Rapid Development of Iatrogenic Cushing Syndrome In A Patient On Ritonavir: The Adverse Metabolic Consequence of Topical Steroid Use

Jeremy D. Purser, MD; Ruba Riachy, MD; Lucas S. Blanton, MD; L. Maria Belalcazar, MD

AACE Clinical Case Reports (Nov 2020)

Rapid Development of Iatrogenic Cushing Syndrome In A Patient On Ritonavir: The Adverse Metabolic Consequence of Topical Steroid Use

Jeremy D. Purser, MD,
Ruba Riachy, MD,
Lucas S. Blanton, MD,
L. Maria Belalcazar, MD

Affiliations

Jeremy D. Purser, MD: Dr. Purser and Dr. Riachy contributed equally to this manuscript.; From the Division of General Internal Medicine, University of Texas Medical Branch, University of Texas Medical Branch, Galveston, Texas
Ruba Riachy, MD: Dr. Purser and Dr. Riachy contributed equally to this manuscript.; the Division of Endocrinology and Metabolism, University of Texas Medical Branch, University of Texas Medical Branch, Galveston, Texas
Lucas S. Blanton, MD: the Division of Infectious Diseases, University of Texas Medical Branch, Galveston, Texas.
L. Maria Belalcazar, MD: Address correspondence to Dr. L. Maria Belalcazar, Associate Professor, Medicine, Division of Endocrinology and Metabolism, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-1060.; the Division of Endocrinology and Metabolism, University of Texas Medical Branch, University of Texas Medical Branch, Galveston, Texas

Journal volume & issue: Vol. 6, no. 6
pp. e346 – e348

Abstract

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ABSTRACT: Objective: Topical steroid use is common, but its association with Cushing syndrome is rare. We report the rapid development of iatrogenic Cushing syndrome in a patient on ritonavir who applied a moderate-potency topical steroid cream, triamcinolone, on his genital mucosa for treatment of phimosis. Methods: Clinical and diagnostic challenges associated with topical steroid use are presented and discussed. Results: A 41-year-old man with human immunodeficiency virus infection on stable antiretroviral therapy that included ritonavir, a cytochrome P450 3A4 inhibitor, presented with new onset diabetes and development of overt cushingoid features over a 4-week period. He reported no known history of steroid use. A midnight salivary cortisol using a quantitative enzyme immunoassay was obtained and reported at >15.0 μg/dL (normal, <0.112 μg/dL). However, free cortisol in a 24-hour urine collection was undetectable by high-performance liquid chromatography and morning plasma cortisol was also unexpectedly low at 1.1 μg/dL (normal, 4.5 to 23.0 μg/dL). Further investigation revealed that the patient had been applying a topical cream with triamcinolone acetonide (0.1%) on the glans penis for treatment of phimosis. The salivary enzyme immunoassay for cortisol appears to have detected the absorbed triamcinolone, a compound known to cross-react with cortisol in this assay. Conclusion: This case raises awareness on the severe metabolic consequence resulting from the seemingly benign use of a topical steroid medication when applied to the genital mucosa in the setting of stable therapy with ritonavir and illustrates the limitations of salivary cortisol enzyme immunoassays for the evaluation of Cushing syndrome in this setting. Abbreviations: ART antiretroviral therapy; CYP3A4 cytochrome P450 3A4; HIV human immunodeficiency virus; LC/TMS liquid chromatography/tandem mass spectrametry

Published in AACE Clinical Case Reports

ISSN: 2376-0605 (Online)
Publisher: Elsevier
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Specialties of internal medicine: Diseases of the endocrine glands. Clinical endocrinology
Website: https://www.journals.elsevier.com/aace-clinical-case-reports

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