Case Report A case of Cushing Syndrome due to accidental intake of dexamethasone: a call for enforcement of regulatory laws Kofi T, Asamoah1, Josephine Akpalu1,2, Yacoba Atiase1,2 and Ernest Yorke1,2 Ghana Med J 2021; 55(2): 152-155 doi: http://dx.doi.org/10.4314/gmj.v55i2.9 1Department of Medicine & Therapeutics, Korle-Bu Teaching Hospital, Accra, Ghana 2Department of Medicine & Therapeutics, University of Ghana Medical School, Accra, Ghana Corresponding author: Kofi Tekyi Asamoah E-mail: asamoahfiifi@gmail.com Conflict of interest: None declared SUMMARY Cushing syndrome could be a complication of long-term steroid use, resulting in a wide range of clinical presentations. Whereas some patients take medically prescribed doses of conventional medicines, including steroids for various ailments, others inadvertently consume unspecified doses by adulterating traditional medicines with these orthodox medications to increase their therapeutic appeal. Furthermore, some individuals with access to conventional medica- tions may sell them in unlabelled packages as traditional medicines (TMs) to unsuspecting customers. This may lead to undesirable side effects and safety concerns. The case report highlights the problem of poorly regulated access to medications and makes suggestions to protect patrons' health of traditional medicines. Keywords: Traditional medicine, Cushing syndrome, corticosteroids, misuse of orthodox medication, drug regulation enforcement Funding: None declared INTRODUCTION The use of traditional medicines (TMs) is widely consid- It is also expected that the report will engender public ered safe and efficacious by citizens of developing coun- awareness and discussions on the subject, which will tries1-4 largely due to the belief that they are produced en- eventually lead to policy reforms and enforcement to tirely from natural sources.4 Though some studies find combat the menace. that patronage is more among rural folk with poor access to modern healthcare services4, other authors found that CASE REPORT highly educated people with good incomes also patronize The patient gave his consent for the use of his infor- TMs.1,5 Some TMs are, however, adulterated with con- mation and pictures for the publication,. ventional medications to widen their therapeutic cover- age and appeal.3 This may alter their safety profiles, A 42-year-old Ghanaian male trader presented with in- which are already poorly understood1, and increases the creasing fatigue, increased appetite, increased body risk of experiencing side effects.3,5 Unsuspecting patrons, weight, polyuria, nocturia, repeated skin infections and due to their trust in TMs, may purchase conventional muscle weakness, especially climbing stairs and washing drugs being marketed as TMs by individuals with access his hair. These symptoms had lasted for over a year after to them. These may be taken at medically harmful doses, taking purported TMs purchased from a bus terminal. He putting the patron at risk. had also been diagnosed with hypertension a year earlier and was prescribed amlodipine but stopped taking it be- We present a report on a patient who developed Cushing cause his condition did not improve. He preferred taking syndrome, a well-known complication of chronic steroid TMs because it made him feel better. He also felt worse use following his patronage of a drug he thought was a whenever he attempted stopping and consequently TM. This report highlights the need for stricter regula- needed help with normal daily living activities. tions governing conventional drugs and those purported to be TMs to protect the public from potential profound He was asked to do an abdominal computed tomography negative health consequences. (CT) scan following an unspecified complaint at a visit to his primary healthcare facility. 