肾上腺疲劳的案例解析

Adrenal Fatigue

In primary care, fatigue is a complaint in more than 20% of all patient contacts, and accounts for more than 18 million physician visits in the United States annually. In unpublished data from the US General Social Survey, at least one fatigue-associated symptom was found in 78% of all women and in 73% of all men. Many cases elude diagnosis, and patients frequently do not pursue follow-up care, although at least half of all cases demonstrate unfavorable outcomes. Adrenal fatigue (stress-induced subclinical adrenal insufficiency) is a well-recognized cause of fatigue in integrative medicine, but its diagnostic validity is challenged by the conventional medical community, who consider frank adrenal insufficiency (the most common cause being exogenous steroid withdrawals) to be the recognized clinical entity. Research, however, supports the occurrence of chronic stress-induced hypocortisolemic states. Furthermore, a remarkable 75% to 90% of all primary care visits are reported to be related to stress. Taken together, these facts suggest that adrenal fatigue may be a common cause of idiopathic fatigue.

肾上腺疲劳

在美国普通门诊的访问量每年超过1800万，其中超过百分之二十的人群有疲劳主诉。未公开的美国综合社会调查数据表明，至少有78%的女性和73%的男性有疲劳的症状。在大多数情况下，许多病例没有明确诊断，患者通常不追求后续治疗，但所有病例中至少有一半表现出不良后果。肾上腺疲劳（压力介导的亚临床型肾上腺功能不全）在整体医学中被认为是疲劳的主要原因，但是其诊断的有效性却未被传统医学界所认可，而传统医学界认为肾上腺功能不全（其最常见的原因是外源性类固醇缺乏）是一种临床阶段，但也有研究支持是慢性应激诱导低皮质醇状态的发生。此外，在所有普通门诊中多达75-90%的病人症状都与疲劳有关。综合以上，这些数据表明了肾上腺疲劳可能就是原发性疲劳最常见的原因。

CASE HISTORY

TJ was 29 years old when she presented with longstanding fatigue. She stated that the fatigue she had felt throughout college had recently worsened. The increased fatigue correlated with the completion of graduate school, which was followed by a move to a new city and the start of a new job. She described her fatigue as being worse in the evening, rating her energy level at 3 out of 10 (0 as lowest energy possible, 10 as highest energy possible). She tended to avoid late night parties, and rested most weekends. She slept well and awoke rested. TJ felt her best in the morning and used this time to maintain a regular exercise schedule of aerobic and anaerobic activities. She use some caffeine as a stimulant but tried to avoid excessive intake. She gained weight easily in her thighs, buttocks, and abdomen. Although she tended to gain it when she was feeling very stressed, she was not a binge eater. She craved salt. She occasionally had severe constipation. In spite of the fact that an elimination diet undertaken while in college revealed dairy, eggs, and soy as constipation triggers, she continued to consume forms of dairy. Her menstrual cycle was regular, with minimal PMS. She denied having had fever or myalgia. Her physical exam was unremarkable, with no fever or lymphadenopathy. Her blood pressure was low normal at 100/60 LAS.

病史

TJ ，女性，29岁，有长期疲劳症状。她说，在大学期间发现自己有疲劳症状，而且最近越来越严重，这些是和到了一座新城市，找了一份新工作以及接踵而来非常复杂的研究生院工作有关。疲劳程度在晚上尤为严重。能量水平评价仅有3 （0代表最低能量水平，10代表最高能量水平）。她尽量避免参加各种晚会，并在周末多休息，睡眠质量还算不错。她觉得自己最好的精神状态是在早晨，并充分利用这段时间有规律地做有氧和无氧运动。偶尔饮用一些咖啡，但尽量避免过多的摄入。由于她的大腿、臀部和腹部容易发胖，所以在她觉得非常疲惫而且想吃东西时，也尽量控制饮食。她喜欢偏咸的食物，经常出现便秘。她在大学期间采取了排除饮食（不含过敏性食物），避免食用乳制品、蛋类、豆制品以及容易引起便秘的食物，但坚持喝牛奶。月经周期正常，轻度经前症候群，无发热或者肌痛。身体检查未见明显异常，无发热或淋巴结肿大。血压正常（100/60mmHg）。

Laboratory tests ordered and rationale:

1.Four point-measurement of salivary cortisol: Evaluate etiology of stress-induced fatigue

2.Thyroid panel: Rule out hypothyroidism, a common cause of fatigue

3.Fasting insulin and blood sugar: Rule out dysinsulinemia, a common imbalance with fatigue and weight gain

4.Iron panel: Rule out iron deficiency, a common cause of fatigue

5.Blood chemistries: Rule out general metabolic dysfunctions, infection, macro-or microcytic anemia. All may be a cause of or associated with fatigue

实验室检查

1.四点法测量唾液皮质醇：评估应激性疲劳的病因。

2.甲状腺评估：排除甲状腺功能减退（疲劳症状的常见病因）。

3.空腹胰岛素和血糖监测：排除胰岛素异常（可引起疲劳和体重增加）。

4.铁测量：排除缺铁情况，缺铁可引起疲劳。

5.血生化：排除一般代谢功能障碍、感染、大小红细胞性贫血（都是与疲劳有关的原因）。

肾上腺疲劳的案例解析

        图1：唾液皮质醇检测结果

Initial Plan

Adrenal glandular formula (with B vitamins)

