This case report aims to raise awareness about the risks of adulteration in complementary and alternative medicines (CAM), through a case of secondary adrenal insufficiency induced by a traditional Chinese medicine adulterated with dexamethasone. It reinforces the need for increased clinical vigilance in detecting undisclosed use of CAM.
We present the case of a 59-year-old female with an incidental finding of adrenal insufficiency during investigation for hypokalaemia and hypertension.
Initial biochemistry revealed an elevated aldosterone:renin ratio of 196 and hypokalaemia of 3.4mmol/L, alongside low ACTH (1.3pmol/L; reference range 1.6–13.9pmol/L) and cortisol (41nmol/L; reference range 172–497nmol/L) levels. Saline suppression test confirmed hyperaldosteronism. A subsequent adrenal CT scan was normal, and adrenal vein sampling was consistent with bilateral hypersecretion of aldosterone, confirming a diagnosis of Conn’s syndrome. To investigate the concomitant low cortisol, a short synacthen test was performed during which our patient demonstrated inadequate cortisol incrementation, reaching only 427nmol/L, confirming a concurrent diagnosis of secondary adrenal insufficiency, which remained unexplained. The patient later disclosed episodic use of a traditional Chinese medicine for chronic sinusitis. A sample of this CAM tested via liquid-chromatography-mass spectrometry was found to contain dexamethasone despite it not being listed on the product label. Two months after discontinuing the CAM, the patient’s serum cortisol and ACTH levels normalized to 203nmol/L and 11.4pmol/L, respectively, confirming transient adrenal insufficiency due to inadvertent exogenous glucocorticoid exposure.
This case illustrates the possible endocrine dysfunction that can be caused by adulterated CAM. It also highlights the importance of thorough drug history taking, including CAM use, and pharmacovigilance amongst health professionals, particularly when faced with unexplained endocrine disorders. Amid the global rise in consumption of CAM products, it is crucial to address misconceptions about the safety of "natural" products and risk of adulteration, especially with potent pharmacological agents which can result in serious complications.