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功能医学与情绪系列之肾上腺疲劳案例分析(下)


DISCUSSION

TJ presented as a typical adrenal fatigue patient, in that the onset of her fatigue was preceded by long-term stress. TJ also complained of salt craving and constipation and exhibited low-normal blood pressure; these signs and symptoms are associated with low cortisol(Table 1). Laboratory analysis confirmed TJ's clinical picture-very low or undetectable baseline salivary cortisol (Figure 1) on all measurements. DHEA-S was normal and remained normal in all laboratory evaluations, which may be somewhat unusual.The levels of DHEA are generally believed to drop first on account of its significantly candy higher quantitative demands. Figure 3 indicated subclinical hypothyroidism, based on a TSH greater than 2.0. TJ also had an insulin level of 7.0, which may be considered suboptimal.The serum chemistry was normal, ruling out other common findings associated with low cortisol, including sodium what surprising, given TJ's reported salt and potassium imbalance; this result was some craving. Her complete blood count and iron studies results were also within normal limits, ruling out infection, metabolic dysfunction and anemia as potential causes of fatigue.

讨论

TJ是一个典型的肾上腺疲劳的病人,长期积累的压力导致发病。TJ平时食用大量的刺激性食物,还有便秘、低血压等状况,这些体征都与低皮质醇水平紧密相关(表1)。实验数据也证实了TJ的临床表现,极其低甚至测不到基线唾液皮质醇的数值。脱氢表雄酮在实验数据中显示是正常的,在脱氢表雄酮检测中,检测的第一滴对高糖定量要求非常重要。在亚临床甲状腺减退的测试中,促甲状腺激素大于2.0,TJ的胰岛素检测结果是7.0,这也表明了她未达到最佳标准。血生化检测结果正常,可以排除与低皮质醇有关的的其他病症,包括血钠正常是让人吃惊的,因为TJ的报告显示盐钾失衡状态。她的全血计数和铁指标也是在正常范围内的,可以排除由感染、代谢功能障碍和贫血导致的疲劳现象。

1:皮质醇缺乏和过量的症状体征

缺乏

过量

慢性虚弱

嗜糖

体重减轻

向心性肥胖

疲乏

胰岛素抵抗

压力耐受能力下降

虚弱

厌食

两餐间颤抖

便秘和腹泻交替

易怒

嗜盐

高血压

体位性眩晕

容易淤青

肌肉关节疼痛

闭经

色素沉着

阳痿

低血压

油性皮肤

贫血

睡眠障碍


头痛

 

Treatment included botanicals and nutrients designed to improve the stress response, as well as stress-reduction techniques and dietary changes to reduce dysinsulinemia. TJ was also advised to begin a fiber supplement and to completely eliminate from her diet the foods she previously identified as contributing to constipation. While constipation was most likely a function of food sensitivities, bowel flora imbalance secondary to stress may have been a complicating factor. At her ten-month follow-up, TJ was pleased to report on how much her life had improved with ongoing treatment. She also reported a 13-pound weight loss. Figure 2 showed normalization of all salivary cortisol measurements. However, results remained in the low-normal range. TJ also indicated that she required ongoing adrenal support to maintain energy The treatment plan was continued, with further follow-up laboratory testing ordered at six months.

综合植物制剂和营养补充剂的治疗可以提高抗压能力,并通过改善饮食习惯来纠正胰岛素异常。建议TJ开始减少那些造成她便秘的食物,改为食用高纤维食物。便秘这种症状可能是她原来食用了某种食物所引起的肠道菌群失衡所造成的。在十个月后的随访中,TJ很满意这些治疗对她的生活状况所起到的改善作用,她也说自己同时还减了13磅。她的唾液皮质醇检测结果逐渐趋向正常,但稍偏低。TJ坚持积极治疗来提升能量,缓解疲劳。在接下来的六个月中,还会对她进行进一步的检查。

 

Elevated TSH frequently accompanies adrenal hypofunction.In frank adrenal insufficiency with hypothyroidism, treatment of the thyroid alone may result in an adrenal crisis. Thus, evaluation of thyroid function is indicated in the adrenal fatigue patient (as is the evaluation of adrenal function in the hypothyroid patient.) Dysinsulinemia is also seen in adrenal insufficiency's which suggests that dysinsulinemia may also be present in adrenal fatigue.These latter two findings may have been associated with TJ's tendency to gain, rather than lose, weight, which is a more common sign of frank cortisol deficiency.

