Unexpected but Not Uncommon - a Case of Adrenal Insufficiency

Abstract Background: Herbal remedies are widely available and whilst portrayed as generally harmless, they may contain a variety of potent medications that can cause unintended potentially serious consequences. This danger is further amplified their use typically inadvertently not divulged to clinicians, such in this case. Clinical Case: A 65-year-old gentleman was referred Endocrinology for assessment adrenal insufficiency (AI) his lethargy. He found have serum cortisol levels 38 nmol/L 68 (150 – 700 nmol/L) on two separate mornings. No identified recent inhaled, topical, intra-articular or oral exogenous steroid therapy noted. had an inadequate response Synacthen stimulation with peak 150 pmol/L at 60-minutes (Adequate Post-Synacthen >430 pmol/L). Baseline plasma ACTH low - 1.1 pmol/L(2.0 10 pmol/L) secondary (pituitary) AI suspected. normal thyroid function prolactin. The patient subsequently admitted taking herbal medication, “Montalin” few months. It obtained over-the-counter Indonesia symptomatic relief “muscle pains”. tablet underwent analysis investigate presence corticosteroid components. An intact Montalin capsule partly dissolved the soluble content diluted analysed via LCMS/MS. Presence dexamethasone/betamethasone confirmed approximate concentration 69.8 constituting 0.548mg 0.81% tablet. At time, betamethasone dexamethasone could be distinguished due stereoisomerism, but since has been dexamethasone. likely suppression hypothalamic-pituitary-adrenal axis from use, causing picture AI. requires ongoing replacement pending recovery endogenous production. Although marketed medication it adulterated corticosteroid. alert issued by Singaporean government details cases adverse effects warns against its use. Conclusion: undisclosed ingredients unknowingly effects. With advances LCMS/MS technology, laboratory either tablets patient’s utilised identify potential exposure.