Successful use of metyrapone suppositories in an infant with neonatal cushing and mccune albright syndrome- a case report

IntroductionPerinatal hypercorticism, regardless of its cause, has a high mortality or leads to life-long lasting complications. Some publications reported on the use of metyrapone in children with McCune Albright syndrome (MAS) and hypercorticism, but also mentioned its poor tolerability.Case presentationWe present the case of a toddler, in whom we diagnosed MAS based on pseudo-precocious puberty and hypercorticism at the age of 10 months. In light of hepatopathy, we decided to start the off-label treatment with metyrapone. Being aware of the challenges of this treatment with the only available product (gelatine capsule containing liquid metyrapone) and reports on local irritation and significant side effects after the oral and intrarectal administration of liquid metyrapone, diluted or undiluted, we decided to use the rectal application as suppositories. We started with the dose of 300mg/m2/day (one administration every 6h), with the intention to "block and replace", using repeated measurements of serum morning and 23:00 cortisol, salivary cortisol and 24h urine steroid profile. After just two weeks, we discharged our patient with normal cortisol levels, without additional hydrocortisone substitution and with a total metyrapone dose of 900 mg/m2/day. Lipid profile and arterial pressure normalised, while growth velocity improved progressively.ConclusionWe present the first successful, long-term use of metyrapone as suppositories, with no adverse side effects and striking clinical and biochemical improvement.