Endocrine Abstracts

History: A 27-year-old woman with a background of HIV presented to the GUM department with sudden onset of weight gain (approximately five stones over 3 months). She had been started on kaletra (Lopinavir with Ritonavir) for her HIV, about 11 months previously, while she was on fluticasone (seretide) for her asthma. Clinically, she had a cushingoid appearance with extensive purplish striae marks over her abdomen and arms. Her Seretide was stopped and changed to ventolin- due to suspicion of exogenous steroid-induced Cushing’s syndrome. 24 h urinary cortisol collection was organised.

She further presented to the endocrine department where urine cortisol levels were reviewed and shown to be undetectable, confirming the suspicion of exogenous steroids. Interestingly, since stopping the serevent (3 weeks previously), she said she had lost approximately half a stone. Her BP was 132/74 mmHg. Clinically there was no evidence of any adrenal insufficiency – which would be expected after a prolonged exposure to exogenous steroids. A short synacthen test has been organised to assess her adrenal sufficiency.

Discussion: Kaletra has Cushing’s syndrome listed as one of its ‘less common’ side effects in the British National Formulary. Ritonavir (a component of kaletra) is also known to interact with inhaled corticosteroids (especially fluticasone), increasing their plasma concentration.

We present a case where there may have been a combination of both the effects i.e. a direct effect of kaletra, along with the effect of the interaction of kaletra with the inhaled steroids. Changing the seretide to ventolin may help to alleviate her iatrogenic Cushing’s syndrome and the loss of weight without developing any clinical features of adrenal insufficiency is encouraging.

As a further learning point, it is also important to keep in mind the effect of prolonged steroid exposure and the possibility of adrenal insufficiency for a period of time.