1601006062 SHORT CASE

Hello everyone, I am a final year medical student. Recently I came across an interesting case in my clinical rotations.

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This is a seemingly interesting case of a 22year old male who came with complaints of distension of abdomen and facial puffiness since 8 months. If my memory served me right I could only think of Cushing’s syndrome but I found it cryptic as to what might have been the cause with no known history of oral steroids. So, here goes my pursuit of finding the genesis of the disease.

HISTORY OF PRESENTING ILLNESS:

The patient was asymptomatic 1.5 years back then he developed red itchy ring like lesions over his thighs for which he heedlessly though intermittently applied over the counter clobeta GM for 7 months. He also took an ayurvedic syrup but all his efforts went in vain when he again started to notice a significant increase in his lesions and this time with an unusual increase in his weight from 50 to 70kgs in October 2019. He then went to hospital where he was diagnosed with tinea incognito and was prescribed antifungals.

Xyzal tablets

Ebernet cream

Sebafin cream

At his 1 month review in December he was prescribed itraconazole and ketoconazole.

The patient denied any kind of oral steriod usage which was a key point. He had no history of constipation or loose stools, fever, cough, abdominal pain, no history of hair loss or thining.

No h/o of hypertension, DM, thyroid, coronary artery disease, epilepsy and no h/o of body pains and delayed wound healing and no h/o of pedal edema emotional lability anorexia, easy fatiguability, no h/o of decreased vision , no h/o weakness, no h/o acne.

PERSONAL HISTORY 

The patient is having a good appetite and mixed diet adequate sleep and bladder movements regular and he does not smoke or drink alcohol.

GENERAL EXAMINATION:

The patient is conscious coherent cooperative, has an obese build and moderately nourished.

He has no pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema.

He had a distended abdomen with purple striae

Facial puffiness was present

BP 120/80

Pulse 82bpm and regular

Temp- afebrile

RR- 20/min

 SYSTEMIC EXAMINATION:

CVS: 

S1 S2 heard , no murmurs.

RESPIRATORY SYSTEM:

Bilateral air entry present , normal vesicular breath sounds heard.

PER ABDOMEN:

 soft non tender distenstion of abdomen present.

CNS: no abnormality detected.

The patient was then asked to stop the clobeta GM that he was using.He suffered severe supression of his HPA axis due to the abrupt cessation of his steroid cream causing adrenal insufficiency and had to be started on Hydrocortisone. It was followed by gradual tapering of the dose

INVESTIGATIONS:

Diagnosis: Exogenous topical steroid induced Cushings syndrome with suppressed HPA axis 

Treatment:

Injection ACTH 0.4 ml IM at 7:00 a.m.

Serum cortisol level check at 8 a.m. and serum cortisol turned out to be 0.35 so patient was started on tab.hydrocortisone 5mg 2tablets in the morning 7am 1tablet at 12pm 1tablet at 5pm for 20days followed by gradual tapering off the dose 

Tab.pantop 40mg OD PO

Tab.MVT OD 

Monitor BP pr RR

Inform SOS

Advice at discharge.                                   

Tab.hydrocortisone 5mg for 20days PO(2tabs 7am-1tab 12pm-1tab 5pm)

Tab.MVT PO OD

Tab.pantop 40mg OD PO

Follow up after 20days and dermatologist opinion for tinea incognito

FOLLOW UP: MY patient is presently alright with his busy SCHEDULE

His abdominal striae has been faded along the course of time 

After starting medication his weight reduced around 10 kgs