Endocrine Abstracts (2012) 29 P107

Tertiary adrenal insufficiency: case report

R. Baloescu1, M. Carsote2, D. Hortopan1, A. Gruia3, R. Miron4, C. Ene1 & C. Poiana1,2

1I.Parhon, Bucharest, Romania; 2UMPh Davila, Bucharest, Romania; 3Medlife, Bucharest, Romania; 4Constanta Hospital, Constanta, Romania.

Introduction: Exogenous Cushing’s syndrome is a challenging diagnosis in non-compliant patients or in cases with difficult anamnesis, while the access to self medication is relatively open.

Aim: We present a young female case presenting with tertiary adrenal insufficiency.

Case report: S.C., 40 years old has progressively weight gain of 30 kilos since the last year. The Body Mass Index is 40 kg/m2, with androgen redistribution. The personal and familial medical history is negative. She accuses asthenia, diffuse muscle pain. She presents facial plethora, diffuse hyperemia over the body, multiple red stria at the level of the arm, abdomen, breasts, legs. The menses stopped for several months. She associates high arterial blood pressure, retinal hypertensive angiopathy, dyslipidemia, hyperuricemia, and high levels of the hepatic enzymes. The serum potassium is 3.9 mmol/l. The plasma cortisol is low: 0.11 μg/dl (normal 11–22). The 24 h free cortisol is 5.04 μg/24 h (normal 30–330). The plasma ACTH is 1 pg/ml (normal 6–65). The computed tomography shows a pituitary microadenoma of 5 by 4.7 mm, that we consider an incidentaloma, and normal adrenals. Central DXA reveales normal bone mineral density for patient’s age. An exogenous Cushing’s syndrome was suspected, and the anamnesis was resumed. The patient denied any ingestion of some medication, but she did affirm that she was using topic glucocorticoid (Dermovate) for all over her skin for more than a year, recommended at some point by her dermatologist for “dry skin”. She no longer used the unguent. Clinical symptoms of adrenal insufficiency were seen. We recommended prednisone 2.5 mg/day for 2 months, then only in case of hypotension or infections, fever. The clinical phenotype persisted for several months with a mild improvement.

Conclusions: In some cases of Cushing’s syndrome, the anamnesis is the main clue of diagnosis. The chronic topic use of glucocorticoids is also important in inducing the Cushing’s phenotype and the stop of their use might induce tertiary adrenal insufficiency.

Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

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