Abstract
A 62-year-old Japanese man, a bronze medal winner in the World Championship of table tennis when in his 20s, was diagnosed with secondary adrenocortical insufficiency due to isolated adrenocorticotropic hormone (ACTH) deficiency, and steroid administration was started. About 1 year after the diagnosis, he took part in a table tennis championship which was open to those 40 years or older. He took 10 mg hydrocortisone after breakfast as usual, played 10 matches, each of which took 20–30 min, and won the championship in about 8 h. Since the man could not always win the gruelling competition even when in his 50s, it is suggested that extra steroid hormone is not necessary for patients with adrenocortical insufficiency due to ACTH deficiency in order to successfully engage in sports requiring such intensity and endurance.
BACKGROUND
Adrenal insufficiency is divided into primary (adrenal cortex impairment) and secondary (hypothalamic–pituitary impairment).1,2 Regardless of the cause, glucocorticoid replacement therapy is required for patients, and increasing the dose of glucocorticoids on sick days is common practice. Some practitioners also recommend extra steroid dosing when patients participate in endurance sports,1,3 while others argue that there is no evidence to support this and that an unnecessary dose of glucocorticoids could even result in risk factors for cardiovascular diseases and osteoporosis.2,4
CASE PRESENTATION
A 62-year-old Japanese man was referred to our hospital in August 2007 because of fatigue and anorexia which he had noticed in June 2007. On admission, his height was 165 cm and his weight was 50 kg, which was 15 kg lower than 2 months earlier.
INVESTIGATIONS
Blood examinations showed low concentrations of fasting blood glucose (62 mg/dl) and serum sodium (132 mEq/l). Plasma concentrations of cortisol and adrenocorticotropic hormone (ACTH) were 0.3 μg/dl (normal range 4.0–18.3 μg/dl) and undetectable (normal range 7–56 pg/ml) in basal, respectively, and did not increase at all in response to an intravenous injection of 100 μg corticotrophin releasing hormone. Other pituitary hormones were all within normal ranges. He was thus diagnosed as having secondary adrenocortical insufficiency due to isolated ACTH deficiency.
DIFFERENTIAL DIAGNOSIS
Causes of ACTH deficiency such as pituitary adenoma and lymphocytic hypophysitis were excluded by magnetic resonance imaging study.
TREATMENT
A twice daily regimen of hydrocortisone (20 mg/day) has been maintained.
OUTCOME AND FOLLOW-UP
After steroid administration was started, the symptoms as well as laboratory data (hypoglycaemia and hyponatraemia) improved. While follow-up magnetic resonance imaging studies were not performed, repeated blood examinations after his discharge in September 2007 demonstrated undetectable plasma ACTH concentrations whereas other pituitary hormones were within normal ranges.
A bronze medal winner in the World Championship when in his 20s, in May 2008 the patient took part in a table tennis championship open to those 40 years or older. He took 10 mg hydrocortisone after breakfast as usual, played the 10 matches, each of which took 20–30 min, and won the championship in about 8 h. Although exhausted afterward, he felt no different from 2 years earlier when he had also played 10 matches in one day in the same championship.
DISCUSSION
While it has been believed that isolated ACTH deficiency is rare in old people, a recent study from Japan showed this is not necessarily true.5 The management of corticosteroid deficiency during exercise remains controversial partly because patients with adrenal insufficiency are heterogeneous, and it is difficult to perform statistical analyses between groups using any end point such as endurance and performance. Our patient, a long time top athlete, gave us an opportunity to address this issue. He won the championship in a very competitive sport, something he could not always achieve even in his 50s. This encourages not only patients with the same disease, but also suggests that extra steroid hormone is not necessary for patients with adrenocortical insufficiency due to ACTH deficiency in order to engage successfully in highly competitive sports requiring great skill, intensity and endurance, although further studies would be required to confirm this hypothesis. It is also important to note that the practice cannot be unconditionally recommended to patients with primary adrenal failure, as these patients could potentially become dehydrated during vigorous exercise.
LEARNING POINTS
An extra dose of steroid hormone might not be necessary for patients with adrenocortical insufficiency due to ACTH deficiency in order to engage successfully in sports requiring intensity and endurance.
Footnotes
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication
REFERENCES
- 1.Arlt W, Allolio B. Adrenal insufficiency. Lancet 2003; 361: 1881–93 [DOI] [PubMed] [Google Scholar]
- 2.Crown A, Lightman S. Why is the management of glucocorticoid deficiency still controversial: a review of the literature. Clin Endocrinol 2005; 63: 483–92 [DOI] [PubMed] [Google Scholar]
- 3.Joint LWPES/ESPE CAH Working Group Consensus statement on 21-hydroxylase deficiency from the Lawson Wilkins Pediatric Endocrine Society and the Europe Society for Paediatric Endocrinology. J Clin Endocrinol Metab 2002; 87: 4048–53 [DOI] [PubMed] [Google Scholar]
- 4.Weise M, Drinkard B, Mehlinger S, et al. Stress dose of hydrocortisone is not beneficial in patients with classic congenital adrenal hyperplasia undergoing short-term, high-intensity exercise. J Clin Endocrinol Metab 2004; 89: 3679–84 [DOI] [PubMed] [Google Scholar]
- 5.Yamamoto T, Kamoi K. Prevalence of maturity-onset isolated ACTH deficiency (IAD) in 2005: Japanese cohort studies. Endocr J 2008; 55: 939–41 [DOI] [PubMed] [Google Scholar]
