Published ahead of print on August 16, 2007, doi:10.1164/rccm.200702-307OC Am. J. Respir. Crit. Care Med., Volume 176, Number 9, November 2007, 913-920 A more recent version of this article appeared on November 1, 2007
Submitted on February 23, 2007 Free and Total Cortisol Levels as Predictors of Severity and Outcome in Community-Acquired PneumoniaMirjam Christ-Crain1*,1 Department of Endocrinology, William Harvey Research Institute, Barts and the London, Queen Mary's School of Medicine, London, United Kingdom, 2 Department of Pneumology, University Hospital, Basel, Switzerland, 3 Department of Internal Medicine, University Hospital, Basel, Switzerland, 4 Department of Endocrinology, University Hospital, Basel, Switzerland, 5 NETRIA, St. Bartholomew's Hospital, London, United Kingdom * To whom correspondence should be addressed. E-mail: christmj{at}bluewin.ch.
Rationale: High cortisol levels are of prognostic value in sepsis. The predictive value of cortisol in pneumonia is unknown. Routinely available assays measure serum total (TC) and not free cortisol (FC). Whether FC concentrations better reflect outcome is uncertain. Objective: To investigate the predictive value of TC and FC in community-acquired pneumonia (CAP). Design: Preplanned subanalysis of a prospective intervention study. Patients: 278 patients presenting to the emergency department with CAP. Measurements: TC, FC, procalcitonin, C-reactive protein and leukocytes, clinical variables and the pneumonia severity index (PSI) were measured. The major outcome measures were PSI and survival. Results: TC and FC, but not C-reactive protein or leukocytes, increased with increasing severity of CAP according to the PSI (P<0.001). TC and FC levels on presentation in patients who died during follow-up were significantly higher as compared to levels in survivors. In a receiver operating characteristic analysis to predict survival, the area under the ROC curve (AUC) was 0.76 (95%CI 0.70-0.81) for TC and 0.69 (0.63-0.74) for FC. This was similar to the AUC of the PSI (0.76 (0.70-0.81), and better as compared to C-reactive protein, procalcitonin or leukocytes. In univariate analysis, only TC, FC and the PSI were predictors of death. In multivariate analysis, the predictive potential of TC equaled the prognostic power of PSI points. Conclusions: Cortisol levels are predictors of severity and outcome in CAP to a similar extent to the PSI, and are better than routinely measured laboratory parameters. In CAP the prognostic accuracy of FC is not superior to TC. Key words: pneumonia, cortisol, prognosis
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