A previously healthy 20-year-old man comes to his college me

[kailash]

A previously healthy 20-year-old man comes to his college medical clinic for headaches and low-grade fevers. He is discharged home with the diagnosis of a "viral syndrome" and instructed to get ample rest. Approximately three hours later his roommate calls 911 reporting that his friend is unconscious and not arousable. On arrival the paramedics find a lethargic, febrile man lying on the floor and unresponsive. The patient is stabilized and he is rushed emergently to the local hospital where an abdominal CT scan shows bilateral adrenal hemorrhages. His blood pressure is 80/40 mm Hg and his pulse is 110/min. He appears very ill and continues to be non-responsive. The most appropriate study at this time is a/an

A. Cort-Stim test
B. cortisol level
C. high-dose ACTH stimulation test
D. insulin response test
E. low-dose ACTH stimulation test

[kailash]

The answer is B. This patient has bilateral adrenal hemorrhages in the setting of fulminant disseminated Neisseria sepsis. This is called the Waterhouse-Friderichsen Syndrome. The patient therefore almost certainly has acute adrenal insufficiency. In a critically ill patient, a random cortisol level that is low confirms this diagnosis.

A Cort-Stim test (choice A) is a test whereby synthetic ACTH is administered and the cortisol response is measured one hour later. It is more sensitive at detecting adrenal insufficiency but is both too time-consuming and unnecessary in this patient. The threshold for supplying exogenous steroids is very low so all that is needed is a suspicion for insufficiency that a random cortisol level can easily provide.

A high-dose ACTH stimulation test (choice C) or low-dose ACTH stimulation test (choice E) are both very sensitive tests that require 24 hours to perform. They both are useful at quantifying adrenal function so that differentiation between various causes of adrenal insufficiency can be made. However, they are not the most appropriate studies in this acute situation.

The insulin response test (choice D) is another method used to indirectly assess adrenal function but will not be useful in this patient since the goal is rapid direct assessment of her adrenal function.