Prevalence of adrenal insufficiency in HIV positive adults presenting with hypotension and history of tuberculosiDepartment of Medicine, University Teaching Hospital, Lusaka

Abstract

Introduction: Adrenal insufficiency is the commonest endocrine disorder affecting HIV infected patients with AIDS. There are different clinical presentations of adrenal insufficiency, including hypotension, hyponatraemia, fatigue, and hyperpigmentation. It is difficult to diagnose adrenal insufficiency in Zambia, where, measuring of cortisol levels can be costly. Since definitive diagnosis is so expensive, the extent of this problem in Zambia is unclear. Knowing the prevalence of and clinical characteristics associated with adrenal insufficiency in this high-risk population would facilitate more accurate clinical diagnosis and treatment. Aim: To determine the prevalence of, and factors associated with, adrenal insufficiency in hospitalized adult HIV infected patients who present with hypotension and past or current tuberculosis to the medical department at UTH, Lusaka.Methods: This was a cross sectional study conducted at University Teaching Hospital, Lusaka, Zambia. HIV positive patients aged 18 and above, with past or current tuberculosis and hypotension were enrolled in the study if they gave informed consent. Their social demographic features, clinical features and biochemical characteristics were ascertained. In accordance with the literature, diagnosis of adrenal insufficiency in critically ill patients was made by a random total cortisol concentration of < 10microgram/dl or a delta total serum cortisol concentration of <9 microgram/dl after 1 microgram injection of adrenocorticotropic hormone. Adrenal insufficiency was assessed using commercially prepared ELISA kits and results were obtained following the manufacturer specifications for data analysis and typical standard curves. Results and discussion: There were 41/51 patients (80.4%, 95%CI 66.9-90.240), who met the diagnostic criteria for adrenal insufficiency based on baseline cortisol concentration alone. There were 46/51 patients (90.2%; 95% CI 78.6-96.7), who met the stimulation adrenal insufficiency criteria. Overall 48/51 (94.1%, 95% CI 83.8-98.8) met criteria for adrenal insufficiency based on either baseline or stimulation cortisol levels. The most frequent clinical feature among the patients with adrenal insufficiency in this study were, weight loss, anorexia, nausea, diarrhoea, cough and abdominal pain. The majority of the patients were WHO stage III and only a few had hyperpigmentation. All the patients had hyponatraemia, and there was no hyperkalaemia. Anaemia was common among all the patients. Conclusion: A high prevalence of adrenal insufficiency was demonstrated among HIV positive patients admitted with hypotension and current or past tuberculosis. The diagnosis of adrenal insufficiency should be considered in such patients, and cortisol testing done when available. These results are interpreted from a small sample size and use of low-dose, rather than high-dose, adrenocorticotropic hormone stimulation. Therefore, additional studies are warranted to confirm these findings.