Endocrine Abstracts

The link between exogenous steroid use and hypothalamo–pituitary–adrenal (HPA) axis suppression is well established. We present an unusual case where the use of an intra-oral steroid paste transiently obscured the diagnosis of Addison’s disease.

A 45-year-old lady presented to hospital with a several week history of weight loss, nausea and vomiting, lethargy and postural dizziness. Physical examination was unremarkable except for hypotension (92/65 mmHg lying, 87/63 standing). Initial blood testing at 10.30 am revealed hyponatraemia and hyperkalaemia (sodium 119 mmol/l, potassium 5.3 mmol/l, cortisol 315 nmol/l, glucose 4.7 mmol/l, adjusted calcium 2.26 mmol/l). Similar results were obtained at midnight (cortisol 319 nmol/l). The pituitary hormone profile was unremarkable except for an elevated ACTH (618 ng/l). A short synacthen test (SST) was performed: basal serum cortisol 301 nmol/l, 30 min 317 nmol/l, 60 min 303 nmol/l).

Further questioning revealed the patient had been prescribed Adcortyl in Orabase paste (triamcinolone acetonide 0.1%) for a mouth ulcer by her practice nurse, which she had taken on three occasions in the 48 h prior to admission. She was discharged on hydrocortisone replacement therapy and the SST was repeated one week later, after discontinuing hydrocortisone: basal serum cortisol 70 nmol/l, 30 min 59 nmol/l, 60 min 57 nmol/l. Anti-adrenal gland antibodies were moderately positive.

The patient’s symptoms were markedly improved on treatment.

Establishing a diagnosis of Addison’s disease in this lady was made difficult because of relatively high random, basal and midnight serum cortisol levels. This is likely to have been due to absorption of the steroid dental paste intra-orally. This is yet another steroid preparation that appears to be systemically absorbed in clinically important amounts. The importance of taking a thorough clinical history in patients with suspected Addison’s disease cannot be overemphasized.