(CSEMP048) CLINICAL HYPERCORTISOLISM AND PITUITARY ATROPHY FROM ORAL CLOBETASOL RINSE

Abstract:

Background:   Exogenous glucocorticoids are available in many formulations for numerous indications, and is an important consideration when patients present with Cushing syndrome and central adrenal insufficiency.  We describe a case of clobetasol mouthwash-induced hypercortisolism presenting as central adrenal insufficiency.

Case:   A 49-year-old man presented to the Emergency department with hypotension, generalized weakness, 30-lb weight loss and was found to have low morning cortisol at 53 with a low ACTH < 0.3.  His examination, however, revealed classic Cushing syndrome, including wide violaceous striae, round facies, facial plethora, abdominal and dorsocervical adiposity, and proximal myopathy  He was recently diagnosed with hypertensive heart disease, type 2 diabetes, osteoporosis with vertebral fragility fractures and cataracts.  A 250 mcg ACTH stimulation test revealed suboptimal cortisol response with peak cortisol level at 342nmol/L at 60-minutes. He was started on hydrocortisone replacement.  The rest of the pituitary panel revealed central hypogonadism with preservation of his thyroid and growth hormone axes. 

An MRI sella was initially reported as no pituitary abnormalities.  When the patient was eventually seen by Endocrinology as an outpatient, a second opinion was sought - there was evidence of severe pituitary atrophy, along with other signs of longstanding hypercortisolism including cerebral and cerebellar atrophy, retro-orbital adiposity and fatty bone-marrow infiltration.  Abdominal CT-scan showed atrophic adrenal glands and fatty liver infiltration.

The patient had initially denied exogenous steroids, including inhalers and creams. On more careful history taking, he stated he had been using a clobetasol 0.15% oral rinse for recurrent aphthous ulcers four-times a day for 8 years.  We counseled him to stop this rinse.  He lost 12 kg in 6 months, his diabetes improved on metformin alone and his facial plethora, abdominal obesity and proximal myopathy were significantly improved. Hypogonadism reverted to normal range.

Discussion:  Clobetasol is the most potent exogenous steroid and is significantly systematically absorbed even if used locally such as oral mouthwash rinse, This patient was using a concentration that was 3-times greater than in similar cases that have previously been reported and was using it daily for 8 years.  This resulted in clinical hypercortisolism and subsequent central adrenal insufficiency from hypothalamic-pituitary-adrenal axis suppression. Careful history taking and the seeking a second opinion were crucial to obtaining the final diagnosis in this case.