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Original Research: PNEUMONIA |

Adrenal Response in Severe Community-Acquired Pneumonia: Impact on Outcomes and Disease Severity

Jorge I. F. Salluh, MD, MSc; Fernando A. Bozza, MD, PhD; Márcio Soares, MD, PhD; Juan Carlos R. Verdeal, MD; Hugo C. Castro-Faria-Neto, MD, PhD; José Roberto Lapa e Silva, MD, PhD; Patrícia T. Bozza, MD, PhD
Author and Funding Information

*From the Intensive Care Unit (Drs. Salluh and Soares), Instituto Nacional de Câncer; Laboratory of Immunopharmacology (Drs. Castro-Faria-Neto and Bozza), Instituto Oswaldo Cruz, Fiocruz; Instituto de Pesquisa Clínica Evandro Chagas (Dr. Bozza), Fiocruz; Intensive Care Unit (Dr. Verdeal), Hospital Barra D'or; and Pulmonary Diseases Department (Dr. Lapa e Silva), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.

Correspondence to: Jorge I. F. Salluh, MD, MSc, Instituto Nacional de Câncer, Centro de Tratamento Intensivo, 10o Andar, Praça, Cruz Vermelha, 23, Rio de Janeiro, Brazil 20230-130; e-mail: jorgesalluh@yahoo.com.br


This study was performed at the Intensive Care Unit, Hospital Barra D'or, Rio de Janeiro, Brazil.

This study is original and was not submitted to another primary scientific journal. Preliminary data will be presented as a poster at the 21st Annual Meeting of the European Society of Intensive Care Medicine in September 21–24, 2008.

Financial support was provided by Conselho Nacional de Desenvolvimento Científico e Tecnológico, Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro, and Programa de Apoio à Núcleos de Excelência.

The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2008;134(5):947-954. doi:10.1378/chest.08-1382
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Background:  High cortisol levels are frequent in patients with severe infections. However, the predictive value of total cortisol and of the presence of critical illness-related corticosteroid insufficiency (CIRCI) in severe community-acquired pneumonia (CAP) remains to be thoroughly evaluated. The aim of this study was to investigate the predictive value of adrenal response in patients with severe CAP admitted to the ICU.

Methods:  Baseline and postcorticotropin cortisol levels C-reactive protein (CRP), d-dimer, clinical variables, sequential organ failure assessment (SOFA), APACHE (acute physiology and chronic health evaluation) II, and CURB-65 (confusion, urea nitrogen, respiratory rate, BP, age ≥ 65 years) scores were measured in the first 24 h. Results are shown as median (interquartile range [IQR]). The major outcome measure was hospital mortality.

Results:  Seventy-two patients with severe CAP admitted to the ICU were evaluated. Baseline cortisol levels were 18.1 μg/dL (IQR, 14.4 to 26.7 μg/dL), and the difference between baseline and postcorticotropin cortisol after 250 μg of corticotropin was 19 μg/dL (IQR, 12.8 to 27 μg/dL). Baseline cortisol levels presented positive correlations with scores of disease severity, including CURB-65, APACHE II, and SOFA (p < 0.05). Cortisol levels in nonsurvivors were higher than in survivors. CIRCI was diagnosed in 29 patients (40.8%). In univariate analysis, baseline cortisol, CURB-65, and APACHE II were predictors of death. The discriminative ability of baseline cortisol (area under receiver operating characteristic curve, 0.77; 95% confidence interval, 0.65 to 0.90; best cutoff for cortisol, 25.7 μg/dL) for in-hospital mortality was better than APACHE II, CURB-65, SOFA, d-dimer, or CRP.

Conclusions:  Baseline cortisol levels are better predictors of severity and outcome in severe CAP than postcorticotropin cortisol or routinely measured laboratory parameters or scores as APACHE II, SOFA, and CURB-65.

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