Iatrogenic Cushing's Syndrome Research Articles

Beware of the rinse: magic mouthwash as a rare cause of iatrogenic Cushing syndrome and secondary adrenal insufficiency.

Beware of the rinse: magic mouthwash as a rare cause of iatrogenic Cushing syndrome and secondary adrenal insufficiency.

Dangers of under-treatment and over-treatment with inhaled corticosteroids in children with asthma.

Two children, both under the care of specialists for mild persistent asthma, flirted with mortality. One lost and one won the battle. A 16-year-old boy never received ICS therapy despite extensive airway inflammation and remodeling and died due to mismanagement of an asthma exacerbation. A 6-year-old girl developed iatrogenic Cushing's syndrome during 18 months of continuous treatment with high, FDA-unapproved doses of both ICS and INCS and nearly died during an adrenal crisis. The role of ICS under-treatment and over-treatment and the possibility that recommendations in asthma guidelines and information in FDA package labels could have prevented both outcomes are explored.

9202 Characterizing The Physiological Side-Effects Of Over-The-Counter Arthritis Supplements

Abstract Disclosure: K.S. Wei: None. M.O. De La Torre: None. A. Flores: None. C.E. Chiu: None. T.E. Angell: None. Introduction: Over the counter (OTC) health supplements are commonly used by patients for a variety of ailments but may contain active ingredients that are not stated, such as glucocorticoids. Here, we present a case series of 12 patients seen by the Endocrinology Consult service at an urban safety net hospital during 2022-2023 and determined to have iatrogenic adrenal insufficiency (AI) from specific OTC supplements that surreptitiously contained glucocorticoids. Clinical Cases:12 patients using OTC arthritis supplements [Artri King (n=8), Ardosons (n=3), and Ajo Rey (n=1)] were identified. Median age was 52 years and 33.3% were female. All started using the supplements because of joint pain. Median length of use prior to cessation was 6 months. The most common presenting symptoms were nausea/vomiting (42%), fatigue (42%), abdominal pain (33%), and dizziness (17%). The most common physical exam findings of steroid excess included moon facies (66%), central adiposity (66%), abdominal striae (50%), dorsocervical fat pad (33%), and bruising (33%). 3/12 patients required ICU admission. Cortisol assessment was performed in 11/12 patients, which showed normal cortisol level in 1 patient (cortisol ≥16 mcg/dL), AI in 3 patients (cortisol ≤3 mcg/dL), and an equivocal level (cortisol 3-16 mcg/dL) in 7 patients. Cosyntropin stimulation testing in 6/7 patients with equivocal cortisol levels suggested AI in 4 (cortisol level <16 mcg/dL at 60 minutes after ACTH stimulation), whereas 2 showed lower but normal response (cortisol levels 18.2 mcg/dL and 18.4 mcg/dL). In total, 10/12 patients were prescribed glucocorticoid tapering replacements to avoid precipitating adrenal crisis. The most common regimens were hydrocortisone 20mg qAM/10mg qPM (33%) and hydrocortisone 5mg qAM/5mg qPM (17%). To date, 2/10 patients have successfully discontinued steroid replacement. Conclusion: These cases demonstrate possible Cushing’s syndrome and/or adrenal insufficiency after unintentional exposure to glucocorticoids in these OTC arthritis supplements, which has only previously been reported in a small number of case reports (1). This series collected over a 2-year period offers important clinical insights: Because patients may not identify or recall a supplement, possible use of OTC medications for arthritis or other anti-inflammatory purposes should be specifically assessed in patients presenting with adrenal insufficiency (especially with concomitant findings suggesting Cushing’s syndrome). For patients on such supplements, immediate discontinuation may not be possible without cortisol replacement and should be done with caution. 1)Boncompagni A.C. et al. A case of iatrogenic Cushing syndrome and subsequent adrenal insufficiency from a hidden ingredient in the supplement Artri Ajo King. J Am Coll Emerg Physicians Open. 2023;4(4):e13007. Presentation: 6/1/2024

Cushing's Syndrome and Topical Corticosteroids in Pediatrics: A Systematic Review

