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trainwreck 03-05-2006 10:52 AM

? Son Adrenal Insufficiency? /Any Endos in SE MI?
My 17 y.o. son has Growth Hormone Deficiency which was already discovered quite late in the game. His endo took him off the growth hormone last July and we just had some labs done and returned for a visit. I just got his labs back and have been reading this board and am wondering if he has adrenal insufficiency as he has many of the symptoms:

low BP/dizziness upon getting up; requires alot of sleep; moody; apathetic; loss of appetite; doesn't socialize like most kids his age; low self-esteem; weight loss; heat intolerance; joint pains, brain fog, among others.

His recent labs are as follows at 9:45am:
IGF-1: [B]147 L[/B] Ref: 193-814 ng/mL
Testosterone: 610 R: 241-827 ng/dL
TSH: 5.35 R: 0.34-5.60 mIU/mL
Free T4: 0.80 R: 0..58-1.64 ng/dL
IGF-II: 994 R: 649-1225 ng/mL
IGFBP3: 4.54 R: 1.70-6.04 mg/L

24H Urine: Total Volume 1500 mL
Cortisol, Urine Free: [B]15.0[/B] Ref: <56.0ug/d
Creatinine, Urine -mg/dL: 78
Creatinine, Urine - mg/day: 1170 Ref: 500-2300 mg/d

Any insight to these lab values would be helpful. He seems to have many of the symptoms and his UFC appears to be on the low end. He did have and ITT for the GHD done a couple years ago which I need to dig up and see what the cortisol did then. But, if Hormoneman, you could give suggestions re: these?

Also, does anyone know of any adult endos or osteos in SE MI that might do extensive evaluation of this and also of AGHD as his Pediatric endo is getting ready to move him out of his practice to an adult doc. Any recommendations would be appreciated. Thanks much. :) Laura

orion 03-05-2006 10:59 AM

Re: ? Son Adrenal Insufficiency? /Any Endos in SE MI?
[QUOTE=trainwreck]requires alot of sleep; moody; apathetic; loss of appetite; doesn't socialize like most kids his age; low self-esteem; weight loss; joint pains, brain fog.[/QUOTE]

Most of the symptoms you describe can also be related to low adult growth hormone and his IGF blood test indicates exactly that.

I think he should have an insulin induced hypoglycemia test to verifiy that his pituitary is actually working properly, perhaps he has other undiscovered hormone problems.

WandaB 03-06-2006 11:17 AM

Re: ? Son Adrenal Insufficiency? /Any Endos in SE MI?
Laura, Here are tests he should have done. Test 1 & 2 being a good start to either confirm addisons or rule it out.

Diagnostic Testing for Addison's Disease

TEST 1: Electrolyte profile:

OBJECT: To determine if the patient exhibits a normal serum (blood) sodium and potassium levels.

THE TEST: A blood draw followed by automated determination of sodium and potassium levels as well as other standard blood markers.

NORMAL RESULT (will vary somewhat from lab to lab): Sodium 135-150 mEq/L; Potassium 3.5-5.2 mEq/L

PRIMARY ADDISONIAN: Will show significantly below normal values of sodium and a elevated (above normal) levels of potassium.

REASON FOR ABNORMALITY: Low or no production of aldosterone from the adrenal cortex. This steroidal hormone regulates our mineral balance and is called a mineralocorticoid. Primary Addisonians lose sodium and retain potassium. Abnormal values here, in additon to physical signs and symptoms, require the next test.

TEST 2: The ACTH stimulation test:

OBJECT: To determine if the patient's adrenal glands can respond to the ACTH message from the pituitary to increase cortisol production in the adrenal cortex.

THE TEST: The test is usually given first thing in the morning when normal cortisol levels are highest. Blood is withdrawn from the patient to establish a baseline (No instructions regarding necessity for fasting). The patient is given 250 micrograms (ug) of ACTH (Cortrosyn, Cosyntropin, or Synacthen) by injection in saline at one time. Blood is drawn at 30 minutes and/or 60 minutes and the serum cortisol level is determined.

NORMAL RESULTS: Normal pre-injection levels of cortisol are 5-25 ug/dL (138-690 nmol/L). The value should double at 30-60 minutes with a minimum of 20 ug/dL (552 nmol/L). PRIMARY ADDISONIAN: There will be no or little increase in cortisol levels upon ACTH injection. Notes: It is stated in several places that a single test of cortisol levels, or even 24 h urinary levels of cortisol and its metabolites, are NOT DIAGNOSTIC! In the normal individual cortisol levels are seen to pulse. Low cortisol production in either the serum or the urine after ACTH stimulation is diagnostic of Addisons disease.

SECONDARY ADDISONIAN (Pituitary malfunction): Low cortisol production can be seen if the patient has "functional adrenal cortical atrophy" due to prolonged absence of normal ACTH secretion. This type of patient would not show the typical hyper-pigmentation of primary Addisons.

REASON FOR ABNORMALITY: Due to autoimmune, or other destruction of enzymatic (biocatalytic) machinery of the adrenal gland, there is no response to ACTH and no production of cortisol and other adrenal steroids necessary for life. If this test gives normal results and the patient has other signs and symptoms then one of the following tests is required.

TEST 3: The insulin stimulation test.

OBJECT: The purpose of this test is to determine whether the patient's pituitary gland can produce ACTH in response to an insulin stimulus. Abnormally high insulin will drive the patient into hypoglycemia and stimulate the production of ACTH from the pituitary. This test is called by Dr. Krasner (JAMA, 1999, 282 671-676) the traditional test to determine the integrity of the messenger pathway between the hypothalamus, pituitary and adrenal gland. He stresses that it should be given by qualified medical personnel under the direct supervision of a physician, because insulin shock can result.

