title: Cushing in a Leaf: Endocrine Disruption From a Natural Remedy.
abstract: Information regarding the safety of herbal drugs is often not reported. We describe the case of a 65-year-old woman referred to us for a iatrogenic hypercortisolism, who denied any previous steroid consumption. She reported only a chronic application of a phytocosmetic cream, containing ethanol extract of the Cardiospermum halicacabum (CH) plant. Adrenal insufficiency occurred after the cream application was stopped. CH is used in traditional and Western medicine for its documented anti-inflammatory properties. Once the presence of synthetic glucocorticoids was ruled out in the phytocosmetic product, we investigated whether and how its chronic application could have caused the iatrogenic hypercortisolism.
  
  
  
  Liquid chromatography high-resolution mass spectrometry (LC-HRMS) was performed to exclude the presence of known glucocorticoids in the cream. ELISA assay and Western blot analysis were employed to assess ACTH secretion and the glucocorticoid receptor expression respectively in murine ACTH-secreting pituitary adenoma cells AtT-20/D16v-F2, treated with dexamethasone, CH tincture, and mifepristone alone or in combination. To detect specific interaction of CH extract with the glucocorticoid receptor, we performed a dual-luciferase reporter assay in HEK293 cells.
  
  
  
  In AtT-20/D16v-F2 cells, CH extract showed to significantly reduce basal and CRH-induced ACTH secretion and the glucocorticoid receptor expression, similarly to dexamethasone; these effects were counteracted by mifepristone. In HEK293 cells, dexamethasone significantly induced luciferase activity after 24- and 36-hour treatment and CH tincture only after 36 hours; these effects were antagonized by mifepristone.
  
  
  
  CH extract displays a glucocorticoid-like activity, by means of a direct binding to the glucocorticoid receptor.
authors.affiliation: Internal Medicine (C.M., E.Z., M.B., R.V.), Department of Medicine, DIMED, University of Padova, Italy; Section of Endocrinology and Internal Medicine (M.D.R., E.G., E.d.U., M.C.Z.), Department of Medical Sciences, University of Ferrara, Italy; Legal Medicine and Toxicology (A.N.), University Hospital of Padova, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Martini
authors.affiliation: Internal Medicine (C.M., E.Z., M.B., R.V.), Department of Medicine, DIMED, University of Padova, Italy; Section of Endocrinology and Internal Medicine (M.D.R., E.G., E.d.U., M.C.Z.), Department of Medical Sciences, University of Ferrara, Italy; Legal Medicine and Toxicology (A.N.), University Hospital of Padova, Italy.
authors.forename: Eva
authors.initials: E
authors.lastname: Zanchetta
authors.affiliation: Internal Medicine (C.M., E.Z., M.B., R.V.), Department of Medicine, DIMED, University of Padova, Italy; Section of Endocrinology and Internal Medicine (M.D.R., E.G., E.d.U., M.C.Z.), Department of Medical Sciences, University of Ferrara, Italy; Legal Medicine and Toxicology (A.N.), University Hospital of Padova, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Di Ruvo
authors.affiliation: Internal Medicine (C.M., E.Z., M.B., R.V.), Department of Medicine, DIMED, University of Padova, Italy; Section of Endocrinology and Internal Medicine (M.D.R., E.G., E.d.U., M.C.Z.), Department of Medical Sciences, University of Ferrara, Italy; Legal Medicine and Toxicology (A.N.), University Hospital of Padova, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Nalesso
authors.affiliation: Internal Medicine (C.M., E.Z., M.B., R.V.), Department of Medicine, DIMED, University of Padova, Italy; Section of Endocrinology and Internal Medicine (M.D.R., E.G., E.d.U., M.C.Z.), Department of Medical Sciences, University of Ferrara, Italy; Legal Medicine and Toxicology (A.N.), University Hospital of Padova, Italy.
authors.forename: Marialberta
authors.initials: M
authors.lastname: Battocchio
authors.affiliation: Internal Medicine (C.M., E.Z., M.B., R.V.), Department of Medicine, DIMED, University of Padova, Italy; Section of Endocrinology and Internal Medicine (M.D.R., E.G., E.d.U., M.C.Z.), Department of Medical Sciences, University of Ferrara, Italy; Legal Medicine and Toxicology (A.N.), University Hospital of Padova, Italy.
authors.forename: Erica
authors.initials: E
authors.lastname: Gentilin
authors.affiliation: Internal Medicine (C.M., E.Z., M.B., R.V.), Department of Medicine, DIMED, University of Padova, Italy; Section of Endocrinology and Internal Medicine (M.D.R., E.G., E.d.U., M.C.Z.), Department of Medical Sciences, University of Ferrara, Italy; Legal Medicine and Toxicology (A.N.), University Hospital of Padova, Italy.
authors.forename: Ettore
authors.initials: E
authors.lastname: Degli Uberti
authors.affiliation: Internal Medicine (C.M., E.Z., M.B., R.V.), Department of Medicine, DIMED, University of Padova, Italy; Section of Endocrinology and Internal Medicine (M.D.R., E.G., E.d.U., M.C.Z.), Department of Medical Sciences, University of Ferrara, Italy; Legal Medicine and Toxicology (A.N.), University Hospital of Padova, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Vettor
authors.affiliation: Internal Medicine (C.M., E.Z., M.B., R.V.), Department of Medicine, DIMED, University of Padova, Italy; Section of Endocrinology and Internal Medicine (M.D.R., E.G., E.d.U., M.C.Z.), Department of Medical Sciences, University of Ferrara, Italy; Legal Medicine and Toxicology (A.N.), University Hospital of Padova, Italy.
authors.forename: Maria Chiara
authors.initials: MC
authors.lastname: Zatelli
mesh_terms: D000368:Aged; D045744:Cell Line, Tumor; D052244:Endocrine Disruptors / Q000009:adverse effects*; D005260:Female; D057809:HEK293 Cells; D029001:Herbal Medicine; D006801:Humans; D047748:Pituitary ACTH Hypersecretion / Q000139:chemically induced* / Q000473:pathology; D018515:Plant Leaves / Q000009:adverse effects / Q000737:chemistry*; D028321:Plant Preparations / Q000009:adverse effects* / Q000737:chemistry; D029631:Sapindaceae / Q000009:adverse effects / Q000737:chemistry; D063465:Skin Cream / Q000009:adverse effects* / Q000737:chemistry
chemical_list: D052244:Endocrine Disruptors; D028321:Plant Preparations