Endocrine Abstracts

Introduction: Iatrogenic Cushing’s syndrome from potent topical steroid use, resulting in suppression of the hypothalamic-pituitary-adrenal axis is well recognised. However, this may not be well acknowledged in amongst a general medical take. We report a case of Cushing’s syndrome from long term use of skin whitening cream and topical steroids, highlighting the importance of detailed history taking.

Case history: A 49-year-old Nigerian female was admitted on an acute medical take with abdominal pain and osmotic symptoms. She was found to have hyperglycaemia with ketoacidosis which was treated with insulin. The medical team noted her to have persistent hypertension and hypokalaemia requiring treatment. Her presentation prompted further endocrine investigations but she was not referred to an endocrinologist at that stage. She denied using exogenous steroid in any form in the following months of outpatient review. A 0900 h cortisol was 120 nmol/l with two random cortisol of 11 nmol/l. But patient was asymptomatic of adrenal insufficiency. CT scanning of the adrenals performed on the suspicion of Conn’s disease, showed no focal adenoma. Because of the discordance in her clinical features and biochemistry, she was eventually referred to an endocrinologist.

Clinical examination was consistent with Cushing’s syndrome with marked features of facial plethora, central obesity, proximal myopathy and striking purple striae over the chest and abdomen. Her new onset diabetes mellitus and hypertension were associated complications of steroid excess. The clinical picture of Cushing’s syndrome with low early morning cortisol raised the likelihood of exogenous steroid use. Her history was re-visited by endocrinology. Long term topical steroid exposure from skin whitening moisturiser and 0.05% Clobetasol cream was identified and stopped.

Conclusion: This case highlights importance of a focussed history, physical examination, correct interpretation of biochemistry and early referral. A detailed drug history including over the counter medications and skin whitening products containing steroids needs to be elicited.