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a The London
Centre for Paediatric Endocrinology and Metabolism, Cobbold
Laboratories, The Middlesex Hospital, Mortimer Street, London, WIN 8AA,
UK, b Sandwell NHS Trust, Hallam
Road, West Bromich, West Midlands, B71 4HJ, UK
Correspondence to: Professor Brook.
Accepted 3 November
1998
AIM
In suspected
adrenal insufficiency, the ideal test for assessing the
hypothalamo-pituitary-adrenal axis is controversial. Therefore,
three tests were compared in patients presenting with symptoms
suggestive of adrenal insufficiency.
METHODResponses to
the standard short Synacthen test (SSST), the low dose Synacthen test
(LDST), and the 08:00 hour serum cortisol concentration were measured
in 32 patients. A normal response to the synacthen test was defined as
a peak serum cortisol of 
500 nmol/l and/or incremental
concentration of 200 nmol/l. The sensitivity and specificity of
the 08:00 hour serum cortisol concentration compared with other tests
was calculated.
RESULTSThree
patients had neither an adequate peak nor increment after the SSST and
LDST. All had a serum 08:00 hour cortisol concentration of
< 200 nmol/l. Eight patients had abnormal responses by both criteria
to the LDST but had normal responses to the SSST. Three reported
amelioration of their symptoms on hydrocortisone replacement. Twenty
one patients had a normal response to both tests (of these, 14 achieved
adequate peak and increment after both tests and seven did not have an
adequate peak after the LDST but had a normal increment). The lowest
08:00 hour serum cortisol concentration above which patients achieved
normal responses to both the LDST and SSST was 500 nmol/l. At this cut
off value (compared with the LDST), the serum 08:00 hour cortisol
concentration had a sensitivity of 100% but specificity was only 33%.
CONCLUSIONThe LDST
revealed mild degrees of adrenal insufficiency not detected by the
SSST. The value of a single 08:00 hour serum cortisol concentration is limited.
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