MON-359 Primary Adrenal Insufficiency Secondary to Chronic Use of Posoconazole: A Case Report

Abstract

Cortisol attenuates inflammatory responses, contributes with glucose homeostasis, and enhances vascular smooth muscle tone augmenting blood pressure among other functions. The symptoms and signs of adrenal insufficiency (AI) depend upon acuity and degree of loss of the adrenal function, including whether mineralocorticoid production is preserved or not. A 65 years-old male with past medical history of mixed connective tissue disease developed 2 weeks of fever and was diagnosed with hemophagocytic lymphohistiocytosis for which he was placed on HLH-94 protocol (ectoposite and high dose pulse steroids). He was also found to have invasive murcomycosis initially treated with amphotericin and posacolonazole(PSO). Given the culture results, amphotericin was stopped and PSO 500mg daily was continued. The patient had a complicated hospital course and was discharged on 2mg of dexamethasone with a pertinent taper. He developed weakness and failure to thrive. His dexamethasone was increased to 3mg daily by his oncologist, and his PSO and chemotherapy was continued. Due to worsen fatigue and deconditioning the patient was brought to the Emergency Room. Upon arrival he was noticed to have persistent orthostatic hypotension despite intravenous fluids, hyponatremia and hyperkalemia (what is the potassium) suggestive of mineralocorticoid deficiency. Further endocrinology workup revealed plasma renin activity of 16.7ng/ml/hr (0.167-5.380) with a low aldosterone level of 1.6ng/dl (0.0-30). CT abdomen imaging showed intact adrenal glands bilaterally. Patient was diagnosed with PSO induced primary AI, he was placed on fludrocortisone with significant symptoms improvement and normalization of electrolytes and blood pressure. After a thorough literature review we found two case reports of iatrogenic Cushing in patients using Fluticasone and PSO, three cases of steroid induced secondary AI in patients treated with inhaled budesonide and PSO; and two cases of primary adrenal insufficiency in patients using PSO without steroids. PSO effects in the adrenal axis are rare, clinicians should be aware of their potential effects on the hypothalamic-pituitary-adrenal axis and pharmacologic interactions with steroids.