MON-491 - Blessing in A Bottle

Introduction:

Over-the-counter joint pain supplements are widely used and often perceived as safe. Undisclosed steroid content in some products may lead to cushingoid features and abnormal cortisol testing, creating diagnostic challenges and potential misdiagnosis as adrenal insufficiency.

Clinical

Case:

A 62-year-old female with systemic lupus erythematosus managed with hydroxychloroquine and methotrexate was referred to endocrine for suspicion of hypercortisolism. She had cushingoid features (puffy face, skin fragility, fatigue, elevated eye and blood pressure) and a confounding lab of suppressed cortisol < 0.4 ug/dl drawn at noon. Endocrinology diagnosed her with adrenal insufficiency due to labs showing suppressed cortisol at 8 am (1.9 ug/dl) along with a failed ACTH stimulation test. She was started on hydrocortisone replacement which did not change her fatigue. She was referred to us for a second opinion. At her appointment, she denied use of any prescription steroid but had been taking a supplement “Blessing in a Bottle” for more than 10 years purchased off the internet. Her appearance and recent lab evaluation was suspicious for exogenous steroid supplementation which was confirmed with serum Synthetic Glucocorticoid Screen that showed Dexamethasone: 1.0 mcg/dL (Reference Value: Cutoff: 0.10). She agreed to stop her arthralgia supplement and was started on treatment with hydrocortisone for adrenal insufficiency with a planned slow taper while waiting for her hypothalamic-pituitary-adrenal axis to be restored.

Discussion:

There have been many studies done in different parts of the world that have shown supplements to contain glucocorticoids. Many clinicians fail to realize supplements as a source of external glucocorticoid and may erroneously treat patients for adrenal insufficiency in view of native cortisol being suppressed, leading to further hypercortisolism and unwanted consequences.

Conclusion:

Our case helps spread awareness of over-the-counter or online supplements as a possible source of exogenous glucocorticoids and to broaden the differential, especially if biochemical evidence is contrary to the clinical picture

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