Introduction Despite the increasing number of pediatric cases of iatrogenic Cushing's syndrome (CS) due to topical corticosteroids, systematic reviews are lacking to provide comprehensive insights into the disease. This study aims to provide a systematic overview of the disease. Methods Relevant literature was identified using Google Scholar and PubMed. The search strategy was restricted to studies on human published in English. The inclusion criteria encompassed confirmed pediatric cases of iatrogenic CS induced by topical corticosteroids. Results The mean age of the cases was 38.8 months, with a female gender predominance (57.1%). Abnormalities in growth patterns were observed in approximately 75% of the cases. The most common clinical presentation was a "moon face" appearance (74.6%), followed by weight gain (55.5%). Clobetasol propionate was the most frequently used topical steroid (54%), followed by betamethasone types (35%). The mean duration of steroid use was 25.4 weeks. The primary indications for steroid use were dermatitis (47.6%), psoriasis (17.5%), and scabies (15.9%). Laboratory tests for adrenocorticotropic hormone and cortisol levels revealed low levels in 73% and 78% of cases, respectively. All cases had their initial steroid discontinued. Oral hydrocortisone was the primary replacement therapy (39.7%), followed by sulfur cream (12.7%). Fifty-one cases (81%) recovered from the disease. Partial recovery was observed in 2 cases (3.2%), while four cases (6.3%) did not survive. Conclusion A specialist should supervise topical corticosteroid administration, and parents need to be fully informed about the proper usage and potential side effects to avoid iatrogenic CS and other complications.

An Interesting Case of Cushing Syndrome

An Interesting Case of Cushing Syndrome A 36 year old female presented to dermatology department with Multiple ulcers present in B/L axilla, B/L inframammary fold and B/L gluteal fold (Left > Right) since 3 months. Patient was referred from dermatology department to General Medicine for opinion on puffiness of face and swelling of legs . Patient had history of topical steroid use for itchy lesions in B/L axilla and inframammary folds 4 months back . H/o weight gain present. (6 kg). H/o puffiness of face and striae present over the abdomen. Patient had no known comorbidities previously. On physical examination patient had moon face ,facial plethora + ,Buffalo hump ,Loss of axillary hair, centripetal obesity , Abdominal striae , Sparse pubic hair , Pallor +. Systemic examination was normal. Investigations revealed new onset diabetes , serum cortisol was low (<0.5 mcg/ml) , serum acth was low (1pg/ml) , HB was low (7.9gm/dl) , total count was elevated (15,600) . Patient was diagnosed to have Iatrogenic (Topical steroid induced) Cushing Syndrome with Steroid induced atrophy and ulceration of skin & subcutaneous tissue leading to secondary fungal and bacterial infection , tinea incognito with secondary bacterial infection , iron deficiency anemia and newly detected Type 2 Diabetes mellitus. Patient was appropiately treated with iv antibiotics (Inj Piperacillin Tazobactum 4.5 g iv thrice daily), daily dressing on other supportive measures along with discontinuation of steroids. Patient improved symptomatically after discontinuing topical steroids, the cushingoid features started decreasing. The ulcers also started to heal. The patient was started on Tab. Hydrocortisone 10mg - 0 – 5mg and was referred for Endocrinologist opinion

Long-term glucocorticoid infusion impairs epididymal adipocyte metabolism and maturation and affects miR-150–5p actions

The most common form of hypercortisolism is iatrogenic Cushing's syndrome. Lipodystrophy and metabolic disorders can result from the use of exogenous glucocorticoids (GC). Adipocytes play an important role in the production of circulating exosomal microRNAs, and knockdown of Dicer promotes lipodystrophy. The aim of this study is to investigate the effect of GCs on epididymal fat and to assess their influence on circulating microRNAs associated with fat turnover. The data indicate that despite the reduction in adipocyte volume due to increased lipolysis and apoptosis, there is no difference in tissue mass, suggesting that epididymal fat pad, related to animal size, is not affected by GC treatment. Although high concentrations of GC have no direct effect on epididymal microRNA-150–5p expression, GC can induce epididymal adipocyte uptake of microRNA-150–5p, which regulates transcription factor Ppar gamma during adipocyte maturation. In addition, GC treatment increased lipolysis and decreased glucose-derived lipid and glycerol incorporation. In conclusion, the similar control and GC epididymal fat mass results from increased dense fibrogenic tissue and decreased adipocyte volume induced by the lipolytic effect of GC. These findings demonstrate the complexity of epididymal fat. They also highlight how this disease alters fat distribution. This study is the first in a series published by our laboratory showing the detailed mechanism of adipocyte turnover in this disease.

