medline, Embase, CINAHL, Cochrane Library, and Africa Journal Online) for published studies on AI in adult patients with tuberculosis or HIV. The pooled prevalence of AI was determined by a random-effect model meta-analysis. A narrative review was used to describe the significant clinical features and predictors of AI in adult patients with tuberculosis or HIV. Results A total of 46 studies involving 4044 adults were included: 1599 with tuberculosis and 2445 with HIV. The pooled prevalence of AI was 33% (95% CI, 22%-45%; I2 = 97.7%, P < .001) in participants with tuberculosis and 28% (95% CI, 18%-38%; I2 = 98.9%, P < .001) in those with HIV. Presentation with multidrug-resistant tuberculosis, abdominal pain, salt craving, myalgia, increased severity and duration of tuberculosis disease, and the absence of nausea predicted AI in participants with tuberculosis in 4 studies. Cytomegalovirus antigenemia positivity, rifampicin therapy, and eosinophilia >3% predicted AI in participants with HIV in 2 studies. Conclusions AI is relatively common in adults with tuberculosis or HIV. Its timely screening, diagnosis, and management in patients with these 2 conditions should be encouraged to avert mortality.
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Affiliation(s)
- Davis Kibirige
- Department of Medicine, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
- Non-communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Noela Owarwo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew Peter Kyazze
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Bethan Morgan
- Education and Research Centre, Wythenshawe Hospital, Manchester, UK
| | - Ronald Olum
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Irene Andia-Biraro
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Patil SV, Toshniwal S, Acharya A, Gondhali G. Cardiac dysfunction in active pulmonary tuberculosis: Mysterious facts of TB’s pandora. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/12834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
<b>Introduction</b>: Cardiac dysfunction in pulmonary tuberculosis is relatively more common and underestimated due to lack of suspicion. We have studied prevalence of cardiac dysfunction in pulmonary tuberculosis with special emphasis on echocardiography, serum cortisol and its correlation in cases with unstable cardiorespiratory parameters.<br />
<b>Methods:</b> Prospective, observational, complete workup, and one year follow up study conducted during January 2016 to December 2020 included 800 cases of active pulmonary tuberculosis with specified inclusion criteria of disproportionate tachycardia, tachypnea with or without hypoxia and shock. Cases with known risk factor for cardiac disease and taking cardiac medicines, and cases with pericardial effusion were excluded from study. All study cases were undergone protocolized analysis such as chest radiograph, pulse oximetry, ECG, sputum examination, cardiac enzymes (CPK-MB, NT-Pro-BNP, and cardiac troponins), serum cortisol, and echocardiography at entry point, at two and six months of treatment with anti-tuberculosis medicines as per NTEP. Statistical analysis was carried out by Chi-square test.<br />
<b>Observations and analysis: </b>In a study of 800 pulmonary tuberculosis cases, 56.00% (448/800) cases were males, and 44.00% (352/800) cases were females. Cases with BMI<18 was 41.62% (333/800) and BMI>18 was 58.37% (467/800). Radiological patterns as unilateral disease in 33.62% (269/800) & bilateral disease in 66.37% (531/800). Hemoglobin less than 10 gm% were documented in 85.12% (681/800) and above 10 gm% were in 14.87% (119/800) cases. Serum albumin less than 3.5 gm% and more than 3.5 gm% were observed in 48.12% (385/800) and 51.12% (415/800) cases respectively. Hypoxia was documented 26.12% (209/800) cases and normal oxygen saturation in 73.87% (591/800) cases. cases with normal and abnormal serum cortisol were 61.37% (491/800) & 38.62% (309/800) respectively. Sputum examination for AFB observed in 30.00% (240/800) and gene Xpert MTB/RIF documented in 51.37% (411/800) cases respectively. Bronchoscopy guided techniques were used in 149 cases and BAL smear AFB in 44.96% (67/149) cases, gene Xpert MTB/RIF in 97.31% (145/149) cases and MGIT culture in four cases (positive in 100% cases subjected to MGIT culture). We have observed global hypokinesia is predominant cardiac dysfunction documented in 82.21% (171/208) cases, followed by left heart systolic dysfunction in 16.34% (34/208) cases and left heart diastolic dysfunction in 75% (156/208) cases. Right heart dysfunction as dilated right atrium and right ventricle documented in 52.88% (110/208) cases and pulmonary hypertension in 40.38% (84/208) cases. Covariates such as age, gender, hemoglobin, BMI, serum cortisol, serum albumin, oxygen saturation and radiological involvement has significant association with cardiac dysfunction. (p<0.00001) Response to treatment with antituberculosis medicines and steroids has documented as improved in 77.40% cases (161/208) cases, persistent in 13.46% (28/2028) cases and progressive in 9.13% (19/208) cases. Final outcome of cardiac dysfunction in Pulmonary tuberculosis cases has significant association with serum cortisol level (p<0.00086).<br />
<b>Conclusion:</b> Cardiac dysfunction is active pulmonary tuberculosis needs prompt workup in presence of disproportionate tachypnea, tachycardia with or without hypoxia and shock. Echocardiography is basic tool to evaluate these cases and global hypokinesis is most common abnormality. Serum cortisol abnormality documented in fair number of cases and very well correlated with left ventricular dysfunction abnormalities. Steroids with antituberculosis treatment backup is mainstay protocol during management of these cases. Cardiac dysfunction is reversible in majority of cases and proportionate number shown complete improvement in cardiac dysfunction.
