SUN-446 - A Case of Exogenous Cushing Syndrome and Secondary Adrenal Insufficiency from Traditional Chinese Medicine

Introduction:
Exogenous glucocorticoids can suppress the hypothalamic-pituitary-adrenal (HPA) axis and cause adrenal insufficiency. Our patient presents with Cushingoid features and is found to have adrenal insufficiency secondary to traditional Chinese medicine (TCM) herbs.
Clinical

Case:
A 21-year-old woman with hypothyroidism presented to the emergency room with two weeks of progressive lower extremity weakness. She endorsed a “puffy” face for the past 3 months and reported menstrual irregularity. Physical examination revealed moon facies, purple striae on her thighs bilaterally, diffuse ecchymosis all over her body, and proximal muscle weakness. Further testing paradoxically revealed a low morning serum cortisol level of 2.4 nmol/L (4.0 - 22.0 nmol/L) and a low adrenocorticotropic hormone (ACTH) level of below 1.5 pg/mL (7.2 - 63.3 pg/mL). Gonadotropins and DHEA were suppressed. Other pituitary hormones were normal. A cosyntropin stimulation test revealed a peak cortisol of 14.1 µg/dL (>18 µg/dL). Pituitary MRI was normal. Patient denied use of any steroid medication. Initially patient denied any supplement use. However, she later endorsed the usage of a Chinese herbal medication used for the regulation of menses. The contents of this herbal supplement included but were not limited to: deer antler glue, deer antler frost, licorice root, Angelica root, yam, ginseng, Chuanxiong, Rehmannia root, Cyperus rotundus, and silkworm cocoon. Exogenous Cushing syndrome with secondary adrenal insufficiency due to herbal supplementation was diagnosed. The patient was discharged home with physiologic hydrocortisone replacement with outpatient reassessment of HPA axis.

Discussion:
Secondary AI from prescribed corticosteroids administered via intranasal, intraarticular, inhaled, and topical routes is a well-established adverse effect. Recently, cases of secondary AI resulting from adulteration of over-the-counter analgesic and anti-inflammatory products have been reported. This case adds to the limited literature describing secondary AI due to TCM, and highlights the importance of thorough supplementation history. Both undisclosed adulteration of supplements as well as intrinsic steroid-like activity of herbs may contribute to HPA axis suppression. Increased recognition of TCM and other alternative medicine is important when evaluating patients with AI, particularly in diverse patient populations. As the field of endocrine disruptor research continues to expand, similar investigative frameworks may facilitate identification of herbal and supplement products with steroid properties.

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