Hypertension and Severe Hypokalemia Associated With Oral Ingestion of Topical Hydrocortisone Cream

Arunava Saha; Suryanarayanan Balakrishnan; Nitin Trivedi; George M Abraham

doi:10.1016/j.aace.2022.10.004

Hypertension and Severe Hypokalemia Associated With Oral Ingestion of Topical Hydrocortisone Cream

AACE Clin Case Rep. 2022 Oct 21;9(1):2-4. doi: 10.1016/j.aace.2022.10.004. eCollection 2023 Jan-Feb.

Authors

Arunava Saha¹, Suryanarayanan Balakrishnan¹, Nitin Trivedi², George M Abraham³

Affiliations

¹ Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts.
² Department of Endocrinology and Metabolic Medicine, Saint Vincent Hospital, Worcester, Massachusetts.
³ Saint Vincent Hospital; Division of Infectious Diseases and Geographic Medicine; University of Massachusetts Medical School, Worcester, Massachusetts.

Abstract

Background: Topical use of corticosteroids causes systemic effects, but systemic toxicity by ingesting topical corticosteroid cream has not been reported. We describe a patient admitted with ingestion of over-the-counter (OTC) hydrocortisone cream.

Case report: A 64-year-old woman presented with 2-weeks of generalized weakness. She had a history of hypertension, anxiety, depression, and chronic fatigue syndrome, but medical records were unavailable and she was not on any medications. She reported taking prednisone 7.5 mg daily for several years, which was discontinued 5 months ago. Due to worsening symptoms, she started ingesting OTC topical hydrocortisone as replacement and admitted to consuming 2 squirts of 1% hydrocortisone cream twice daily over the previous month leading up to hospitalization. Her pulse rate was 77/min, blood pressure was 232/110 mmHg. There was no pedal edema, elevated jugular venous pressure, hirsutism, muscle wasting, or purplish skin striae. Labs revealed potassium 1.5 mg/dL (3.6-5.4), serum cortisol 61.5 μg/dL (2.3-19.4), Creatine Kinase 1864 IU/L (24-173), undetectable adrenocorticotropic hormone. She received potassium, labetalol, and intravenous fluids. Her serum cortisol level decreased to 11 μg/dL and potassium to 4.1 mg/dL within 24 hours. She left the hospital against medical advice on Day 2.

Discussion: Although both prednisone and hydrocortisone have glucocorticoid properties, only hydrocortisone has mineralocorticoid properties. Hydrocortisone 20 mg provides a mineralocorticoid effect equivalent to 0.1 mg fludrocortisone.

Conclusion: Hydrocortisone cream was confirmed as the source of exogenous corticosteroid by an undetectable adrenocorticotropic hormone and rapid decrease in cortisol following discontinuation. Incorrect use of OTC medications can lead to life-threatening side effects.

Keywords: ACTH, Adrenocorticotrophic hormone; FDA, Food and Drug Administration; OTC, Over-the-counter; hypercortisolism; ingestion; mineralocorticoid receptor activation; over-the-counter; topical hydrocortisone.

Publication types

Case Reports