22 year old male with abdominal striae

 A 22 year old male resident  came with complaints of         

                        Distension of abdomen and 

                       facial puffiness since 2years

History of preseant illness:
He was apparently asymptomatic 3.5years back then developed red itchy ring like lesions over the thighs for which he applied clobeta GM for 7months and intermittently he also took raktha shodini syrup (ayurvedic patanjali)400ml. 
      
 Eventually  (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
    
At a review after 1 month for his allergy he was prescribed  itraconazole and ketoconazole during follow  up in December.

In june 2020 he visited our hospital with complaints of abdominal distension, fascial puffiness and purple straie which he noticed initially on the abdomen and slowly progressing to back which were persisting since 8 months.

No history of  chest pain , shortness of breath, palpitations.

No history of pedal edema or frothiness of urine.

Past history: 
No history of similar complaints in the past and 
No history of DM, Hypertension, Tuberculosis, HIV,
Thyroid disorders.

Personal history:
The patient is having a good appetite mixed diet and 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.

Abdominal distension present.

Moon face present

Pink striae noted over anterior abdominal wall.

Thin skin present . 

Buffalo hump present .

Skin examination - Multiple itchy erythematous annular leisons noted over groin and inner thigh region 



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 , Distended

CNS: No abnormality detected


Provisional Diagnosis : 
Iatrogenic Cushing syndrome secondary to exogenous steroid use.
Tinea incognito.

Investigations

CBP - HB - 14.0g/dl 

TLC - 10,700

PLT - 3.69lakhs.

RBS - 94 mg/dl 

CUE - ALBUMIN -trace

SUGARS - NIL .

PUS CELLS - 2-4

RBC - NIL .

LFT - TB -1.03

DB-0.21

ALBUMIN - 3.9


RFT - UREA - 23

SERUM CREATININE  - 1

ELECTROLYTES - Na - 141 meq/L

K- 4 meq/L

CL-98 meq/L

USG ABDOMEN - NORMAL.




Chest X-ray PA view - Full inspiratory, with no malrotation or angulation. The ribs are normal. 
No cardiomegaly and domes of diaphragm clearly seen and well defined.
No mediastinal lymph nodes or enlargement.
Bones are normal. The hear borders right heart border and left heart border appears to be normal.

ECG showing sinus rhythm with normal p wave , QRS complex and T wave morphology.


We took dermatologist opinion for tenia incognito where they advised 

FUSIDIC ACID CREAM.

SALINE COMPRESS OVER LEISONS.

Plan to start anti fungals on next visit once dose of steroids is reduced .

OPTHAL opinion Was taken to look for visual acuity and cataract .

No features of lens opacities noted .

We advised pt to get fasting  8am serum cortisol levels and was planned to start on low dose steroids to avoid adrenal crisis.

Summary 

        Time line with events and serum cortisol trends.

June 8:00 am cortisol levels were 0.05microgram/dl
( normal range - 4.3-22.4 mcg/dl).

In the month of June : ACTH STIMULATION TEST WAS DONE .

BY INJECTING 0.4 ML OF ACTOM PROLONGATUM INJECTION (ACTH) INTRA MUSCULAR  @ 7am 

1 HR LATER FASTING SERUM CORTISOL SAMPLE WAS SENT .

VALUE - 0. 35mcg/dl 

Indicating there was HPA AXIS suppression and pt was started on TAB HIZONE 20mg per day in three divided doses @ 8am ,12 pm and 4 pm.

Pt was asked for follow up.


Treatment : 
Tab Hisone 10 mg -5 mg -5mg
Tab Pan 40 mg OD

8AM CORTISOL LEVELS 31/5/2022 : 10.90 microgram/dl

Discussion : 


1)The most common cause of cushings syndrome is exogenous steroid abuse 
This patient developed cushings due  topical steroids because

  1. Systemic SideEffects of Topical Corticosteroids

Sandipan Dhar, Joly Seth, and Deepak Parikh


Diseased skin has impaired barrier function resulting in enhanced percutaneous absorption and systemic side effects.

The patient despite diagnosed with cushings syndrkme was started on Tab Hisone 20 mg /day in divided doses was to prevent the adrenal insufficiency 
Hisone is an intermediate acting glucocorticoid given in the morning, afternoon and evening and night dose is missed so that time is given for the HPA axis to recover.

3) Why does few people develop ICS( Iatrogenic cushing Syndrome) with TS(Topical steroids)
 
The risk of developing steroid-induced ICS is reported to be associated with the age of the patient, size and localization of lesions, the epithelium integrity, individual metabolic variation, duration of use, powder of drug, duration of therapy, and the sensitivity of steroid receptors [1]. CP binds with high affinity to steroid receptors, with a long half-life making it an effective agent.

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