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High Prevalence of Central Adrenal Insufficiency in Patients with Prader-Willi Syndrome

Dutch Growth Research Foundation (R.F.A.d.L.v.W., D.A.M.F., A.C.S.H.-K.), 3016 AH Rotterdam, The Netherlands; Departments of Pediatric Endocrinology (R.F.A.d.L.v.W., D.A.M.F., A.C.S.H.-K.) and Pediatric Intensive Care (K.F.M.J.), Erasmus University Medical Center/Sophia Children's Hospital, 3015 GJ Rotterdam, The Netherlands; Department of Pediatric Endocrinology (B.J.O.) and Chemical Endocrinology (F.C.G.J.S.), Radboud University Nijmegen Medical Center, 6525 GA Nijmegen, The Netherlands; and Department of Internal Medicine (F.H.d.J.), Laboratory of Endocrinology, Erasmus University Medical Center, 3015 GE Rotterdam, The Netherlands

Address all correspondence and requests for reprints to: Roderick de Lind van Wijngaarden, Clinical Research Fellow, Dutch Growth Research Foundation and Erasmus University Medical Center/Sophia Children’s Hospital, Westzeedijk 106, 3016 AH Rotterdam, The Netherlands. E-mail: r.delindvanwijngaarden{at}erasmusmc.nl, r.delind{at}kindengroei.nl.

Context: The annual death rate of Prader-Willi syndrome (PWS) patients is very high (3%). Many of these deaths are sudden and unexplained.

Objective: Because most deaths occur during moderate infections and PWS patients suffer from various hypothalamic insufficiencies, we investigated whether PWS patients suffer from central adrenal insufficiency (CAI) during stressful conditions.

Design: Overnight single-dose metyrapone tests were performed. Metyrapone (30 mg/kg) was administered at 2330 h. At 0400, 0600, and 0730 h, ACTH, 11-deoxycortisol, cortisol, and glucose levels were measured. Diurnal salivary cortisol profiles were assessed on a different day at wake-up, 30 min after wake-up, at 1400 h, and at 2000 h.

Setting: The study was conducted in a pediatric intensive care unit.

Patients: Patients included 25 randomly selected PWS patients.

Main Outcome Measure: Patients were considered as having CAI when ACTH levels remained below 33 pmol/liter at 0730 h.

Results: Median (interquartile range) age was 9.7 (6.8–13.6) yr. Fifteen patients (60%) had an insufficient ACTH response (CAI, P < 0.001). There was no significant difference in age, gender, genotype, and body mass index SD score between patients with CAI and those without. Morning salivary cortisol levels and diurnal profiles were normal in all children, suggesting that CAI becomes apparent only during stressful conditions.

Conclusions: Strikingly, 60% of our PWS patients had CAI. The high percentage of CAI in PWS patients might explain the high rate of sudden death in these patients, particularly during infection-related stress. Based on our data, one should consider treatment with hydrocortisone during acute illness in PWS patients unless CAI has recently been ruled out with a metyrapone test.

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