PREVALENCE OF CORTISOL DEFICIENCY IN LATE HIV DISEASE

In order to determine the prevalence of cortisol deficiency in advance d HIV disease and to examine whether it may be be predicted by clinica l features or biochemical abnormalities, we conducted a prospective st udy which assessed responses to a rapid ACTH stimulation test (short-d uration synthetic corticotrophin test, synacthen test) in HIV-positive patients with tr CD4 count of less than or equal to 50 x 10(6)/l. Sub jective fatigue, postural drop in blood pressure, electrolyte changes, presence of concurrent opportunist infection and drug treatment were recorded. Cortisol responses were defined as 'normal' (a post stimulat ion cortisol level greater than or equal to 450 nmol/l), 'abnormal' (p ost stimulation cortisol level <350 nmol/l) or 'impaired' (an intermed iate response). Of 49 patients tested (42 male, seven female), a subop timal response (abnormal or impaired) a,as found in 14 (29%) and frank insufficiency in eight (16%). Cortisol deficiency was not predicted b y postural drop in blood pressure, biochemistry or symptoms of fatigue . Patients with an impaired/abnormal test were not more likely to have cytomegalovirus or mycobacterial disease but were more likely to be t aking megestrol acetate (P = 0.05, Fisher's exact test), Two of three patients with initially normal tests developed impaired/abnormal corti sol responses on re-testing 6-9 months later. Cortisol deficiency is c ommon in late stage HIV disease, but symptoms of fatigue and postural hypotension, as well as biochemical findings, are poor predictors of c ortisol deficiency. We found good subjective response to therapy. Rout ine screening by a rapid ACTH stimulation test is recommended in HIV-p ositive patients with CD4 count less than or equal to 50 X 10(6)/l. Re -testing at regular intervals may be necessary. The interaction betwee n megestrol acetate, cortisol, metabolism and synacthen testing requir es further investigation.