SUN-478 - Hidden Steroids: A Case of Exogenous Cushing'S Syndrome Caused by Unregulated Traditional Chinese Medicine

This is a case of a 40-year-old female presenting with intermittent generalized body weakness and easy fatigue, which she associates with improvement after taking “bone and muscle vitamins,” which she had been taking intermittently for the past 8 years. She reportedly had progressive weight gain, facial puffiness, abdominal obesity, and bipedal edema with no associated chest pain, dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. Initial consultation with a cardiologist led to a work-up and diagnosis of prediabetes, hypertension, and heart failure. She was given angiotensin receptor and beta-adrenergic blockers, and a short course of furosemide. Non-resolution of symptoms prompted consultation.
On presentation, she was noted to have a slightly elevated blood pressure, no tachycardia and tachypnea. She has an elevated BMI of 33.4 kg/m2, with cushingoid features. She presented with bodily changes such as moon facies, thinning of hair on the frontotemporal area, dorsocervical fat pad, and central obesity with prominent purplish abdominal striae that started to appear approximately two years before consultation.
Medicine brown bag review included a packet of Cow’s Head Brand, also known as Tung Shueh pills. Uncertain of the cause of Cushing’s syndrome, a 1-mg overnight dexamethasone suppression test was requested, revealing unsuppressed cortisol levels (2.90 mcg/dL), establishing the presence of cortisol excess. ACTH level testing was not done due to unavailability in our local setting. Referral to the national poison control center recognized this as the 2nd reported case in their records regarding tung shueh pills, which were previously known to contain unmeasured amounts of betamethasone and heavy metals. Blood level testing for lead, cadmium, and arsenic was suggested; however were also unavailable in our setting.
Discontinuation of the presumed exogenous steroid source could potentially resolve the patient’s condition; however, she presented with adrenal insufficiency. Currently, the patient is feeling well and adheres to the prednisone tapering schedule.
This highlights awareness of unregulated use of medicines with hidden contents such as steroids and heavy metals, which may cause significant health risks to our patients.

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