A Case Report on Iatrogenic Cushing Syndrome with Diabetes Mellitus

Cushing syndrome (CS) is a condition caused due to high levels of cortisol in which weight gain and fat tissue build-up take place. Generally, patients with Cushing syndrome also suffer from diabetes. A 57-year-old female patient with aggravated cortisol levels. Laboratory investigations of the patient were performed and they showed decreased haemoglobin levels, but increased vitamin B12 levels, and TSH levels. The patient was prescribed a combination of medications to manage anemia, anemia, and diabetes. The patient's medical history included splenomegaly, cholelithiasis, panniculitis, and kidney enlargement. The patient's diabetes was responding well to the treatment and was better after 10 days.
 Keywords: Cushing syndrome, Diabetes mellitus, corticosteroid.

Evaluation of psoriasis patients with long-term topical corticosteroids for their risk of developing adrenal insufficiency, Cushing’s syndrome and osteoporosis

Purpose In this study, we will investigate the possible side effects of psoriasis patients using long-term topical corticosteroids (TCS) such as adrenal insufficiency, Cushing’s Syndrome (CS) and osteoporosis and determine how these side effects develop. Material and Methods Forty-nine patients were included in the study. The patients were divided into two groups based on the potency of the topical steroid they took and the patients’ ACTH, cortisol and bone densitometer values were evaluated. Results There was no significant difference between the two groups regarding the development of surrenal insufficiency, CS and osteoporosis. One patient in group 1 and 4 patients in group 2 were evaluated as iatrogenic CS. ACTH stimulation tests of these patients in group 2 showed consistent results with adrenal insufficiency, while no adrenal insufficiency was detected in the patient in Group 1. Patients who used more than 50g of superpotent topical steroids per week compared to patients who used 50g of superpotent topical steroids per week. It was identified that patients who used more than 50g of superpotent topical steroids had significantly lower cortisol levels, with a negatively significant correlation between cortisol level and the amount of topical steroid use (p < .01). Osteoporosis was detected in 3 patients in group 1 and 8 patients in Group 2. Because of the low number of patients between two groups, statistical analysis could not be performed to determine the risk factors. Conclusions Our study is the first study that we know of that investigated these three side effects. We have shown that the development of CS, adrenal insufficiency and osteoporosis in patients who use topical steroids for a long time depends on the weekly TCS dosage and the risk increases when it exceeds the threshold of 50 grams per week. therefore, our recommendation would be to avoid long-term use of superpotent steroids and to choose from the medium-potent group if it is to be used.

A case of unhealing skin ulcer with iatrogenic Cushing’s syndrome

Cutaneous Leishmaniasis is a rare disease in South-East Asian countries like Bangladesh, often presenting as skin lesions, ulcers or granulomatous plaques on the arm or back. As the disease is uncommon, high index of suspicion is required for the diagnosis. We are presenting a case of cutaneous Leishmaniasis in a migrant Bangladeshi worker in the Kingdom of Saudi Arabia (KSA). The case was initially treated with antibiotics, emollients and systemic steroid for a long time. However, the disease progressed, and the patient developed features of iatrogenic Cushing syndrome. The diagnosis was confirmed with a skin biopsy, which revealed Leishmania parasite. He received treatment with Injectable liposomal Amphotericin B (LAmB) and oral Miltefosine with promising clinical response. Clinicians should be vigilant while treating non-healing ulcers, and consider CL when there is history of travelling to CL endemic areas J Bangladesh Coll Phys Surg 2023; 41(4): 334-337

Efficacy/Safety of the Use of Glucocorticoids in Oral and Maxillofacial Surgery.

