Role of fluconazole in a case of rapid onset ritonavir and inhaled fluticasone-associated secondary adrenal insufficiency.
A 52-year-old man with well-controlled HIV infection taking ritonavir and increasing doses of inhaled fluticasone for chronic bronchitis developed thrush. Within days of discontinuing fluticasone and initiating fluconazole, he presented with fatigue, malaise, lower-extremity oedema and orthostasis. Testing confirmed exogenous Cushing's syndrome and secondary adrenal insufficiency. Although ritonavir-fluticasone interactions have been previously reported as a cause for adrenal insufficiency, we propose that fluconazole increased the rapidity of onset and severity of symptoms through synergistic inhibition of the adrenal axis.
Division of Infectious Diseases, Department of Internal Medicine, Naval Medical Center Portsmouth, Portsmouth, VA,  USA.
K
K
St Clair
J D
JD
Maguire
D000309:Adrenal Insufficiency / Q000139:chemically induced*; D000730:Androstadienes / Q000008:administration & dosage / Q000009:adverse effects*; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000009:adverse effects*; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage / Q000009:adverse effects*; D001991:Bronchitis / Q000188:drug therapy*; D004347:Drug Interactions; D015725:Fluconazole / Q000008:administration & dosage / Q000009:adverse effects*; D000068298:Fluticasone; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D019438:Ritonavir / Q000008:administration & dosage / Q000009:adverse effects*
D000730:Androstadienes; D019380:Anti-HIV Agents; D000893:Anti-Inflammatory Agents; D015725:Fluconazole; D000068298:Fluticasone; D019438:Ritonavir