Endocrinology, Diabetes & Metabolism Fellow University of Central Florida Orlando, Florida, United States
Introduction : Mifepristone is used to control hyperglycemia secondary to hypercortisolism in adult patients with endogenous Cushing’s syndrome who have type 2 diabetes mellitus by blocking the cortisol receptor. We present a case of a patient on Mifepristone for Cushing’s syndrome with improvement of clinical and biochemical manifestations of the hypercortisolism, but with outbreak of psoriasis.
Case(s) Description : A 34-year-old man with a medical history significant for hypertension, type 2 diabetes mellitus, and morbid obesity presented to our clinic to establish care. He displayed significant central adiposity, buffalo hump, supraclavicular fat pads, abdominal striae with skin thinning and breakdown at abdominal skin folds, and proximal muscle weakness noticeable when rising from a seated position. Patient was on metformin 1000mg BID, glargine 30 units daily, and semaglutide 1 mg weekly. Results of lab testing confirmed adrenal hypercortisolism on two sets of dexamethasone suppression test, 24hr urine cortisol, and late-night salivary cortisol (3 samples each). CT abdomen with and without contrast showed lobular contour of adrenals without discrete masses. After discussion of medical therapy, the patient was started on Mifepristone 150 mg twice daily and later it was increased to 300 mg twice daily. At the 3-month follow-up after initiating medical therapy, the patient noticed a noticeable improvement in glucose readings and a 42 lbs weight loss. He experienced hypertension due to effect of cortisol on mineralocorticoid receptors. This improved with initiation of spironolactone. Additionally, the patient had reported a new pruritic, scaly rash on the extensor surface of his hands and right leg. This was consistent with recurrence of his psoriasis. Given significant improvement of hypercortisolism symptoms and only mild psoriasis, the patient remains on Mifepristone and is using topical treatments for the limited skin lesions with close monitoring.
Discussion : Psoriasis is an autoimmune disorder where the body's immune system mistakenly attacks the skin cells, causing a rash with itchy, scaly patches, most commonly on the knees, elbows, trunk and scalp. Mifepristone works by selectively antagonizing the progesterone receptor at low doses and blocking the glucocorticoid receptor at higher doses. This could be an exacerbation of an underlying condition or possible side effect of the medication. Mifepristone's actions on the glucocorticoid receptors may have an impact on the immune system which includes skin health, potentially leading to the development or worsening of psoriasis in susceptible patients. Mifepristone does have a warning that if used in patients who receive corticosteroids for other conditions which can include autoimmune disorders it may lead to exacerbation or deterioration of that condition due to Mifepristone antagonizing the desired effects of glucocorticoid in these clinical settings. We describe one case where a patient developed psoriasis while taking Mifepristone for hyperglycemia secondary to hypercortisolism with improvement in clinical and biochemical manifestations of hypercortisolism.