Glucocorticoids, also known as corticosteroids or steroids, are drugs derived from cholesterol. They are synthesized by the adrenal cortex, along with other hormones, such as cortisol and aldosterone. Glucocorticoids are drugs recommended for patients undergoing surgery on the oral cavity, facial skeleton, and related cervical structures due to their high efficacy against inflammatory and immune processes. However, these drugs are restricted due to their multiple and serious adverse effects. The objective of this study was to verify the efficacy of corticosteroids administered in major surgeries of the oral cavity, as well as of the cervical and facial structures, based on the characteristics of the patient so as to select the best therapeutic strategy. Articles in the databases of PubMed, Nature Portfolio, Medline, Cochrane Library, and Google Scholar were thoroughly examined. A total of 54 articles were selected to address the proposed objectives. The results obtained show that it is effective and safe to use glucocorticoids as pre- or postsurgical therapy in oral and maxillofacial surgery to control the processes of inflammation, pain, lockjaw, and edema. However, when referring to the use of these drugs, one must proceed with caution and pay particular attention when handling them. The concentration of the glucocorticoids used must be individualized, as well as the selection of the route of administration. Various studies show that, although the oral route is the most used route, the most effective route is the intramuscular route due to its easy absorption. However, for patients who have recurrent inflammatory and vesiculobullous ulcerative lesions, the topical route should be chosen to mitigate side effects, considering that recurrent applications must be made to prevent the worsening of the lesion and to avoid having to use medications enterally. In patients with cervicofacial infections, antibiotics continue to be the main drugs used to manage the condition in conjunction with corticosteroids. It is important to know the possible interactions of glucocorticoids with other medicines or food: it has been described that the interaction between Ritonavir, an antiretroviral drug that inhibits human immunodeficiency virus (HIV) proteases, and prednisone causes an increase in the concentration of prednisone, leading to possible toxicity in normally safe doses and, in many cases, iatrogenic Cushing's syndrome. It is also important to know the systemic or topical adverse effects of the chronic or high-dose use of glucocorticoids. It can be concluded that by making adequate use of glucocorticoid therapy in oral and maxillofacial surgery to manage clinical manifestations, it is possible to attenuate the morbidities of treatment and intervention.

H - 28 Assessment Following Acquired Injury to the Bilingual Brain: La Importancia De Los Determinantes Sociales De La Salud.

Given the growth of Latine populations in the U.S., variations in language fluency, educational attainment, quality of academic exposure, and access to medical care are essential social determinants of health to consider when assessing language in first generation immigrants, as illustrated through the following case study. A 17-year-old, Spanish-dominant, right-handed, Latina female with right frontoparietal stroke in the setting of arteriovenous malformation (AVM) was referred for neuropsychological evaluation one year following two consecutive gamma knife procedures. Complications included seizures (well-managed with Vimpat) and cerebral edema (treated with prolonged, high-dose Dexamethasone) followed by iatrogenic Cushing's syndrome. Brain MRI/CT were consistent with ruptured right frontoparietal AVM and vasogenic edema. Patient was a sequential language learner; education was received in Spanish until immigration from Colombia to the U.S. two years prior to injury. Parents completed higher education in Colombia. Consistent with stroke location/associated treatments, results indicated a mild neurocognitive disorder with deficits in cognitive efficiency, executive functioning (particularly on visual-based tasks), and memory. Academic skills also aligned with AVM (word reading: high average; reading comprehension: average; calculation: below average). Interestingly, even in the context of high parental education and dual language learner status, personal weaknesses in native language were identified (one-word expression: low average; semantic verbal fluency: below average). Integrating sociocultural demographic factors into the neuropsychological evaluation process supports a culturally-informed assessment approach and is imperative for practice with multilingual speakers. In this case, language concerns may have indicated premorbid weakness or right-sided/bilateral hemispheric language involvement, warranting follow-up fMRI/language mapping prior to further intervention.

