Endocrine Abstracts

We present a case of a 53 year-old lady with HIV, who was referred to the endocrine service with a random cortisol of <20 nmol/l. She complained of fatigue, appetite loss and 13 kg weight loss. She had a history of brain histoplasmosis, which had been successfully treated >5 years previously. At that time she required a short course of steroid therapy acutely. Short synachthen test revealed inadequate response (cortisol at 0 min: 378 nmol/l, 30 min: 481 nmol/l, 60 min: 488 nmol/l. At the time she was on Ritonavir. CD4 count was 222 cells/microlitre but viral load was undetectable. All other endocrine axes were intact. She was commenced on low dose prednisolone 3 mg and adequate replacement was confirmed with a prednisolone curve. She was also changed to Raltegravir. The patient reported feeling stronger on steroid replacement therapy, regained her appetite and started to regain the lost weight. Adrenal and pituitary MRI revealed no pathology. Serial synacthen tests showed inadequate peak responses and she has continued on steroid replacement. However, when her CD4 count incremented to 667 cells/microlitre, a long synacthen test was performed and that showed a baseline cortisol of 232 nmol/l with a peak cortisol of 834 nmol/l, implying steady recovery of her axis. We plan to withdraw steroid therapy and monitor. The mechanism by which HIV might affect endocrine function involves mostly immunomodulatory effects of cytokines. Impaired adrenal reserve is a common finding in HIV-infected patients. Changes in cortisol diurnal rhythm have been reported in HIV patients, along with changes in ACTH stimulation according to CD4 count and viral load in the phase of their disease. The diagnosis of adrenal insufficiency in the setting of HIV infection may be challenging because many of these patients have nonspecific symptoms such as fatigue, weight loss, nausea and vomiting, resembling those of adrenal insufficiency.