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Affiliation(s)
- Shital Vishnu Patil
- MIMSR Medical College, Latur, INDIA
- Venkatesh Chest Hospital and Critical Care Center, Latur, INDIA
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Neogi S, Mukhopadhyay P, Sarkar N, Datta PK, Basu M, Ghosh S. Overt and Subclinical Adrenal Insufficiency in Pulmonary Tuberculosis. Endocr Pract 2021; 27:601-606. [PMID: 33645514 DOI: 10.1016/j.eprac.2020.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tuberculosis of the adrenal glands may cause overt or subclinical adrenal insufficiency. An algorithm-based approach including assessment of paired basal cortisol and plasma adrenocorticotropic hormone (ACTH), short Synacthen, and plasma renin activity assays could be useful to diagnose all forms of adrenal insufficiency. METHODS This cross-sectional study included consecutive, treatment-naive subjects diagnosed with pulmonary tuberculosis. Tuberculosis severity was classified by radiological criteria. Baseline parameters plus morning (8 am) serum cortisol and paired plasma ACTH were measured in all patients. Synacthen stimulation tests and plasma renin activity assays were performed as required. RESULTS Eighty-four treatment-naive consecutive cases of pulmonary tuberculosis were evaluated for adrenal insufficiency. Twenty-seven (32.14%) subjects had normal adrenocortical function and 8 (9.5%), 7 (8.3%), 40 (47.6%), and 2 (2.4%) subjects had stage 1, stage 2, stage 3, and stage 4 adrenal insufficiency, respectively. Serum cortisol was negatively correlated with radiological severity (P = .01) and duration of illness (P = .001). Adrenal dysfunction was present in 27.3%, 82.5%, and 80% of those with radiologically minimal, moderately advanced, and far-advanced disease, respectively. Mean cortisol was 19.74 ± 5.52, 17.42 ± 8.53, and 15.71 ± 7.14 (μg/dL) in the 3 groups, respectively (P = .042). Hyponatremia was present in 83.3% of the patients. Serum sodium was negatively correlated with severity but not with the duration of disease. CONCLUSION The prevalence of overt and subclinical adrenal dysfunction in pulmonary tuberculosis was high and was correlated with disease severity and duration. An algorithmic approach may be useful to detect the same and may have important clinical implications.
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Affiliation(s)
- Subhasis Neogi
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Niladri Sarkar
- Department of General Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal
| | - Pradip Kumar Datta
- Department of General Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal
| | - Madhurima Basu
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Sujoy Ghosh
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India.
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Rodríguez-Gutiérrez R, Rendon A, Barrera-Sánchez M, Carlos-Reyna KEG, Álvarez-Villalobos NA, González-Saldivar G, González-González JG. Multidrug-Resistant Tuberculosis and Its Association with Adrenal Insufficiency: Assessment with the Low-Dose ACTH Stimulation Test. Int J Endocrinol 2016; 2016:9051865. [PMID: 27006656 PMCID: PMC4781954 DOI: 10.1155/2016/9051865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/14/2016] [Accepted: 01/26/2016] [Indexed: 11/18/2022] Open
Abstract
Background. Multidrug-resistant tuberculosis (MDR-TB) is a major public health care concern that affects the life of millions of people around the world. The association of tuberculosis and adrenal insufficiency is well known; however, it is thought to be less prevalent every time. A spike in TB incidence and a lack of evidence of this association in patients with MDR-TB call for reassessment of an illness (adrenal dysfunction) that if not diagnosed could seriously jeopardize patients' health. Objective. To determine the prevalence of adrenocortical insufficiency in patients with MDR-TB using the low-dose (1 μg) ACTH stimulation test at baseline and at 6-12 months of follow-up after antituberculosis treatment and culture conversion. Methods. A total of 48 men or women, aged ≥18 years (HIV-negative patients diagnosed with pulmonary MDR-TB) were included in this prospective observational study. Blood samples for serum cortisol were taken at baseline and 30 and 60 minutes after 1 μg ACTH stimulation at our tertiary level university hospital before and after antituberculosis treatment. Results. Forty-seven percent of subjects had primary MDR-TB; 43.8% had type 2 diabetes; none were HIV-positive. We found at enrollment 2 cases (4.2%) of adrenal insufficiency taking 500 nmol/L as the standard cutoff point value and 4 cases (8.3%) alternatively, using 550 nmol/L. After antituberculosis intensive phase drug-treatment and a negative mycobacterial culture (10.2 ± 3.6 months) adrenocortical function was restored in all cases. Conclusions. In patients with MDR-TB, using the low-dose ACTH stimulation test, a low prevalence of mild adrenal insufficiency was observed. After antituberculosis treatment adrenal function was restored in all cases. Given the increasing and worrying epidemic of MDR-TB these findings have important clinical implications that may help clinicians and patients make better decisions when deciding to test for adrenocortical dysfunction or treat insufficient stimulated cortisol levels in the setting of MDR-TB.