152 www.ghanamedj.org Volume 55 Number 2 June 2021 Copyright © The Author(s). This is an Open Access article under the CC BY license. Case Report The scan showed hepatomegaly, increased peritoneal fat On request, he presented with his TM. These were two and a diaphragmatic hernia containing fat. Following pills: a green one of unknown composition and a white this, he was referred to the Korle Bu Teaching Hospital one with a "DEXA" inscription (Figure 3). The strength for further management. was, however, unknown. Physical examination showed he was obese (BMI of 32kg/m2) with a moon face, a buffalo hump, acneiform eruptions on his face and chest. He also had pseudo-gy- naecomastia, thin arms compared to his trunk, and florid wide, purple striae on his abdomen (Figures 1 and 2). His blood pressure was 143/93mmHg, with a regular pulse of 120 beats per minute. There was evidence of mild proxi- mal muscle weakness. Figure 3 Pictures of traditional medications purchased by the patient from a traditional healer Given his symptoms, signs, low 8 AM serum cortisol level and intake of the DEXA tablet, the following diag- Figure 1 Pictures showing moon face, acneiform erup- noses were made: Exogenous Cushing syndrome and Hy- tions on the chest and striae on the abdomen pertensive heart disease with a reduced ejection fraction He was commenced on carvedilol 12.5mg daily, furo- semide 40mg bd, lisinopril 10mg daily and tapering doses of prednisolone and counselled about the content of his TMs and its possible relationship with his current presentation. A dietician visit was arranged because of his hypertensive heart disease, and an oral glucose toler- ance test (OGTT) was requested due to the discordant FBS and HBA1c results. The OGTT was, however, not done. He reported improved exercise tolerance and an improved sense of general well-being after his third fol- low up visit, but unfortunately, the patient was lost to fol- low up despite efforts to get him to return for a review. Figure 2 Lateral view of the patient's chest and abdomen DISCUSSION showing pseudo-gynaecomastia and striae on the abdo- Cushing syndrome is a rare condition caused by hyper- men cortisolism characterized by phenotypic changes in fat distribution, myopathy, skin and metabolic changes. 6 In Laboratory investigations requested showed a fasting subclinical hypercortisolism, clinical features are absent blood sugar of 5.6mmol/L (normal), glycated haemoglo- or very mild, with biochemical evidence of elevated cor-7,10,11 bin of 6.7% (elevated), and 08:00 hours serum cortisol tisol. was 8umol/L (low). Blood urea, electrolytes and creati- nine were all within normal ranges. An electrocardio- The commonest cause is iatrogenic (exogenous), due to gram showed left ventricular hypertrophy, while an echo- the use of steroids in managing chronic inflammatory, 7,9 cardiogram revealed hypertensive heart disease with a re- neoplastic and autoimmune conditions. duced ejection fraction of 26%. 153 www.ghanamedj.org Volume 55 Number 2 June 2021 Copyright © The Author(s). This is an Open Access article under the CC BY license. Case Report Though oral steroids are the most frequent culprits, all The perception that medical practitioners disapprove of other routes, including inhaled, topical, intramuscular, the use of TMs 2,5,14 affects patients' disclosure of their are implicated in the development of Cushing syn- use of TMs. James et al. found that there was a non-dis- drome.7,12 Diagnosis of exogenous Cushing syndrome is closure rate of up to 83%.4 This is somewhat corrobo- dependent on a good clinical history to identify potential rated by our patient's failure to disclose and present his exogenous sources of glucocorticoids.13 Endogenous drugs until the attending physician expressly asked him. Cushing syndrome, mainly due to tumours of the pitui- It is therefore important for doctors to accept that TMs tary and adrenal glands, is treated surgically. are rife12 and specifically ask about their usage.5,13 The use of TMs is rising exponentially worldwide.2,14 A Policy reforms and enforcement study in Malaysia showed that up to 50% of citizens with The integration of traditional and complementary medi- chronic illnesses patronized TMs5, while Ugandan stud- cines into the medical school curriculum to educate doc- ies report a prevalence of about 60%.1,2 TMs are patron- tors more of TMs and their safe use, backed by scientific ized for various reasons; cultural beliefs of safety and ef- research, is highly recommended.2, 4 This is particularly ficacy despite a dearth of scientifically proven infor- important because identifying the TM and its constitution mation, a recommendation from friends and family, inac- may be all that is required to make a diagnosis, as in this cessibility to or frustration with conventional medical case. Furthermore, concomitant use of TMs and orthodox services, lower cost than orthodox medicine, among oth- medicines could increase the frequency of adverse reac- ers.1,2,4,5 Only a few