Relative adrenal insufficiency post-discontinuation of topical steroids in a patient with acute lymphoblastic leukemia

Abstract

Abstract Accelerated cortisol production is observed in patients with severe infections, trauma, burns, illness, and surgery. The cortisol levels observed in relative adrenal insufficiency are insufficient for controlling the inflammatory response. Sudden discontinuation of glucocorticoid therapy is one of the causes of relative adrenal insufficiency. A 63-year-old-man who had undergone cord blood transplantation for T-cell acute lymphoblastic leukemia (T-ALL) and had shown complete remission for 2 years was admitted to our hospital because of high fever, general fatigue, lowering blood pressure, and tachycardia. Physical, laboratory, and imaging examinations revealed T-ALL relapse and pneumonia. Although administration of antibacterial drugs and vasopressors relieved his symptoms and temporarily resolved his fever, he showed prolonged fatigue and mild fever; thus, we could not stop administering vasopressors. He had been using the following three types of topical steroids for chronic eczema for several years: betamethasone butyrate propionate, prednisolone valerate acetate, and hydrocortisone acetate. Thereafter, he had himself discontinued topical steroids because of general fatigue. We suspected his symptoms were caused by relative adrenal insufficiency due to sudden discontinuation of topical steroids; thus, we administered 100 mg of hydrocortisone intravenously. His fever resolved remarkably, and he resumed application of topical steroids and started oral steroid supplementation. His temperature was maintained in the normal range. He successfully achieved complete remission with salvage chemotherapy followed by a second transplantation; with the use of low-dose oral steroids, he did not develop relative adrenal insufficiency. Adrenal insufficiency is known to be caused by sudden discontinuation of oral steroids. Furthermore, we should pay attention to sudden discontinuation of topical steroids, which could cause relative adrenal insufficiency.