Adrenal botanical formula (Cordyceps mycelium, Panax ginseng, and Rhodiola rosea)

Vitamin C,1-3 grams/day

Multivitamin mineral formula

Re-evaluate adrenal and thyroid function in four months

Stress-reduction techniques discussed

Recommend continued exercise to tolerance

Recommend complete dairy elimination with reduction in simple carbohydrates including grains, starchy vegetables, and high-sugar fruits

Recommend minimize or discontinue coffee

Recommend fiber formula with added prune extract

初步计划：

肾上腺支持配方（添加B族维生素）

肾上腺植物性配方（冬虫夏草、人参、红景天）

维生素C 1~3g/天

多种维生素矿物质配方

四个月后重新评估肾上腺和甲状腺功能

讨论如何减压

继续运动耐受练习

避免食用奶制品并减少食用碳水化合物，包括谷物、含淀粉类蔬菜和高糖水果

减少或避免饮用咖啡

建议搭配大枣萃取液和粗纤维食物一起服用

Treatment plan rationale:

Nutrient and botanical preparations associated with adrenal function were initiated. Adrenal gland extract void of active hormone has a long been used as a supportive intervention for hypoadrenalism. Cordyceps mycelium, Panax ginseng, and Rhodiola rosea have demonstrated favorable modulation of adrenal function, stress and fatigue. Vitamins C and B complex have also been shown to be helpful in normalizing adrenal function. Stress reduction techniques were taught and exercise was encouraged. It was recommended that the coffee be discontinued, because of its well-recognized potentiation of the stress response. A low glycemic, low simple carbohydrate diet was started to assist in improving insulin sensitivity. For constipation, fiber with prune extract was started and complete dietary elimination of dairy products was suggested.

治疗计划理由：

与肾上腺皮质功能相关的营养素和植物性制剂在初始应用。无激素活性的肾上腺萃取物长期以来被用于肾上腺功能减退的支持性干预。冬虫夏草、人参、红景天等都具有调整肾上腺功能作用，并可以缓解压力和疲劳。维生素C和维生素B族对改善和调整肾上腺功能具有辅助功效。应教会病人如何减压，鼓励他们多做运动。建议不要饮用咖啡，因为咖啡被认为有潜在的应激反应，不利于压力的释放。另外，低血糖、低碳水化合物的食物对提高胰岛素敏感性可起到促进作用。对于便秘人群，建议应多服用含有大枣萃取液的粗纤维食物，避免食用乳制品。

Four-Month Follow-up

TJ reported that the supplements improved her energy and constipation was much better when she eliminated dairy altogether and used the fiber. She also noticed her clothes fit better. She was pleased with her progress. She noticed that one day, after having two cups of coffee, she became very tired. TJ therefore decided to eliminate coffee and switch to green tea, which did not have the same effect on her.Four-Month Follow-up

TJ reported that the supplements improved her energy and constipation was much better when she eliminated dairy altogether and used the fiber. She also noticed her clothes fit better. She was pleased with her progress. She noticed that one day, after having two cups of coffee, she became very tired. TJ therefore decided to eliminate coffee and switch to green tea, which did not have the same effect on her.

四个月后随访

从TJ的反馈来看，自从她不再食用乳制品，而是改为食用大量粗纤维食物之后，她觉得自己每天都能量倍增，便秘情况也有所改善，同时身材也变得苗条了，这些改变都令她非常高兴。此外，一次在她喝了两杯咖啡之后，竟然觉得更加疲惫了，所以TJ决定要远离咖啡，改喝茶，茶不会让她感到疲劳。

Four-Month Follow-up Plan

Reduce adrenal formulas

Continue other nutrients and lifestyle suggestions as directed

Re-evaluate adrenal function in six months

四个月后跟进计划

肾上腺支持配方减量

继续使用其他营养素，选择健康的生活方式

六个月后复查肾上腺功能

Ten-Month Follow-up

TJ was happy to report that she could finally be adventurous in her life, that she had

sough energy to step out and explore her new city and meet new people. Her endurance and coping ability improved. Her stress response improved. She lost 13 pounds, requiring her to buy a smaller pant size. Her GI function was good as long as she avoided her trigger foods, particularly dairy. TJ was very pleased with her progress, but noted that her fatigue would return if she didn't supplement regularly with the adrenal support products.

十个月后随访

TJ非常兴奋的说她的生活终于展开了新的一面，因为有足够的能量支持她去探索新的城市，结识新的朋友。同时，她的耐力和应对能力也有所提高，释放压力的水平也得到了相应改善。体重减轻了13磅，以后可以穿小号的裤子了。只要不吃诱发性食物尤其是乳制品，她的肠胃还是相当不错的。TJ对这些改变非常满意。但是，如果她不按时服用那些有助肾上腺功能改善的补充剂，还是会感到疲惫不堪。

肾上腺疲劳的案例解析

    图2：十个月后唾液皮质醇检测结果

Ten-Month Follow-up Plan

Continue plan

Re-evaluate thyroid and adrenal function, fasting blood sugar, and insulin in six months

十个月后跟进计划

继续按原定计划执行

六个月后复查甲状腺功能、肾上腺皮质功能、空腹血糖和胰岛素指数

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。

肾上腺疲劳的案例解析

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。