Exogenous Cushing Syndrome Caused by a “Herbal” Supplement

BACKGROUND/OBJECTIVE: Exogenous Cushing syndrome is usually diagnosed in the setting of known glucocorticoid exposure; however, occult glucocorticoid use is possible. We present 2 cases of patients who developed Cushing syndrome while taking Artri King (AK), an over-the-counter “herbal” supplement for joint pains reported to contain glucocorticoids. CASE REPORT: Patient 1, a 49-year-old woman, reported rapid weight gain, large stretch marks, poor wound healing, and recent diagnoses of type 2 diabetes mellitus and hypertension over a course of 1 year. Her serum am cortisol level was <0.5 μg/dL (reference range, 4.0-22.0 μg/dL) and adrenocorticotropic hormone (ACTH) level was <5 pg/mL (reference range, 5-60 pg/mL). Synthetic glucocorticoid screening revealed a dexamethasone level of 210 ng/dL (reference value < 100 ng/dL) while she was taking AK; 5 days after stopping the supplement, the level was 24 ng/dL (reference value < 20 ng/dL). Patient 2, a 61-year-old woman, presented with weight gain, fatigue, swelling, and recent diagnoses of prediabetes and hypertension over a span of 6 months. Her serum am cortisol level was <1.0 μg/dL (reference range, 8.0-25.0 μg/dL) and ACTH level was <5 pg/mL (reference value < 46 pg/mL). She stopped AK, and 1 month later, her am cortisol level rose to 9.1 μg/dL (reference range, 8.0-25.0 μg/dL) and ACTH level rose to 68 pg/mL (reference value < 46 pg/mL). DISCUSSION: Supplements containing hidden glucocorticoids and causing Cushing syndrome have been reported in rare cases and can pose a diagnostic challenge for providers. CONCLUSION: Exogenous glucocorticoid use because of unregulated herbal supplements should be considered when Cushing syndrome is suspected.