Dexamethasone abuse with fatal CNS complication.

A 24 yrs old unmarried chronic alcoholic male, compounder by occupation was admitted with multiple patchy discolouration of skin and swelling all over the body for 2 months and sudden onset altered sensorium for one day. History of self medication in the form of intravenous injection of dexamethasone for last 11⁄2 years was also present. History of sexual contact was not available. History of fever, headache, vomiting, seizure, loose motions, bleeding, ear discharge, jaundice, hematemesis / malena, tuberculosis or ATT intake and diabetes mellitus were absent. On examination, he was obese, vitals were stable and smell of alcohol was absent. Cervical hump, moon facies and lower abdominal purple striae were present. Cutaneous examination revealed multiple annular lesion with hyperpigmented margin and centre clearing along with ulcerative whitish lesions present in the oral cavity and plaques all over the genital region and cleft suggestive of candidiasis. Lesions were also present in between toes. In CnS examination patient was unconscious, responding to deep painful stimuli, focal neurological deficit and signs of meningeal irritation were absent , bilateral pupils were normal in size and reaction and bilateral plantars were nonelicitable. rest of the examinations were normal. Provisional diagnosis of chronic alcoholism with intravenous dexamethasone abuse with iatrogenic Cushing’s with tinea corporis with oral and genital candidiasis with intertrigo with encephalopathy cause ?infection, stroke, metabolic was kept. Emergency nCCT head showed multiple hypodense lesion in both cerebral hemisphere suggestive of infarct . He was started on intravenous mannitol, dexamethasone, dextrose along with multivitamins. Tablet ecosprin, fluconazole and cetrizine, clotrimazole and candid B ointment and betadine lotion for local application. Investigations revealed hemoglobin-10.7 g/dl, total leucocyte count4800/mm3, differential leukocytes count-polymorph 72% ,lymphocytes25%, eosinophils 3% ,and platelet count 49000 /mm3. Blood urea 51 mg/dl, serum creatinine 1.1 mg/dl, serum sodium 146 mEq/l, serum potassium 4.4 mEq/l, random blood sugar 88 mg/dl, total bilirubin 1.3 mg/dl, aspartate transaminase 258 u/l, alanine transaminase 265 u/l, alkaline phosphatase 70 u/l, total protein 5.1 g/dl (serum albumin 2.0 g/dl). Fundoscopy and chest radiograph were normal. ELISA for HIV 1 & 2 – non-reactive. Blood and urine culture – sterile.