A 44‐year‐old man presented to the emergency department with one month of worsening breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, and pitting oedema to the thighs. Past medical history included hypertension, dyslipidaemia, and tophaceous gout. His regular medications were perindopril, amlodipine, atorvastatin and frusemide. On examination, his blood pressure was 189/99 mmHg and oxygen saturation was 90% on room air. The patient had cushingoid features such as dorsocervical fat pad, livid abdominal striae, and moon facies. His investigations included chest x‐ray showing pulmonary congestion; transthoracic echocardiogram demonstrating diastolic dysfunction, with preserved ejection fraction of 55%; and normal urinary protein, with creatinine ratio and liver screens not suggestive of cirrhosis. Blood tests showed undetectable morning cortisol (< 10 nmol/L; reference interval [RI], 200–650 nmol/L), low adrenocorticotropic hormone (ACTH; < 5 ng/L; RI, 10–50 ng/L) and low urinary free cortisol (13 nmol/d; RI, 10–165– nmol/d). It was suspected the patient had secondary adrenal insufficiency from exogenous glucocorticoid use. However, both the general practitioner and the patient denied any recent glucocorticoid use.
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- 1. Fiad TM, Kirby JM, Cunningham SK, McKenna TJ. The overnight single‐dose metyrapone test is a simple and reliable index of the hypothalamic‐pituitary‐adrenal axis. Clin Endocrinol (Oxf) 1994; 40: 603‐609.
- 2. Melmed S, Polonsky KS, Larsen PR, Kronenberg HM. The adrenal cortex. In: Williams textbook of endocrinology. 12th ed. Philadelphia (PA): Elsevier, 2020; pp. 517‐520.
- 3. Dinsen S, Baslund B, Klose M, et al. Why glucocorticoid withdrawal may sometimes be as dangerous as the treatment itself. Eur J Intern Med 2013; 24: 714‐720.
- 4. Erturk E, Jaffe CA, Barkan AL. Evaluation of the integrity of the hypothalamic‐pituitary‐adrenal axis by insulin hypoglycemia test. J Clin Endocrinol Metab 1998; 83: 2350‐2354.
- 5. Watts NB, Tindall GT. Rapid assessment of corticotropin reserve after pituitary surgery. JAMA 1988; 259: 708.
- 6. Smans LCCJ, Van der Valk ES, Hermus ARMM, Zelissen PMJ. Incidence of adrenal crisis in patients with adrenal insufficiency. Clin Endocrinol 2015; 84: 17‐22.
- 7. Prete A, Bancos I. Glucocorticoid induced adrenal insufficiency. BMJ 2021; 374: n1380.
- 8. Kaur R, Chiu W, Ou ZQ, Dissanayake A. Cushingoid features and adrenal insufficiency from herbal supplement consumption: alerts released from the Therapeutic Goods Administration and Medsafe. Intern Med J 2023; 53: 656‐657.
- 9. Therapeutic Goods Administration. Nhan Sam tuyet Lien Truy Phong Hoan capsules: safety advisory. Canberra: TGA, 2022. https://www.tga.gov.au/news/safety‐alerts/nhan‐sam‐tuyet‐lien‐truy‐phong‐hoan‐capsules (viewed Feb 2023).
- 10. Medsafe. Alert communication: Medsafe is publishing a warning that the product Nhan Sam Tuyet Lien Truy Phong Hoan should not be consumed. Wellington: Medsafe, 2022. https://www.medsafe.govt.nz/safety/Alerts/NhanSamTuyetLienTruyPhongHoan.asp (viewed Feb 2023).
- 11. US Food and Drug Administration. Public notification: Artri Ajo King contains hidden drug ingredient. Silver Spring (MD): FDA, 2022. https://www.fda.gov/drugs/medication‐health‐fraud/public‐notification‐artri‐ajo‐king‐contains‐hidden‐drug‐ingredient (viewed Mar 2023).
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