Acute Kidney Injury Due to Interaction of Methyl-1-testosterone with Ciclosporin Metabolism in a Patient with Severe Atopic Dermatitis
A 29-year-old male patient with longstanding atopic dermatitis was referred to the dermatology outpatient department (Dermatology Department, York Hospital, UK) with a history of rapid deterioration of his condition despite optimal topical therapy. Due to the severity of the symptoms and condition, he was started on systemic ciclosporin (3.0 mg/kg, twice daily). His ultimate ciclosporin dose was 4.0 mg/kg which was gradually increased from the initial dose of 3.0 mg/kg. The patient’s baseline findings are presented in Table . Good clinical response was achieved whilst on ciclosporin and he was maintained on it for 4 months (the later 3 months on the maximum dose) with stable serial blood tests.\nDuring routine follow-up, he was found to be in acute renal impairment with urea of 17 μmol/L, creatinine of 266 μmol/L and deranged liver function tests with bilirubin 37 μmol/L, alanine transaminase 304 U/L and aspartate transaminase 48 IU/L. Investigations included a urine dipstick and renal ultrasound which were both normal. The ciclosporin level during routine follow-up was elevated (trough level 622 μmol/L) despite consistency with the dose over 3 months and two stable previous blood tests.\nOn direct questioning, the patient admitted that he had been recently taking a “supplement”. The patient had purchased this over the Internet from an online shop and this was dispatched along with some written information. Subsequently, the “supplement” was found to be oral methyl-1-testosterone (systematic name: 17 alpha methyl-17beta-hydroxy-androst-1-ene-3-one). The patient discontinued both ciclosporin and methyl-1-testosterone and his renal function and liver function tests returned to normal within 1 week. The patient had been administered irregular amounts of methyl-1-testosterone with no regular pattern. Atopic dermatitis gradually flared up over 3 months and was treated with ultraviolet B phototherapy as he was reluctant to restart ciclosporin treatment.\nInformed consent was obtained from the patient for being included in the study. This article does not contain any studies with human subjects performed by any of the authors.