Journal Article

MON-536 Exogenous Cushing Syndrome Resulting from Undisclosed Dexamethasone in an Over-the-Counter Arthritis Supplement

Abraham, Devaprabu, Wagle, Sneha

2024

Overview

S. Wagle: None. D. Abraham: None. Introduction: Exogenous Cushing syndrome is prevalent due to prolonged exposure to glucocorticoid-containing medications, often found in over-the-counter (OTC) products imported from overseas. We report a patient who developed Cushing’s Syndrome after self-medicating with an agent from Mexico called Artri King. Case Description: A 39-year-old female with a history of non-alcoholic fatty liver disease and arthralgia presented to the emergency department with epigastric pain, melena, 60 lbs weight gain, and bilateral lower leg swelling for 4 months. Her medications included Artri King for arthralgia (2 tablets twice daily for the last four months) and Spironolactone, for leg swelling. Vital signs revealed an elevated blood pressure of 141/108 mmHg and a BMI of 31.28 kg/m². Clinical examination revealed purplish wide striae, bruising, proximal muscle weakness, and peripheral edema. Laboratory testing showed a white blood cell count of 26.73 k/μL, a blood glucose level of 132 mg/dL, HgbA1C 5.9%, a cortisol level of 0.3 µg/dL, and an ACTH level of < 1.5 pg/mL. Her TSH was 3.07 mU/L with a free T4 of 0.6 ng/dL. Imaging studies, including computed tomography and magnetic resonance imaging, revealed a normal adrenal gland. Gastroscopy was unremarkable. An exogenous source for corticosteroids was suspected with suppressed ACTH levels and normal adrenal glands on imaging. Therefore, mass spec testing for corticosteroids was performed. Her serum dexamethasone level of 1076 ng/dL confirmed the diagnosis. Upon inquiry, the patient recalled that her symptoms began after starting the Artri King supplement. Discontinuation of Arti King for two days resulted in a cortisol level of 6.8 µg/dL suggesting rapid recovery of adrenal function. Discussion: Artri King, an OTC supplement marketed for joint pain in Mexico, recommends a dosage of two tablets three times daily. On April 20, 2022, the FDA issued public warnings against its use, as laboratory testing detected undisclosed amounts of dexamethasone and diclofenac, which were not listed on the product label. The presence of surreptitious steroids in supplements should be suspected in patients presenting with exogenous Cushing syndrome. Physicians should review self-administered supplements closely and counsel patients on the risks. Monday, June 3, 2024