TMs go through rigorous testing for tions due to potential drug interactions.1 safety, posing a potential risk to patrons.14 Some of these medicines are sold in pouches, with no information on TMs are less likely to be subjected to quality control dosing, composition or expected side effects.15 The pa- measures including post-marketing surveillance, accord- tient presented in this paper intended to purchase TMs ing to James and Ekor.4,14 Adequate surveillance will as- but unwittingly ended up with oral dexamethasone. His sist in detecting wrongful sale of medications under the supplier was in direct contravention of the Public Health guise of others, which could have curtailed this patient's Act of Ghana (Act 851, 2012), which states specifically exposure. Local law enforcement agencies and task that it is an offence to adulterate drugs, incorrectly label forces set up by regulatory authorities therefore need to and misinform about therapeutic value.16 This is espe- hold TM producers and merchants to the same standards cially a problem because our patient may just have been as their counterparts who deal with orthodox medicines, one of many others who have patronized those services. as stated in the national laws. Ghana's Public Health Act (Act 851, 2012) spells out clear standards to be fol- Though unlawful to advertise a product as a cure for lowed16 and contraventions must be punished appropri- chronic ailments and subfertility as stated in the 5th ately. Medical practitioners also need to play an active Schedule of the Public Health Act 851,16 TMs are often role in monitoring and reporting any related unlawful ac- marketed as a panacea for these, including hyperten- tivity to the regulatory authorities. sion.1,5 TMs are widely available in Ghana, with some being sold on public transportation, by the roadside, in Allocation of resources for research into the appropriate pharmacies or even prepared at home. TMs and some or- formulation and dosage of TMs will help ensure that the thodox medications are purchased without prescriptions. best is being offered to the public and give them confi- This gives many people unrestricted access to them, an- dence that these medications, to which they have cultural other regulatory lapse that must be addressed, as these ties, are being acknowledged. This may impact positively orthodox medications can be repurposed in any way on adherence. deemed fit by the buyer. Ching et al. found that adultera- tion of TMs with other chemicals was quite common, Efforts on public education also need to be improved, tar- with steroids as the third commonest contaminant found geting both the producer and consumer. Producers and in proprietary Chinese medicines in a study in Hong merchants need to be aware of the standards to which Kong.3 A similar observation was quoted by Sazlina et they are being held and ways to improve their output al. in a Malaysian report, with other common contami- based on modern Science and Technology, as well as the nants being weight-loss drugs, oral hypoglycaemic consequences of flouting the laid-down rules of practice. agents and non-steroidal anti-inflammatory drugs.5 Tong Consumers must be empowered on these medications, and Rajoo reported on a patient who also developed particularly their spectrum of activity and considerations Cushing syndrome after taking proprietary Chinese med- before purchase, to safeguard their own health. icine known to contain glucocorticoids.13 These all high- light the misuse of orthodox medications by individuals trusted to supply TMs to unsuspecting clients. 154 www.ghanamedj.org Volume 55 Number 2 June 2021 Copyright © The Author(s). This is an Open Access article under the CC BY license. Case Report CONCLUSION 7. Sharma ST, Nieman LK and Feelders RA. Cushing's Individuals with access to medications may repurpose syndrome: epidemiology and developments in dis- them any way they desire, potentially putting health con- ease management. Clin Epidemiol. 2015;7: 281–293 sumers at risk as seen in this case. This calls for vigilance 8. Nieman LK. Adrenal Cortex in Goldman L and by all stakeholders to safeguard the health of the public. Schafer AI (editors). Goldman-Cecil Medicine, 25th edition. 2015. Elsevier, pp. 1514-1521 REFERENCES 9. Yorke E, Atiase Y, Akpalu J and Sarfo-Kantanka O. 1. Nyeko R, Tumwesigye NM and Halage AA. 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