SG15 A topical matter: iatrogenic adrenal crisis following excessive prescription corticosteroid use

Abstract A 39-year-old man with intermediate junctional epidermolysis bullosa (EB) was admitted with a 2-week history of nausea, vomiting, diarrhoea, weakness, loss of appetite and abdominal pain. He described worsening pain within his chronic wounds, which were widespread, crusted and producing extensive green exudate. On admission, he was hypotensive, tachycardic and pyrexial. Investigations showed anaemia (haemoglobin 86 g L−1), hyponatraemia (132 mmol L−1), hypokalaemia (3.3 mmol L−1), raised lactate (3.29 mmol L−1), raised C-reactive protein (263 mg L−1), and leucocytosis (white cell count 22.2 × 109 L−1, neutrophils 10.5 × 109 L−1, and eosinophils 1.88 × 109 L−1). Despite treatment for sepsis secondary to cutaneous infection, inflammatory markers remained high, and the wounds deteriorated, with continuous production of yellow exudate, increasing pain and new blistering. Additionally, medical interventions failed to resolve persistent abdominal symptoms, haemodynamic compromise and pyrexia. On further review, the dermatology team noted that, unbeknownst to them, the patient had been prescribed 100 g of clobetasol propionate monthly by his general practitioner for at least the last year. Adrenal insufficiency was suspected and subsequently confirmed by a 09.00 h cortisol test (79 nmol L−1). The dermatology team initiated a 100-mg intravenous hydrocortisone bolus, followed by a 6-hourly 50-mg regimen, with consequent resolution of hypotension, tachycardia, pyrexia, hyponatraemia and eosinophilia. Targeted antibiotic therapy (tazobactam and vancomycin), 50 : 50 ointment and wound management improved inflammatory signs. The endocrinology team confirmed secondary adrenal insufficiency and provided a steroid emergency kit and advice on sick day rules at point of discharge. Adrenal crisis in secondary adrenal insufficiency is a life-threatening medical emergency requiring immediate intervention. In this case, adrenal insufficiency was caused by repeated exposure to excessive exogenous topical corticosteroids, and acute wound infection precipitated adrenal crisis. Given the nonspecific presentation, adrenal crisis is frequently overlooked in favour of other more common differential diagnoses. However, eosinophilia, hypotension, unresolving pyrexia and ongoing acute systemic inflammatory response symptoms aid accurate diagnosis. This patient’s hypokalaemia was likely secondary to vomiting, highlighting the importance of clinical context, as hyperkalaemia is more commonly noted during adrenal crisis. Most importantly, this case highlights the importance of clinician-led corticosteroid stewardship and the need for a higher index of suspicion for adrenal insufficiency in patients with a history of significant topical corticosteroid use.