24-HOUR URINARY FREE CORTISOL IN PATIENTS WITH ACQUIRED-IMMUNODEFICIENCY-SYNDROME

Many patients with acquired immune deficiency syndrome (AIDS) have sym ptoms consistent with adrenal insufficiency, but only a small subset o f these patients meet criteria for adrenal insufficiency during a shor t corticotropin (ACTH) stimulation test. We hypothesized that patients with AIDS and symptoms of adrenal insufficiency who produce normal am ounts of cortisol in response to administration of 0.25 mg cosyntropin may nevertheless produce lower amounts of cortisol in a course of 24 hours than comparably sick AIDS patients without symptoms of adrenal i nsufficiency or comparably sick patients without AIDS. We studied four groups of male patients: AIDS patients with symptoms suggestive of ad renal insufficiency but with a normal response to cosyntropin (group I ), AIDS patients without symptoms suggestive of adrenal insufficiency (group II), human immunodeficiency virus (HIV)-negative patients with serious acute or chronic illness (group III), and healthy subjects (gr oup IV). The following variables were examined: age, CD4 cell count, A cute Physiologic and Chronic Health Evaluation (APACHE) score, serum c ortisol and plasma ACTH at baseline; serum cortisol at 30 and 60 minut es after intravenous administration of 0.25 mg cosyntropin; and 24-hou r urinary free cortisol, The four groups had a similar mean age and ba seline plasma ACTH and serum cortisol levels. However, a change in cor tisol from baseline to 30 and 60 minutes after administration of cosyn tropin was significantly smaller in both groups of AIDS patients than in the sick patients without AIDS and normal subjects. There were also differences noted between the two groups of AIDS patients: both basel ine and stimulated levels of cortisol tended to correlate directly wit h ACTH levels in patients without symptoms of adrenal insufficiency, w hile this relationship appeared to be inverse in patients with symptom s suggestive of adrenal insufficiency (r = -.57 to -.7, P < .05 to .14 ), The 24-hour urinary free cortisol levels were similar among all gro ups, but correlated strongly with baseline and stimulated serum cortis ol levels only in patients with AIDS and symptoms of adrenal insuffici ency (r = .8 to .9, P < .002 to .015). We conclude that (1) AIDS patie nts with and without symptoms of adrenal insufficiency may have either normal adrenal function or somewhat suboptimal adrenal reserve as dem onstrated by a blunted cortisol response during the short ACTH stimula tion test in comparison to HIV-negative comparably sick patients or he althy subjects; and (2) 24-hour urinary free cortisol is not a useful test for detection of subtle abnormalities of adrenal function in pati ents with AIDS. Copyright (C) 1998 by W.B. Saunders Company.