case

Hello everyone I'm a medical intern.This blog is to share my experiences and cases I came across during this period

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This is a case of 22yr old male with Cushings syndrome

Case history:

A 22 year old male resident of devarkonda came with Chief complaints of distension of abdomen and facial puffiness since 8months 

HOPI

He was apparently asymptomatic 1.5years back then developed red itchy ring like lesions over the thighs for which he applied clobeta GM for 7months intermittently he also took raktha shodini syrup (ayurvedic patanjali)400ml

 then (October 2019)his lesions increased and blood was oozing from them and he also noticed that he is gaining weight (from 50kgs to 70kgs)  then the patient went to kamineni LB nagar  in October and he was diagnosed with tinea incognito and he was prescribed antifungals

Xyzal tablets

 Ebermet cream 

Sebafin cream

He had fever after 5 days  which was high grade and associated with chills and rigors for 2 days and joint pains for which he was prescribed  antoxid cefixim for 1 week     

At a review after 1 month for his allergy he was prescribed  itraconazole and ketoconazole during follow  up in December

Patient didn't give any history of oral steroid intake

No history of constipation or loose stools ,fever cough, abdominal pain, no history of hair loss or thinning ,no history of hypertension, diabetes mellitus ,thyroid, coronary artery disease, epilepsy no history of body pains, delayed wound healing no history of pedal edema, emotional lability ,anorexia ,easy fatigability ,no h/o decreased vision, no h/o weakness, no h/o acne

Personal history

The patient is having a good appetite mix diet adequate sleep and bladder movements regular and no addictions

General examination

Pt is conscious coherent cooperative obese and moderately nourished 

No pallor, icterus , cyanosis,clubbing,lymphadenopathy and  pedal edema

Distended abdomen with purple striae present

Facial puffiness present

BP 120/80mm of hg

Pulse 82bpm regular

Temp afebrile 

RR 20 cpm

Systemic examination:

 CVS: s1 S2 heard no murmurs

Respiratory system: bilateral air entry present normal vesicular breath sounds heard

Per abdomen soft nontender distension of abdomen present

CNS no abnormality detected

Investigations

Cortisol after ACTH stimulation

Diagnosis: drug induced (topical steroids) Cushings syndrome with suppressed hpa axis 

Treatment:

Injection ACTH 0.4 ml IM at 7:00 a.m.

Serum cortisol level check at 8 a.m. and serum cortisol turned out to be 0.35 so patient was started on tab.hydrocortisone 5mg 2tablets in the morning 7am 1tablet at 12pm 1tablet at 5pm for 20days followed by gradual tapering off the dose 

Tab.pantop 40mg OD PO

Tab.MVT OD 

Monitor BP pr RR

Inform SOS

Advice at discharge.                                   

Tab.hydrocortisone 5mg for 20days PO(2tabs 7am-1tab 12pm-1tab 5pm)

Tab.MVT PO OD

Tab.pantop 40mg OD PO

Follow up after 20days and dermatologist opinion for tinea incognito

And his serum cortisol on 28th February when he came for a follow up 

Itraconazole increased methylprednisolone concentrations markedly with enhanced suppression of endogenous cortisol secretion, but had no effect on prednisolone pharmacokinetics. The pharmacokinetic interaction between methylprednisolone and itraconazole is probably related to inhibition of hepatic CYP3A4 activity by itraconazole

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2014476/

Reversible adrenal insufficiency occurred in one among eight patients receiving high-dose itraconazole (600 mg day−1) for a mean duration of 5.5 months [39]. In our study, the baseline profile of cortisol during the itraconazole phase was not determined. However, the cortisol concentrations at 08.00 h t0 did not differ during the itraconazole phase compared with drug free values. Thus we postulate that the secretion of cortisol was maintained after 4 days of itraconazole administration. It seems reasonable to consider that suppression of endogenous cortisol is related only to the effect of the corticosteroid.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2014476/