ETIOLOGY OF A SYNDROME OF FACTITIOUS MINERALOCORTICOID EXCESS - STEROID-CONTAINING NASAL SPRAY

A syndrome of hypertension and hypokalemic alkalosis with low plasma renin activity and low aldosterone levels was found in users of an Italian proprietary steroid-containing nasal spray. There was complete remission of these abnormalities when use of the spray was discontinued. The steroidal component of the spray was thought to be 6.alpha.-fluoroprednisolone, but when the steroid hormone receptor affinity of a reference sample was evaluated, its properties, which were predominantly glucocorticoid, did not explain the observed biological effects. Isolation of the active steroidal component in the spray was therefore undertaken. Chromatographic properties and mass spectrometry established its identity as 9.alpha.-fluoroprednisolone (11.beta.,17.alpha.,21-trihydroxy-9.alpha.-fluoro-1,4-pregnadiene-3,20-dione). This steroid was as potent a mineralocorticoid as aldosterone in terms of its affinity for the kidney cytoplasmic mineralocorticoid receptor and its effect on the urinary Na to K ratio in the adrenalectomized rat. Patients taking the recommended dose of the 1 mg/ml solution of the spray received more than 1 mg/day 9.alpha.-fluoroprednisolone or more than 10 .times. the physiological replacement. It has been difficult to induce the full syndrome of primary mineralocorticoid excess in man by the aldosterone administration. This study demonstrates that such a syndrome can be produced in normal individuals by a synthetic, intranasally administered mineralocorticoid and adds another cause of factitious mineralocorticoid excess to be considered in the differential diagnosis of primary aldosteronism.