Unrecognized Steroid Exposure: Tawon Liar Induced Adrenal Insufficiency.

Abstract

Introduction: Adrenal insufficiency can present with adrenal crisis as a life-threatening complication, especially following glucocorticoid withdrawal as exogenous steroids can disrupt the HPI axis. Any form of stress, like an infection, can act as the precipitating factor.

Case report: A 65-year-old male with type 2 diabetes presented with weakness and confusion due to sepsis, requiring temporary intubation. Labs revealed severe hypercalcemia (calcium: 15.3 mg/dL) and mild acute kidney injury (creatinine: 1.55 mg/dL). PTH was appropriately suppressed, with normal vitamin D and PTHrP levels. Extensive malignancy investigations, including a CT scan, bone scan, and multiple myeloma workup, were negative. The patient denied using medications affecting calcium homeostasis, but further history revealed chronic use of "Tawon Liar" (containing ketorolac, meloxicam, and dexamethasone) for joint pain, which he had stopped a month prior. His rapid deterioration in the setting of sepsis suggested adrenal crisis, confirmed by a cosyntropin stimulation test. Given the negative workup otherwise, adrenal insufficiency was also likely contributing to hypercalcemia.

Conclusions: This case highlights the importance of obtaining a thorough medication history, including over-the-counter supplements, when evaluating unexplained metabolic abnormalities. Despite no obvious steroid use, this patient's prolonged use of an unregulated supplement led to the suppression of the HPA axis. While such patients may maintain some baseline cortisol production under normal circumstances, their impaired stress response increases the risk of adrenal crisis during acute illness. Early recognition and prompt management of adrenal insufficiency are crucial in preventing life-threatening complications.