Cushing's syndrome with low levels of serum cortisol: the role of inhaled steroids.

摘要

With the introduction of new drugs and new devices believed to have less potential for systemic effects, the propensity for potent inhaled glucocortlcoids to cause potent hypothalamic-pitultary-adrenal axis suppression is still under recognised. Lesson In January 2010, a 22-year-old man presented to Barts and the London School of Medicine for investigation of apparent adrenal insufficiency but with a cushingoid habitus. Around one year earlier, he had complained to his GP of central weight gain and the appearance of purple striae on his upper body; the GP found, to his surprise, that the patient's random serum cortisol was <50 nmol/l on three occasions (normal range 200-600 nmol/1); on a short synacthen test (adrenocorticotropic hormone (ACTH) (1-24) 0.25 mg, intravenous (iv)) the basal cortisol of 28 nmol/l and only rose to 133 nmol/l 30 minutes after stimulation (normal, >550 nmol/l). His 0900 plasma ACTH was 22 ng/l (normal, 10-60 ng/1). Other markers of pituitary function were normal. A pituitary magnetic resonance image was reported as normal. In view of these results, interpreted as adrenal insufficiency, the patient was initiated on hydrocorti-sone replacement treatment 30 mg daily in divided doses. Over the following 11 months he continued to gain weight centrally and noticed the further development of his striae, and thus sought medical assistance.