Prevalence and factors associated with functional adrenal insufficiency in severely ill HIV patients in Mulago hospital

Abstract

Introduction: The adrenal gland is the endocrine gland most commonly involved in patients infected with human immunodeficiency virus (HIV). It is important to recognize patients with adrenal insufficiency because this disorder may be fatal if untreated. Adequate adrenal function is essential to survive critical illness. Most critically ill patients display an elevated plasma cortisol level, reflecting activation of the pituitary adrenal axis. Adrenal insufficiency may be primary or secondary. Functional adrenal insufficiency, however is transient and refers to subnormal cortisol production during acute severe illness sand reflects the fact that adrenal insufficiency can occur without structural defects in the hypothalamic-pituitary-adrenal axis. Deficiency of cortisol is associated with increased morbidity and mortality during critical illness among HIV patients. Diagnosis of this syndrome is of great importance since these patients may benefit from supplementation with stress doses of steroids. Objectives: To determine the prevalence and factors associated with functional adrenal insufficiency in severely ill HIV positive patients in Mulago hospital. Methodology: This was a cross sectional study in which consecutive sampling of adults admitted on the medical emergency ward (3BE) was done. HIV positive adults, who gave informed consent, were severely ill (based on the PART criteria) and not receiving corticosteroids were enrolled. Demographic and clinical data were recorded including, Karnofsky score, vital signs, WHO HIV stage and the clinical diagnosis. Sodium, potassium, total serum cortisol level (8-9am), albumin, blood glucose and eosinophil count were determined. These records were used to define the prevalence of adrenal insufficiency and to identify factors associated with adrenal insufficiency among severely ill HIV positive patients in Mulago hospital. Results: The mean patients' age was 35 (±9) years with the majority (56%) being female. Forty percent (40%) of enrolled patients were not previously diagnosed with HIV infection. Thirty percent (30%) of patients died. The prevalence of adrenal insufficiency (define by 8-9am cortisol levels ≤ 25µg/dl was 19% among severely ill HIV patients in Mulago Hospital. The mortality rate among patients with adrenal insufficiency (19%) compared to those with morning cortisol levels above 25µg/dl (33%) (p=0.221) was not significantly different. The use of rifampicin (p=0.004) and eosinophilia (<3%) (p=0.008) were associated with adrenal insufficiency among severely ill HIV patients. The use of septrin was found to be protective in relation to adrenal insufficiency (p=0.041). Adrenal insufficiency was found to be associated with stage IV HIV disease (p=0.046). Eosinophilia and the use of Rifampicin only identified about 40% of patients with adrenal insufficiency when ROC curves were plotted. Although associated with adrenal insufficiency, hyponatremia, hypoglycemia, hyperkalemia and postural hypotension were not found to be associated with functional adrenal insufficiency in this study. Conclusion: Considering the non-specific symptoms associated with adrenal insufficiency, and the high cost of assessing abnormalities of the HPA axis in severely ill, Stage IV HIV patients who are on rifampicin treatment or who are found to have unexplained eosinophilia. Adrenal insuf'ficiency should still be considered among critically ill HIV patients with normal vital signs, glucose levels and electrolytes. Prompt assessment and treatment of critically ill HIV patients should be prioritized to reduce the high mortality rate among critically ill HIV patients. Further studies are needed to assess the benefit of steroids on morbidity and mortality among critically ill HIV patients in our setting.