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Affiliation(s)
- René Rodríguez-Gutiérrez
- Endocrinology Division, University Hospital “Dr. Jose E. Gonzalez”, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
- Department of Internal Medicine, University Hospital “Dr. Jose E. Gonzalez”, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Adrian Rendon
- Department of Internal Medicine, University Hospital “Dr. Jose E. Gonzalez”, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
- Centro de Investigacion, Prevencion y Tratamiento de Infecciones Respiratorias (CIPTIR), Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
| | - Maximiliano Barrera-Sánchez
- Department of Internal Medicine, University Hospital “Dr. Jose E. Gonzalez”, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
| | - Kevin Erick Gabriel Carlos-Reyna
- Department of Internal Medicine, University Hospital “Dr. Jose E. Gonzalez”, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
| | | | - Gloria González-Saldivar
- Department of Internal Medicine, University Hospital “Dr. Jose E. Gonzalez”, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
| | - José Gerardo González-González
- Endocrinology Division, University Hospital “Dr. Jose E. Gonzalez”, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
- Department of Internal Medicine, University Hospital “Dr. Jose E. Gonzalez”, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
- Clinical Research Unit, Medical School, Autonomous University of Nuevo Leon, 64460 Monterrey, NL, Mexico
- *José Gerardo González-González:
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Ikoma A, Namai K, Saito T, Kawano T, Saito T, Kasono K, Tamemoto H, Yamada S, Kawakami M, Ishikawa SE. Unilateral active adrenal tuberculosis featuring persistent intermittent fever. Endocr J 2004; 51:463-6. [PMID: 15516779 DOI: 10.1507/endocrj.51.463] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The adrenal gland is one of the organs which tuberculosis infects. In most clinical settings bilateral adrenal tuberculosis has been clarified after adrenal insufficiency is overt. On the contrary, active adrenal tuberculosis is rarely detected during the survey of infectious disease. A 68-year-old man was admitted because of intermittent fever. The fever had continued for the last 3 months. The intermittent fever was accompanied with leukocytosis and elevation of C-reactive protein. Serum soluble interleukin-2 receptor was 1920 U/ml, and beta2-microglobulin was 4.0 mg/l. Bacterial cultures of blood, sputa, urine, bone marrow and cerebrospinal fluid did not show any particular bacteria. Mycobacterium tuberculosis was negative in culture of sputa, and there was no tuberculin reaction. Plasma ACTH and serum cortisol were 18.5 pmol/l and 527.0 nmol/l, respectively. Abdominal CT scan showed right adrenal mass with a size of 28 x 20 mm, which was low density and had a well-encapsulated homogenous appearance. After the adrenalectomy, histology verified active adrenal tuberculosis. The intermittent fever disappeared, and white blood cells and C-reactive protein normalized. These findings indicate an atypical, rare case of unilateral, active adrenal tuberculosis closely linked to intermittent fever, and without any other organ involvement.
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Affiliation(s)
- Aki Ikoma
- Department of Medicine, Jichi Medical School Omiya Medical Center, Saitama, Japan
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Endocrine and Metabolic Manifestations of Tuberculosis. Tuberculosis (Edinb) 2004. [DOI: 10.1007/978-3-642-18937-1_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hawken MP, Ojoo JC, Morris JS, Kariuki EW, Githui WA, Juma ES, Gathua SN, Kimari JN, Thiong'o LN, Raynes JG, Broadbent P, Gilks CF, Otieno LS, McAdam KP. No increased prevalence of adrenocortical insufficiency in human immunodeficiency virus-associated tuberculosis. TUBERCLE AND LUNG DISEASE : THE OFFICIAL JOURNAL OF THE INTERNATIONAL UNION AGAINST TUBERCULOSIS AND LUNG DISEASE 1996; 77:444-8. [PMID: 8959149 DOI: 10.1016/s0962-8479(96)90118-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
SETTING Acute medical wards, Kenyatta National Hospital, Nairobi, Kenya. OBJECTIVE To determine the prevalence of adrenocortical insufficiency in human immunodeficiency virus (HIV)-1 infected and non-infected patients with tuberculosis. DESIGN One hundred and seventy-four patients with proven tuberculosis (90 HIV-1 positive and 84 HIV-1 negative) were assessed for adrenocortical insufficiency with a 30 min synacthen stimulation test. RESULTS Fifty-one percent of those with pulmonary tuberculosis and 56% of those with extra-pulmonary tuberculosis had a subnormal cortisol response. However there was no statistically significant difference between the HIV-1 infected and non-infected patients in either group. CONCLUSION While an impaired cortisol response is common in tuberculosis, it is no more prevalent in HIV-1 infected patients than non-infected patients with tuberculosis.
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Affiliation(s)
- M P Hawken
- Clinical Research Centre, Kenya Medical Research Institute, Nairobi, Kenya
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