Serum cortisol and inflammatory response in neutropenic fever
Rationale: The aim was to prospectively examine adrenal function including cosyntropin stimulation and its prognostic value in patients with moderate CAP. Methods: 59 consecutive adult patients hospitalised at normal ward because of CAP were enrolled. A cosyntropin stimulation test was performed and serum concentrations of CRP, PCT, IL-6, TNFα, ACTH, cortisol, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate (DHEAS) were measured. Predefined outcome parameters were clinical instability after 72 hours, mortality and combined ICU-admission or mortality. Results: Critical illness related corticosteroid insufficiency (CIRCI) occurred in 6 patients (10,3%). Cortisol, age-corrected DHEA, ACTH and the DHEA/DHEAS ratio were elevated in patients remaining unstable after 72h. In multivariate analysis, cortisol (p=0.03), ACTH (p=0.04) and the PSI-score (p=0.005) independently predicted clinical instability after 72h, and only cortisol predicted mortality (p=0.04) and combined ICU-admission or mortality (p=0.006). The predictive value of serum cortisol after ROC-curve-analysis equalled that of the PSIscore. Patients with serum cortisol >734 nmol/l had a high probability for mortality (OR 38,3, p=0.002). Conclusion: CIRCI is rare in patients with moderate CAP. Adrenal function is related to the prognosis of CAP. The diagnostic accuracy of serum cortisol equals that of the PSI-score. Serum cortisol should be evaluated within clinical prediction scores on larger studies.