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CPE-008 · synthetic case ADR-FX-08
Cortisol 3.0 with ACTH 5, after head trauma
A secondary pattern.
Purpose: A secondary pattern.
Inputs the engine received
Cortisol testing
- 8 am total cortisol
- 3 µg/dL
- ACTH
- 5 pg/mL
- DHEA-S low for age and sex
- Yes
Chemistry and vitals
- Age
- 39 years
Symptoms and signs
- Fatigue
- Yes
Exposures, history and context
- Pituitary or hypothalamic disease, head trauma, surgery or radiation
- 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. 3 µg/dL: adrenal insufficiency is very likely (Endocrine Society; consensus statement).
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Assess the other pituitary axes and consider pituitary imaging.
Differentials, pitfalls and contradicting signals
- Exogenous glucocorticoid suppression gives the same pattern; review all steroid routes, opioids and megestrol.
- DHEA-S is age-dependent and supportive only; it is not a screening test.
Evidence and rule trace · 4 rules
AI-04Morning cortisol band
Inputs: 8 am cortisol 3 µg/dL
Adrenal insufficiency very likely (<5 µg/dL).
AI-07Secondary or tertiary pattern
Inputs: cortisol 3 µg/dL · ACTH 5 pg/mL (not raised)
Pattern of secondary or tertiary adrenal insufficiency.
AI-09Hypopituitarism context
Inputs: secondary pattern · pituitary or hypothalamic context
Assess all pituitary axes.
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
More adrenal cases
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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