Abstract | December 19, 2022

Adrenal Insufficiency – a Rare Adverse Effect of Bexarotene

Presenting Author: Rabia Khan, MD, PGY3, Department of Medicine GME, Wellstar Kennestone Hospital, Marietta, GA

Coauthors: Vandana Grover, MD, Internal Medicine, PGY1, Wellstar Kennestone Hospital, Kennesaw, GA; Prasad Rao, MD, Internal Medicine, Attending Physician, Wellstar Kennestone Hospital, Kennesaw, GA.

Learning Objectives

  1. Discuss adrenal insufficiency as a rare side effect of Bexarotene

Introduction: Bexarotene is a retinoid, currently approved for treating cutaneous T-cell lymphoma. The most common side effects of bexarotene include skin reactions (rash and itchiness), hypertriglyceridemia, and central hypothyroidism. This case report investigates an occurrence of adrenal insufficiency which is one of the rare side effects.

 

Case: A 39-year-old female was admitted for three days of worsening lethargy, drowsiness, confusion, and changes in her speech. She had a medical history of cutaneous T-cell lymphoma diagnosed a year ago, hypertension, hypothyroidism, and a recent 10-day hospitalization for sepsis secondary to non-hemolytic streptococci bacteremia. Her lymphoma was being treated with bexarotene for 12 months prior. Of note, her bexarotene was stopped during her prior hospitalization and her current symptoms started after she resumed taking it. 

 

On presentation, she was hypothermic (T = 93°F), tachypneic (RR = 20 bpm), and hypertensive (SBPs 150s to 170s and DBPs 70s to 80s). Heart rate was in the 70s; SpO2 = 97 % on room air. On exam, she did not converse and was not alert.  She was not oriented to person, place, time, or situation. There were no neurological focal deficits. Labs were notable for elevated TSH (8.9 mlU/ml), positive ACTH assay (ACTH of 30 pg/ml), low cortisol (baseline cortisol 13.8 ug/dL and cortisol of 13.7 ug/dL and 10.6 ug/dL at 30 and 60 respectively), low DHEA-S (<20 ng/dL), normal FSH (9.4 mlU/ml), normal LH (1.2 mlU/ml) and low prolactin (4.5 ng/mL). MRI brain showed 4 mm microadenoma in the pituitary gland. 

 

Diagnosis: She was diagnosed with adrenal insufficiency and poorly controlled hypothyroidism. She was started on IV hydrocortisone 100 mg tapered down over seven days. She was discharged with hydrocortisone 10 mg twice daily for adrenal insufficiency and thyroxine 100 mcg once daily (increased from 50 mcg). She was instructed to stop bexarotene indefinitely. She was also instructed to follow up with her oncologist for alternative therapy for her lymphoma.  

 

Outcome: Clinicians should have a high index of suspicion for adrenal failure in patients under bexarotene therapy. Cortisol levels should be monitored, especially in those patients who develop suggestive symptoms.

 

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