促甲状腺激素数值随着肾上腺皮质功能减退的状况而有所改变。在伴有甲状腺功能减退的的同时出现肾上腺皮质功能减退,单一的治疗甲状腺疾病就会造成肾上腺危象。因此,甲状腺功能检测可以发现病人是否是肾上腺疲劳。胰岛素异常也常见于肾上腺皮质功能不全的症状,这表明胰岛素异常也可以造成肾上腺疲劳。这两个调查结果都与TJ的报告类似。体重增加是皮质醇缺乏最为常见的症状。

 

There are a number of possible reasons for the difficulty in accepting adrenal fatigue as a valid, measurable condition. First, the multiplicity of potential symptoms (Table 1), can make the diagnosis difficult. Also, objective diagnosis requires multiple measurements to capture perturbations in circadian cortisol. Since blood remains the gold-standard specimen, divided specimen collection is less likely to occur in routine clinical practice. Furthermore, since ranges set for blood cortisol are designed to capture frank deficiency excess states, subclinical deficiency may be missed. Saliva, while long-used in integrative circles, is a relative newcomer among specimen types. Although not frequently tested by conventional doctors, salivary cortisol is easily collected over time, at multiple points, allowing the results of its assay to capture subtle perturbations in circadian cortisol dysregulation. It has been reported that circadian assessments of cortisol using saliva and serum were shown to be correlated. In our experience, salivary cortisol reference ranges that include quintile rankings (a frequent tool used in research to sort data) have more subtle interpretive power. With greater acceptance of salivary cortisol testing, formal recognition of adrenal fatigue as a clinical entity may develop.

有很多因素可以引起肾上腺疲劳。首先,症状具有多样性,这会造成诊断困难。另外,客观的诊断需要多次检测来寻找扰动皮质醇昼夜节律的原因。由于血标本一般作为检测的金标准,在临床实践中,分类取样是不容易实现的。而且,由于血浆皮质醇的测量范围是用来检查数据是否过低,但一般临床症状不明显的数据是不会被发现的。唾液,由于它的复杂性,被当做标本取样相对较晚。尽管一些传统的医生不会用唾液来做检测,但它还是有优点的,唾液容易收集,方便多次检测,可以查出皮质醇昼夜节律是否失调,而且已经有报告显示,用唾液和血清检查都可以对皮质醇进行检测。在我们的试验中,唾液皮质醇参考范围则更为精确。所以,唾液皮质醇检测可以用来检查肾上腺疲劳,在以后的临床试验中也会有潜在的发展。

 

CONCLUSION

Fatigue and stress are common complaints, and they play a role in the majority of primary care visits. Far too often, however, the cause of the fatigue is never found. Perhaps as a result, more than half of all fatigue patients fail to return for follow-up visits, which may contribute to the high incidence of unfavorable outcomes found in this population.

总结

我们经常抱怨疲劳,也有一大部分病人由于疲劳去看门诊,然而,疲劳的原因却没有找到,这是因为大多数的疲劳患者就诊之后,并未对他们继续跟踪随访,这也就造成了疲劳成为常见病,但却找不到原因的这样令人担忧的结果。

 

The cluster of symptoms experienced by TJ is a common finding in any clinical practice. Without recognition of adrenal fatigue as a legitimate clinical complaint, TJ would have been one of the patients for whom no diagnosis was found. Fortunately, her clinician recognized her presentation as chronic stress-induced adrenal fatigue, and she performed the appropriate evaluations. TJ responded very favorably to a treatment program directed at supporting adrenal function and stress reduction; it was safe, straightforward and relatively easy to implement.

TJ作为临床实践的常见案例,如果肾上腺疲劳没有引起临床上的重视,TJ也会和其他人一样,查不出原因,从而不了了之。幸运的是,TJ的临床医生发现了她是由积累的压力所引起的肾上腺疲劳,而且TJ也积极配合检查和治疗。TJ的治疗方案对她的病情起到了缓解的作用,让她释放压力,而且此治疗方案是非常安全的、直接的、有效的。


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