THE TEST: Baseline blood levels are taken. Insulin is injected into the patient until the blood glucose level falls below 2.2 mmol/L (40 mg/dL). Blood is drawn at intervals up to 90 minutes and the serum cortisol is measured. (This is simpler than determining the ACTH level).

NORMAL RESULTS: A normal patient will show an increase of cortisol production (due to increased ACTH production of not less then 550 nmol/L or (20 ug/dL).

DISEASED PATIENT (SECONDARY ADDISONS): If there is no or little increase in cortisol production as measured by several blood draws after this test is given, then, according to Dr. Krasner, the patient has significant hypothalamic-pituitary-adrenal (HPA) axis impairment.

REASON FOR ABNORMALITY: Basically, either the pituitary or the hypothalamus glands are not showing normal physiology. There can be several reasons for this. The pituitary may have lost its ability to make ACTH due to autoimmune impairment. The hypothalamus may not be sending the right signal to pituitary. There may be a pituitary tumor. Finally, the HPA axis may be suppressed due to sustained therapeutic use of steroids like prednisone which is given to those with chronic inflammation of various kinds. Asthmatics sometimes get in this situation.

TEST 4: The overnight metyrapone test:

OBJECT: This test is an alternative to the insulin test mentioned above and has basically the same objective which is to determine if the pituitary is making ACTH in response to a stimulus. Metyrapone is a drug that blocks the last step of the synthesis of cortisol in the adrenal gland.

THE TEST: The patient is given 30 mg/kg(body weight) at midnight without food. Blood is drawn at 8 AM ad the levels of cortisol and 11-deoxycortisol are measured.

NORMAL RESULTS: A normal individual will show morning plasma cortisol levels below 10 ug/dL (276 nmol/L) and 11-deoxycortisol levels at 7-22 ug/dL (0.2 to 0.6 umol/L).

DISEASED PATIENT: A patient with HPA axis impairment will not show increased levels of 11-deoxycortisol. NOTE: This test can drive a patient into adrenal crisis!!!

REASON FOR ABNORMALITY: same as above, no ACTH production

TEST 5: CRH stimulation.

OBJECT: The purpose of this test is to determine whether CRH (cortico-releasing hormone) is being produced by the hypothalamus and is stimulating the pituitary to make ACTH, and thence the adrenal to make cortisol.

THE TEST: CRH is given the patient by injection and blood is drawn in the manner described above to determine whether cortisol is produced in response to the stimulus. CRH is very expensive and the test, while better than either of the other two above, is not as common for this reason.

NORMAL RESULTS: Serum cortisol levels are seen to increase following the injection just as in Test 3.

DISEASED PATIENT: If the previous tests were normal and this test gives a normal result, then hypothalamic disorder could be indicated. If the test does not give rise to increased cortisol production then the patient could have either primary (adrenal) or secondary (pituitary) adrenal cortical insufficiency. The tests above must distinguish.

RADIOGRAPHIC DIAGNOSTIC TESTS: MRI or CAT scans can be made of either the adrenals or pituitary to determine the presence of abnormalities, but they are only of value when they are done with the tests above.

trainwreck 03-06-2006 09:20 PM

Re: ? Son Adrenal Insufficiency? /Any Endos in SE MI?
Wow. Thanks for the detailed info! I am going to fax his results to his endo and hopefully discuss them and the possibility of doing some of these tests. You have been very helpful. Thank you so much for taking the time to provide all this info. It is very much appreciated!

SadFreek 03-07-2006 09:51 AM

Re: ? Son Adrenal Insufficiency? /Any Endos in SE MI?
With a TSH of 5.3 and FreeT4 that low, he is deffinatly hypothyroidism as well. You should also request FreeT3 and antibodies to check for auto-immune diseases of the thyroid

WandaB 03-07-2006 11:07 AM

Re: ? Son Adrenal Insufficiency? /Any Endos in SE MI?
Good point about the 5.3 TSH. I like mine to be below 2. It is about 1.3 now. It is interesting how the docs just ignore things like this. They should jump right on treating a TSH this high. :bouncing:

Keraly 05-06-2006 07:58 PM

Re: ? Son Adrenal Insufficiency? /Any Endos in SE MI?
I agree with the reply ahead of mine. His TSH was what really caught my eye. Has the doctor ever spoken to you about his being hypothyroid? This could account for his letargy and fatigue. But to test out the theory of whether he has adrenal problems, ask for an ACTH stim test, and to have renin and aldosterone levels measured by blood test. So sorry to hear about your son. My son was just diagnosed in February with POTS, after he was ill for 2-1/2 years without a diagnosis! I know what it is like to know something is wrong, but not be able to find out WHAT. Hang in there; you'll get answers. ~ :wave: Tracy

eclipse27 05-09-2006 01:01 PM

Re: ? Son Adrenal Insufficiency? /Any Endos in SE MI?
All this sounds like something i dr. refered me to an endo in nashville im in huntsville like 2 hours away. Im gonna go there soon. The wierd thing is im 6'5 and still growing. Keep me informed about it

orion 05-09-2006 06:31 PM

Re: ? Son Adrenal Insufficiency? /Any Endos in SE MI?
[QUOTE=eclipse27]All this sounds like something i dr. refered me to an endo in nashville im in huntsville like 2 hours away. Im gonna go there soon. The wierd thing is im 6'5 and still growing. Keep me informed about it[/QUOTE]

You may have excess growth hormone rather than a deficiency.

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