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
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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