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 <mu>g/dL (reference range, 4.0-22.0 mu g/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 mu g/dL (reference range, 8.0-25.0 mu g/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 mu g/dL (reference range, 8.0-25.0 mu g/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. (c) 2022 AACE. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).