SAT331 A Case Of Iatrogenic Cushing’s Syndrome Due To The Concomitant Use Of Cobicistat With An Inhaled Glucocorticoid Followed By Adrenal Insufficiency Upon Discontinuation Of Cobicistat

Abstract Disclosure: L. Noor: None. J. Mullally: None. R. Glassman: None. Cobicistat is an inhibitor of cytochrome P4503A (CYP3A) used to increase the systemic exposure of antiretroviral drugs for treatment of HIV, and because of it’s mechanism of action, can have significant drug interactions. A similar “pharmacologic booster” ritonavir has now been widely reported to cause cases of iatrogenic Cushing’s syndrome when used in combination with glucocorticoids, but the data on this risk with cobicistat is much more limited. This case describes a patient who developed florid Cushing’s syndrome while on cobicistat and inhaled glucocorticoids followed by secondary adrenal insufficiency upon discontinuation of cobicistat. A 60 year old male with past medical history of well-controlled HIV on elvitegravir, cobicistat, emtricitabine and tenofovir, asthma on chronic inhaled fluticasone/salmeterol, presented with several months of progressive abdominal distention, back pain, irritability, easy bruising, proximal muscle weakness and weight gain. On physical exam, he appeared Cushingoid with central obesity, supraclavicular fullness, dorsocervical fat pad, wide violaceous striae on his abdomen and multiple ecchymoses. Iatrogenic Cushing's syndrome was suspected and labs showed undetectable morning serum cortisol and 24 hour urine free cortisol as well as newly elevated A1C of 5.7%. DEXA scan showed osteopenia. CT abdomen pelvis showed small adrenal glands. His HIV medication was switched to a combination of bictegravir, emtricitabine and tenofovir and he subsequently developed significant fatigue, nausea, abdominal discomfort and headaches. He was started on replacement doses of prednisone and his symptoms improved significantly. The prednisone dose is being gradually tapered, with ongoing recovery of the hypothalamic-pituitary-adrenal(HPA) axis, with now low, but detectable cortisol and ACTH levels. We present a unique case of iatrogenic Cushing’s syndrome due to concomitant use of cobicistat with inhaled fluticasone and the subsequent development of secondary adrenal insufficiency upon discontinuation of cobicistat. Cobicistat is an inhibitor of CYP3A which can cause decreased metabolism of exogenous glucocorticoids resulting in HPA axis suppression and exogenous Cushing’s syndrome. Fluticasone causes more cortisol suppression than other inhaled steroids because of it’s long half-life, higher binding affinity for glucocorticoid receptors and high lipophilicity. Concomitant use of cobicistat and glucocorticoids, including inhaled fluticasone, should be avoided and clinicians should be aware of the potential for iatrogenic Cushing’s syndrome and consequent adrenal insufficiency upon discontinuation of cobicistat after use with concomitant glucocorticoids. Presentation: Saturday, June 17, 2023

Impact of Cushing's syndrome on the gonadotrope axis and testicular functions in men.

