PSAT185 Pseudohypoparathyroidism Type 1B: A Medication Compliance Challenge

Introduction

Pseudohypoparathyroidism (PHP) encompasses five metabolic disorders characterized by target organ PTH resistance. The focus of this paper is PHP Type 1B (PHP1B), a disease that typically presents in children with symptomatic hypocalcemia. Only 15-20% of cases are genetic, making our case of Familial PHP1B even rarer.

Case Presentation

A 23-year-old African-American female with hypothyroidism and PHP1B diagnosed in 2005 presented to the emergency department with symptomatic hypocalcemia. As a child, she was evaluated for progressive femur, tibia, radius, and ulna bowing in the setting of short stature without phenotypic features of Albright's Hereditary Osteodystrophy. Her biochemical profile was consistent with pseudohypoparathyroidism and imaging showed costochondral junction enlargement. Genetic testing revealed STX mutation confirming PHP1B diagnosis. Extensive studies of her family revealed several affected members, including one of her two children.Patient has history of multiple hospitalizations for symptomatic hypocalcemia. During this admission, her laboratories demonstrated: calcium 4.4 mg/dL (8.6-10.3 mg/dL), phosphorus 7.3 mg/dL (2.5-4.5 mg/dL), PTH 574 pg/mL (16-65 pg/mL), 1,25-dihyroxyvitamin D < 8 ng/mL (18-78 ng/mL), and 25-hydroxyvitamin D 7.6 ng/mL (30-100 ng/mL).She has an extensive history of non-compliance with medications and endocrinology appointments. During the last visit, she complained of ostealgia, particularly in long bones. While discussing the importance of maintaining adequate calcium levels, the patient expressed feeling overwhelmed by her regimen (calcitriol 1 mcg QAM and 0.5 mcg QHS, calcium carbonate 1,200 mg TID). After a lengthy conversation regarding the need for long-term medical therapy, she became increasingly distraught.

Conclusion

When normocalcemia is achieved with high doses of calcium and calcitriol, patients with PHP1B have an average life expectancy. Given that patients are typically diagnosed in childhood, taking several medications multiple times a day can be challenging and lead to poor compliance. When this occurs, PHP1B becomes a life-altering disease with a significant decrease in quality of life.In 2018 Wierenga et al. reported that being emotionally overwhelmed by chronic disease prevents a patient from appropriately caring for themselves. Their research shows that older males with higher levels of education have better emotional regulation than young females with low educational levels. Providing patients at high risk of psychological stress with a multidisciplinary team including cognitive-behavioral therapists can improve their quality of life and compliance while decreasing the healthcare costs associated with poorly controlled chronic diseases.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PMON284 Triamcinolone Cream-Induced Cushing Syndrome

Introduction

Iatrogenic Cushing syndrome (CS) is typically due to systemic corticosteroids. Less frequently, it can be caused by inhaled, ocular, intra-articular, and topical glucocorticoids.

There are multiple reported cases of pediatric CS due to topical corticosteroids, this is partly due to this patient's population thinner dermis which allows for higher absorption. In adults, there are few reported cases of iatrogenic CS secondary to Clobetasol, one of the highest potency topical steroids available. We present a unique case of severe Iatrogenic CS secondary to topical Triamcinolone in a patient with no medications that could interfere with glucocorticoid metabolism.

Case

A 30-year-old-female with Type 2 Diabetes Mellitus and psoriatic arthritis was admitted with generalized psoriatic lesions affecting 70% of her body surface area (BSA) and non-healing open wounds affecting two thirds of her upper legs. The leg wounds had failed to improve after seven washouts and three skin grafts in the course of four months. Additionally, she reported recent weight gain and a new diagnosis of hypertension. Pertinent physical exam findings included moon facies, dorsocervical fat pad, acanthosis nigricans, and open wounds in 67% of bilateral upper legs. Subsequently, her cortisol was found to be 1.2 mg/dL (6.2-19.4 mg/dL) with an ACTH level of 1.2 pg/mL (7.2-63.3 pg/mL). ACTH stimulation test confirmed adrenal insufficiency.

The only medication she was prescribed for psoriasis at the time of admission was 0.1% Triamcinolone cream. She had been applying the steroid to over 50% of her BSA, including open wounds, for the past four months. Upon admission, Triamcinolone was discontinued, and she was started on cyclosporine and a TNF inhibitor for psoriasis management as well as oral hydrocortisone for adrenal insufficiency. Three months later, during her last office visit, her facial rounding and plethora, dorsocervical fat pad and hypertension had moderately improved.

Discussion

To the best of our knowledge, this is the first reported case of adult iatrogenic CS secondary to topical Triamcinolone in the absence of any drug-drug interaction. Purser et al reported Triamcinolone induced CS in an HIV patient taking Ritonavir, a cytochrome P450 inhibitor that increases the amount of active steroid. Our patient had increased absorption due to the application of the cream to a large BSA and to open wounds. The two main factors that determine the development of iatrogenic CS are the potency of the glucocorticoids and the duration of exposure. The pathophysiology of wound healing in CS has been well studied and reported, therefore, the objective of this report is to understand how a relatively benign topical medication can have detrimental systemic effects.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

The effects of twenty-one nutrients and phytonutrients on cognitive function: A narrative review

BACKGROUND AND AIM

Brain health is becoming more important to the average person as the number of people with cognitive impairments, such as Alzheimer's disease (AD), is rising significantly. The current Food and Drug Administration-approved pharmacotherapeutics for dementia neither cure nor halt cognitive decline; they just delay the worsening cognitive impairment. This narrative review summarizes the effects of nutrients and phytonutrients on cognitive function.

METHODS

A comprehensive literature search of PubMed was performed to find clinical trials in humans that assessed the effects of nutrients and phytonutrients on cognitive function published in English between 2000 and 2021. Six independent reviewers evaluated the articles for inclusion in this review.

RESULTS

Ninety-six articles were summarized in this narrative review. In total 21 categories of nutrients and phytonutrients were included, i.e., α-lipoic acid, Bacopa monnieri, B vitamins, cholinergic precursors, vitamin D, vitamin E, Ginkgo biloba, ginseng, lion's mane mushroom, N-acetyl cysteine, omega-3 fatty acids, aloe polysaccharides, Rhodiola rosea, rosemary, saffron, tart cherries, turmeric, wild yam, Withania somnifera, xanthines, and zinc. Particular noteworthy effects on cognition included memory, recollection, attention, intelligence, vocabulary, recognition, response inhibition, arousal, performance enhancement, planning, creative thinking, reaction time, vigilance, task switching, orientation to time, place, and person, reading, writing, comprehension, accuracy, learning, information processing speed, executive function, mental flexibility, daily functioning, decrease in mental fatigue, and freedom from distractibility. Some nutrients and phytonutrients also improved mood and contentedness and reduced anxiety and the need for caregiving. These effects are not completely consistent or ubiquitous across all patient populations or health statuses. Adverse effects were minimal or nonexistent.

CONCLUSION

Due to the growing population of people with cognitive impairment and the lack of effective pharmacotherapeutics, it is prudent for those afflicted or their caregivers to find alternative treatments. Our narrative review shows that many of these nutrients and phytonutrients may be promising for treating some aspects of cognitive impairment, especially for people afflicted with AD.

RELEVANCE FOR PATIENTS

As demonstrated in a number of clinical trials, healthy adults and patients with various health challenges (e.g., AD, mild cognitive impairment, multiple sclerosis, and Parkinson's disease) exhibiting a wide range of severity in cognitive defects would be best served to consider multiple nutrients and phytonutrients to improve aspects of their cognitive function.