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CPE-008 · synthetic case ADR-FX-07
Stimulated peak cortisol of 11 µg/dL
Insufficient response.
Purpose: Insufficient response.
Inputs the engine received
Cortisol testing
- 8 am total cortisol
- 8 µg/dL
- ACTH
- 12 pg/mL
- Peak cortisol after 250 µg cosyntropin
- 11 µg/dL
Chemistry and vitals
- Age
- 55 years
Symptoms and signs
- Fatigue
- Yes
What the engine reports
Detected clinical pattern
Pattern of Secondary or Tertiary Adrenal Insufficiency
Low cortisol with ACTH not raised. Pituitary disease and exogenous glucocorticoid suppression are the leading considerations.
- Axis: Secondary / tertiary pattern (ACTH not raised)
Why this pattern was identified
- Morning cortisol. 8 µg/dL: indeterminate, an ACTH-stimulation test is needed (Endocrine Society; consensus statement).
- ACTH-stimulation test. Peak 11 µg/dL is below 18: insufficient adrenal response.
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Perform an ACTH-stimulation test (250 µg cosyntropin) to settle an indeterminate morning cortisol.
Differentials, pitfalls and contradicting signals
- Exogenous glucocorticoid suppression gives the same pattern; review all steroid routes, opioids and megestrol.
Evidence and rule trace · 3 rules
AI-04Morning cortisol band
Inputs: 8 am cortisol 8 µg/dL
Indeterminate (5 to <15 µg/dL): an ACTH-stimulation test is needed.
AI-05ACTH-stimulation result
Inputs: stimulated peak cortisol 11 µg/dL
Insufficient adrenal response (<18 µg/dL).
AI-07Secondary or tertiary pattern
Inputs: cortisol 8 µg/dL · ACTH 12 pg/mL (not raised)
Pattern of secondary or tertiary adrenal insufficiency.
Evidence
- EV-ES-PAI-2016 · Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.
- EV-HUSEBYE-2014 · Husebye ES, Allolio B, Arlt W, et al. Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. J Intern Med. 2014;275(2):104-115.
- EV-ES-HYPOPIT-2016 · Fleseriu M, Hashim IA, Karavitaki N, et al. Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(11):3888-3921.
Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and safety situations. It does not diagnose adrenal insufficiency, name a glucocorticoid dose, or replace emergency treatment. Physician adjudication is required.
Change the values
The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.
Morning cortisol bands
Cortisol testing
- <5 very likely
- 5–14.9 indeterminate
- ≥15 unlikely
46 pg/mL is assumed when empty.
Chemistry and vitals
Symptoms and signs
Exposures, history and context
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ADR-FX-01
Low sodium, high potassium, weight loss and nausea
A 44-year-old with hyperpigmented scars.
ADR-FX-02
Hyperpigmentation and fatigue
No labs yet.
ADR-FX-03
Salt craving and dizziness on standing
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ADR-FX-04
Cortisol 2.1 with ACTH 180
Low cortisol and high ACTH: a primary pattern.
ADR-FX-05
Morning cortisol 9 µg/dL
Indeterminate.
ADR-FX-06
Morning cortisol 17 µg/dL
Unlikely.
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