Low cortisol levels

[Giovanni]

Dear Doctor,
I would wish to know if there is in your experience or in medical literature a possible explanation of costant very low cortisol levels without symtoms.
This is a condition of a patient of mine.

What is the possible explanation about this condition?

Thank you in advance for your help.
Sincerely
Giovanni Amato

[Dr. Tamer Fouad]

Dear Dr. Giovanni,
Thank you for your question.
You must first confirm that indeed the patient has a pathologically low serum cortisol level.

Cortisol is secreted in circadian rythm with a maximum 5-25ug/dL in the early morning (8:00 am) and minimum values of 3-16ug/dL in the late afternoon.

To diagnose low serum cortisol (Addison's disease):
Serum cortisol taken at 8:00am < 5ug/dL [SI:140nmol/L] (some authorities say < 3ug/dL [SI: 86nmol/L]) confirms the diagnosis. A result of > 20ug/dL [SI: 550nmol/L] excludes the diagnosis in an unstressed individual.
Between these values if the condition is still suspected a rapid ACTH stimulation test should be performed. When impaired a long ACTH stimulation test should be performed to differentiate primary from secondary insufficiency.
A high plasma ACTH level with a low or normal cortisol level confirms primary adrenocortical insufficiency.

You say that this is your patient's results. What is your patient suffering from?

A short review of hypocortisism can be found on thedoctorslounge here:
:arrow: Click here!

[Giovanni]

Dear Doctor Tamer Fouad,
thank you for immediate answer.

I am an endocrinologist and now I'll give you more informations about the patient.

Male patient (58 yrs) with hypopituitarism (thyroid, adrenal, gonadal and
growth hormone adult deficiency) due probable hypofisitis.

The failures of the thyroid, gonadal and growth hormone were adeguately
corrected without any complications.

Also the secondary adrenal failure was terapeutized with cortisone treatment
(37.5 mg/die), but this last kind of therapy induced the appearance of
several side effects (hypertension, headache, hyperglicaemia, etc.)
suggestive for an excess of corticosteroid therapy.
Then, the cortisone treatment was stopped.

Now, after six months, the patients is off opotherapic adrenal treatment
and, again, he presents very low cortisol levels without any symptoms.

What is the possible explanation about this situation? Is there in your
experience similar data in medical literature?

Thank you in advance.
Giovanni Amato

[Guest]

Low cortisol by itself does not mean a lot. You need to have a stimulation test (cosyntropin test) to know whether the low cortisol levels are of signficance or not.
Those with low cortisol may respond normally to the stimulation test. Then they are normal. However if they do not respond normally to the stimulation test, then they are considered to have SIGNFICANT low cortisol. At that time they should have more tests to find out the reason for the low cortisol. Those reasons may be in the brain (hypothalmus or pituitary) or may be in the adrenal gland itself or may be because people take cortisol pills (e.g. prednisone...)