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The Hypothalamic-Pituitary-Adrenocortical Axis in Severe Falciparum Malaria: Effects of Cytokines¹

University of Western Australia, Department of Medicine, Fremantle Hospital (T.M.E.D., J.R.D., D.M., M.H.B.), Western Australia, Australia; Tropical Diseases Research Center, Cho Ray Hospital (L.T.A.T., P.T.D., T.K.A.), Ho Chi Minh City, Vietnam; and Biochemistry Department, Royal Perth Hospital (K.R.), Perth, Western Australia, Australia

Address all correspondence and requests for reprints to: Professor T. M. E. Davis, University of Western Australia, Department of Medicine, Fremantle Hospital, P.O. Box 480, Fremantle, Western Australia 6160, Australia. E-mail: tdavis{at}cyllene.uwa.edu.au

Patients with malaria can have features of adrenal insufficiency. Because of the pathophysiological and clinical implications of an Addisonian state, the hypothalamic-pituitary-adrenocortical axis was assessed in nine Vietnamese adults with complicated malaria. A CRH test was performed on admission (in convalescence in five cases) and in six healthy controls. Basal plasma ACTH concentrations in the patients and controls were similar [median (range): 2.9 (0.2–9.7) vs. 3.5 (1.9–13.4) pmol/L, respectively; P > 0.1]. Serum cortisol levels were greater in the patients [882 (294–1682) vs. 190 (110–676) nmol/L; P < 0.01], but three (33%) had values within the control range. Basal serum corticosteroid-binding globulin concentrations were similar in patients and controls (P = 0.23). The post-CRH rise in plasma ACTH was attenuated in the patients [peak: 6.1 (0.9–23.2) vs. 14.5 (6.2–21.5) pmol/L in controls; P < 0.05]; basal and peak plasma ACTH correlated with plasma interleukin-6 in this group (r_s 0.60; P 0.04). Serum cortisol responses to CRH were depressed in acute illness [peak 990 (394–1, 805) nmol/L or 10 (0–50%) above baseline vs. 500 (429–703) nmol/L or 160 (10–380%) in controls; P < 0.05]. The median estimated serum cortisol t_1/2 was 4.6 h in the patients and 1.6 h in the controls. These data suggest that, relative to a normal stress response, primary and secondary adrenal insufficiency can occur in severe malaria but may be attenuated by increased circulating interleukin-6 concentrations and impaired cortisol metabolism. The benefits of stress-dose corticosteroid replacement are unknown but could be considered in hypoglycemic patients or those with a serum cortisol within or below the reference range.

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				R. I. Dorin, C. R. Qualls, and L. M. Crapo Diagnosis of Adrenal Insufficiency Ann Intern Med, August 5, 2003; 139(3): 194 - 204. [Abstract] [Full Text] [PDF]