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Traditional testing of the hypothalamo-pituitary-adrenal axis function has relied essentially upon the insulin tolerance test or the metyrapone challenge: both tests are not only uncomfortable, but carry also real dangers. The standard ACTH stimulation test uses an extremely hyperphysiological amount (250 microg) of ACTH to evaluate a physiologic response, which may result in false normal responses. The proposed low dose (1 microg) ACTH test is more physiological and more sensitive, especially in cases of mild adrenal insufficiency and allows also to assess pituitary-adrenal suppression after long-term treatment with glucocorticoids. According to the rules of evidence-based medicine, the low dose ACTH test should replace the conventional 250 microg test when evaluating for central adrenal insufficiency.

In a 72-year-old Dutchman Brucellae suis spondylodiscitis TXII-LI was diagnosed, complicated by a paraspinal abscess, for which surgical drainage was carried out. The patient failed to recover after the combined antibiotic regimen of doxycycline, rifampicin and trimethoprim-sulfamethoxazole. There was good clinical improvement after a course of doxycycline and streptomycin, however. After a symptom-free period of 9 weeks a relapse occurred. The patient refused treatment and died 6 weeks later at home. The infection had probably been contracted after handling wild boar carcasses from eastern Europe.

A 53-year-old woman with reversible bone marrow insufficiency caused by aminoglutethimide (AGT) treatment of metastatic breast carcinoma is described. The clinical picture included moderate thrombocytopenia and severe granulocytopenia complicated by Gram-positive septicaemia and skin infections, and by oral candidiasis. Withdrawal of AGT and antibiotic therapy resulted in clinical and haematological recovery, but the patient died suddenly, probably from a cardiac cause. Autopsy revealed widespread bone metastases, but no bone marrow infiltration of breast carcinoma. The haematological hazards caused by application of AGT are discussed.