{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T18:17:56Z","timestamp":1783448276115,"version":"3.55.0"},"reference-count":10,"publisher":"Bioscientifica","issue":"4","license":[{"start":{"date-parts":[[2026,6,13]],"date-time":"2026-06-13T00:00:00Z","timestamp":1781308800000},"content-version":"vor","delay-in-days":255,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["journals.bioscientifica.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2025,10,1]]},"abstract":"<jats:sec>\n                    <jats:title>Summary<\/jats:title>\n                    <jats:p>Several reports focus on azole-induced primary adrenal insufficiency (PAI); however, none have specifically focused on the absence of hypotension and hyperkalemia among the clinical features of adrenal insufficiency (AI). Here, we report a case of posaconazole-induced PAI with normal blood pressure. A 74-year-old male patient was diagnosed with lymphoma in July 2019 and underwent chemotherapy. He gradually began to experience anorexia, fatigue, and a fever of 37\u00b0C\u201338\u00b0C from mid-March 2022. He was diagnosed with pneumonia on April 4, 2022, and antibiotics and posaconazole at 300 mg daily were initiated post-hospitalization. Symptoms of anorexia, nausea, fatigue, and fever demonstrated no improvement despite the regression of the consolidation on the chest computed tomography. The early morning cortisol level was 2.4 \u03bcg\/dL despite a high adrenocorticotropic hormone (ACTH) level (101.7 pg\/mL). Therefore, we diagnosed the patient with PAI according to the low cortisol level (maximum of 8.6 \u03bcg\/dL at 60 min) in a rapid ACTH stimulation test. Despite having PAI, the patient exhibited normal blood pressure and hypokalemia. Posaconazole was considered to cause PAI; therefore, it was discontinued, and hydrocortisone replacement was initiated. His symptoms improved, and rapid ACTH stimulation test reassessment 1 month after posaconazole discontinuation revealed normal basal ACTH, cortisol, and ACTH response. However, the renin\u2013angiotensin\u2013aldosterone system did not fully improve, as opposed to the hypothalamic\u2013pituitary\u2013adrenal axis. Posaconazole inhibits 11\u03b2-hydroxylase and 11\u03b2-hydroxysteroid dehydrogenase type 2, causing pseudohyperaldosteronism, which persists. Notably, posaconazole causes PAI without hypotension and hyperkalemia, which are its major clinical characteristics.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Learning points<\/jats:title>\n                  <\/jats:sec>","DOI":"10.1530\/edm-24-0024","type":"journal-article","created":{"date-parts":[[2025,11,10]],"date-time":"2025-11-10T14:28:39Z","timestamp":1762784919000},"update-policy":"https:\/\/doi.org\/10.1530\/crossmarkpolicy-2","source":"Crossref","is-referenced-by-count":1,"title":["Posaconazole-induced primary adrenal insufficiency concomitant with pseudoaldosteronism under normal blood pressure"],"prefix":"10.1530","volume":"2025","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4286-0039","authenticated-orcid":true,"given":"Miho","family":"Katsumata","sequence":"first","affiliation":[{"name":"1"},{"name":"2"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masaki","family":"Miura","sequence":"additional","affiliation":[{"name":"2"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masahiro","family":"Masuzawa","sequence":"additional","affiliation":[{"name":"2"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"416","published-online":{"date-parts":[[2025,11,10]]},"reference":[{"key":"2026070713534491700_bib1","article-title":"Posaconazole-induced adrenal insufficiency in a case of chronic myelomonocytic leukemia","volume":"2018","author":"Miller","year":"2018","journal-title":"Case Rep Endocrinol"},{"key":"2026070713534491700_bib2","doi-asserted-by":"crossref","DOI":"10.3389\/fendo.2023.1168797","article-title":"Case report: hypercalcemia as a manifestation of acute adrenal crisis precipitated by fluconazole use, and a review of the literature","volume":"14","author":"Choo","year":"2023","journal-title":"Front Endocrinol"},{"key":"2026070713534491700_bib3","doi-asserted-by":"crossref","first-page":"620","DOI":"10.3390\/jof7080620","article-title":"Severe posaconazole-induced glucocorticoid deficiency with concurrent pseudohyperaldosteronism: an unfortunate two-for-one special","volume":"7","author":"Villar-Prados","year":"2021","journal-title":"J Fungi"},{"key":"2026070713534491700_bib4","first-page":"e62","article-title":"Primary adrenal insufficiency secondary to chronic posaconazole use","volume":"6","author":"Araque","year":"2020","journal-title":"AACE Clin Case Rep"},{"key":"2026070713534491700_bib5","doi-asserted-by":"crossref","DOI":"10.1016\/j.ijantimicag.2022.106587","article-title":"Reducing the off-target endocrinologic adverse effects of azole antifungals-can it be done?","volume":"59","author":"Balcerek","year":"2022","journal-title":"Int J Antimicrob Agents"},{"key":"2026070713534491700_bib6","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1210\/jc.2015-1710","article-title":"Diagnosis and treatment of primary adrenal insufficiency: an endocrine society clinical practice guideline","volume":"101","author":"Bornstein","year":"2016","journal-title":"J Clin Endocrinol Metab"},{"key":"2026070713534491700_bib7","article-title":"Adrenal insufficiency","volume-title":"Endotext","author":"Alexandraki","year":"2000"},{"key":"2026070713534491700_bib8","doi-asserted-by":"crossref","DOI":"10.1161\/01.HYP.3.6_Pt_2.II-102","article-title":"DOCA test for aldosteronism: its usefulness and implications","volume":"3","author":"Rodr\u00edguez","year":"1981","journal-title":"Hypertension"},{"key":"2026070713534491700_bib9","doi-asserted-by":"crossref","first-page":"1223","DOI":"10.1056\/NEJM199110243251706","article-title":"Licorice-induced hypermineralocorticoidism","volume":"325","author":"Farese","year":"1991","journal-title":"N Engl J Med"},{"key":"2026070713534491700_bib10","doi-asserted-by":"crossref","first-page":"b3688","DOI":"10.1093\/jac\/dkaa366","article-title":"Management of posaconazole-induced pseudohyperaldosteronism","volume":"75","author":"Davis","year":"2020","journal-title":"J Antimicrob Chemother"}],"container-title":["Endocrinology, Diabetes &amp; 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