PSAT046 Herbal Supplement Causing Cushing's Syndrome in a Patient With Severe Tophaecous Gout

Previous reports describe self-prescribed prolonged use of steroids resulting in Cushing Syndrome to treat tophaceous gout1,2. We present a case of Chinese herbal supplements used for severe tophaceous gout causing Cushing's syndrome. The patient is a 29-year-old male with prior history of severe tophaceous gout since age 18y, who presented to the hospital for fatigue and episodes of lightheadedness associated with shortness of breath and melena over the past four months. On physical examination, he had moon facies, central obesity, purple striae in the abdominal wall and axillary region, and large, deforming tophi in bilateral elbows and toes. He reported using a Chinese herbal supplement of unknown contents for the past year to maintain his gout attacks under minimal control. Admission hemoglobin was 4.2 mg/dL with severe iron deficiency. Due to suspected gastrointestinal bleed, he underwent work-up with EGD and colonoscopy, which did not reveal a bleeding source. His hemoglobin stabilized after four red blood cell transfusions with plans to do a video capsule outpatient. His celiac disease work-up was negative. Due to persistent fever and tachycardia, infection was ruled out with negative COVID PCR, viral panel, and QuantiFERON test. Work-up for suspected Cushing's syndrome showed ACTH level < 3 pg/mL (7-84 pg/mL), morning cortisol 10 mg/dL (5-20 mg/dL), and DHEA sulfate 21.6mg/dL (160-449 mg/dL). Subsequent 24-hour urine collection showed elevated free cortisol at 127 µg/24hr (£60 µg/24hr) with ratio 101 µg/g Cr (< 32 µg/g Cr). It was suspected that the Chinese herbal supplement had high contents of synthetic steroids as previously reported in literature(2) with resultant development of exogenous Cushing syndrome. He reported not taking his herbal supplement for a couple of days before admission; therefore, he was treated with high-dose steroids for suspected acute gout flare with resolution of his tachycardia and fever after completing testing for Cushing Syndrome. No further episodes of melena were reported, and his hemoglobin remained stable. He was discharged with steroid taper over eight weeks and planned a Cortrosyn test when the steroid dose is 5 mg before discontinuing treatment. Chinese herbal supplements can contain synthetic steroids, and unsupervised use can lead to adverse effects like Cushing's syndrome, as reported in our patient. 1. Lo TEN, Racaza GZ, Penserga EG. "Golden Kernels within the skin": disseminated cutaneous gout. Case Reports 2013; 2013. 2. Edwards CJ, Lian TY, Chng HH. Cushing's syndrome caused by treatment of gout with traditional Chinese medicine. QJM 2002; 95: 705–705. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.