To estimate the frequency of adrenal insufficiency (AI) using the low dose (10 μg) ACTH test in patients with severe active tuberculosis (SATB).
Consecutive patients admitted with SATB, defined as microbiological proven tuberculosis and clinical criteria of severe sepsis (SCCM/ACCP) were included in the study. None of them had previous steroid or antituberculous treatment. After a low dose ACTH test, 60 mg of intravenous hydrocortisone was administered and repeated every 6 h for two weeks.
18 patients, 16 men and 2 women with an average age of 38 years (17-53) were evaluated and treated. Twelve patients had pulmonary and 6 had disseminated disease. Only one case had concomitant HIV infection. Mean cortisol value ± SD (ug/dL): Basal 20.05 ± 5.30 60 min 28.66 ± 8.51 60 min - basal 8.6 ± 7.82(delta) Six patients had a basal cortisol value < 18 μg/dL; whereas 11 patients showed an abnormal post stimulation value with a ƒ′ < 9 μg/dL. All patients showed clinical improvement after hydrocortisone treatment. There were two deaths, one patient with HIV infection that died at day 4; another with intestinal tiberculosis and large bowel perforation in wich hydrocortisone was administrated until death (day 35). Both patientes had an abnormal response to low dose ACTH test. Among the 18 patients evaluated, only three had an hypoalbuminemia (albumin < 2.5 g/dL).
Due the high frequency of AI in our study, we recomend intravenous corticosteroid supplementation in SATB.
1. Our paper contributes to the ongoing controversy of adrenal insufficiency and therapeutic corticosteroid supplementation in critical illness like severe acute tuberculosis. 2. Corticosteroid treatment is safe and of benefit in some clinical presentations of tuberculosis (meningeal and pericardial).
L. Casanova-Cardiel, None.