Does Cushing's syndrome (CS) differently affect the gonadotrope axis and testicular functions (GA/TF) according to the hypercortisolism intensity and underlying etiology? Endogenous cortisol excess caused by CS leads to varying degrees of hypogonadotropic hypogonadism (HH) with more severe GA/TF impairment and altered spermatogenesis in men with intense hypercortisolism associated with paraneoplastic/ectopic adrenocorticotrophic hormone (ACTH) secretion (EAS). CS is very rarely studied in men due to its lower prevalence in men than in women. In a few old reports focusing exclusively on a limited number of men with Cushing's disease (CD), the occurrence of hypogonadism was reported. However, a detailed assessment of the impact of CS on the GA/TF in a significant series of patients has not been performed. Yet, hypogonadism could worsen CS-associated comorbidities such as osteoporosis and myopathy. To date, the full spectrum of GA/TF impairment in men with CS of different etiologies and intensity remains unknown. In this monocentric study, 89 men with CS diagnosed at a tertiary endocrine university center (Bicêtre, Paris Saclay) between January 1990 and July 2021 were evaluated and compared to 40 normal men of similar age. The CS patient cohort of 89 men included 51 with CD, 29 with EAS and 9 with CS of adrenal origin i.e. (ACTH-independent CS (AI-CS)). They all had frank hypercortisolism, with increased 24 h-urinary-free cortisol (24 h-UFC) in two separate samples. A case-control study was performed focusing on pituitary gonadotrope function and testicular sex steroids and peptides. An additional set of six CS men had an evaluation including semen analysis. In a subgroup of 20 men with available data after CS remission, a longitudinal analysis was conducted to assess the reversibility of GA/TF defects. Compared to controls, men with CS had significantly lower total testosterone (TT), bioavailable TT, and free TT (P < 0.0001). Hypogonadism, defined as serum TT levels <3.0 ng/ml, was present in 83% of men with EAS, in 61% of men with CD, and in 33% of men with AI-CS. Low-normal LH concentrations in the included men with hypercortisolism indicated HH. Serum sex hormone-binding globulin levels were moderately decreased in men with CD (P = 0.01 vs controls). Among the CS men, those with EAS had significantly lower TT, LH, and FSH levels than those with CD or AI-CS. When compared to controls, patients with EAS were the only group exhibiting a significant decrease in both serum FSH (P = 0.002) and the testicular peptides inhibin B (P < 0.0001) and anti-Müllerian hormone (P = 0.003). Serum INSL3 levels were significantly lower in men with CD than in the controls (P = 0.03). Of note, 24 h-UFC and ACTH were inversely and significantly associated with the majority of reproductive hormones including LH, FSH, TT, and inhibin B. Following successful curative therapy, reproductive assessment at a mean of 6.0 ± 4.3 years showed a significant increase in serum TT (P < 0.0001) and plasma LH (P = 0.02) levels, indicating a reversal of HH in 75% of the affected males. Among the six patients with available semen analysis, the two EAS cases exhibited a decrease in Sertoli cell peptides associated with a severe oligozoospermia, which completely normalized following removal of the source of hypercortisolism. The potential bias due to the retrospective design is counteracted by the analysis of the largest male CS cohort to date as well as the use of stringent inclusion and exclusion criteria. Due to the low number of patients with semen analysis in this study, further research is needed to unravel the full spectrum of spermatogenesis defects in men with CS. This work reveals the variable spectrum of reproductive impact in men with CS. We demonstrate that GA/TF impairment depends on the intensity of hypercortisolism which in turn is related to the underlying etiology. The causal link between hypercortisolism and GA/TF impairment was attested by its reversibility in most patients after CS remission. The wider implications of our findings lie in the potential generalization to a much commoner entity, iatrogenic CS due to chronic exposure to exogenous glucocorticoids. Several research grants were attributed to J.Y.: (i) a grant from Programme Hospitalier de Recherche Clinique (PHRC # P081212 HYPOPROTEO); (ii) a grant from the French Association of Patients with Adrenal Diseases ('Association surrénales'); and (iii) independent Investigator Research Grants from HRA Pharma, Novartis and Recordati Pharma. A SICPA Foundation grant (Lausanne, Switzerland) allowed protected research time for G.E.P. The above sponsors were not involved in any part of the study. The authors have no competing or other conflicts of interest to declare. N/A.

Syndrome de Cushing sous fluticasone inhalée : interactions médicamenteuses à éviter

Cushing's syndrome is an iatrogenic event occurring during co-administration of inhaled corticosteroids and potent inhibitors of P450 cytochromes. We report the clinical case of a 29-year-old woman with a past history of asthma treated with inhaled fluticasone propionate (FP), chronic pulmonary aspergillosis and allergic bronchopulmonary aspergillosis (ABPA) treated with itraconazole (ITZ), and Mycobacterium xenopi infection treated with moxifloxacin (MXF), ethambutol (EMB) and clarithromycin (CLR). Four months after initiation of antibiotic and antifungal medication, the patient contracted Cushing's syndrome. Its etiology consisted in interaction between FP, ITZ and CLR, which led to pronouncedly increased corticosteroid concentrations in circulating plasma cells. Following on the one hand cessation of FP and ITZ and on the other hand hydrocortisone supplementation, evolution was favorable. Several cases of iatrogenic Cushing's syndrome induced by co-administration of FP and potent CYP3A4 inhibitors have been reported in the literature. If possible, FP should be avoided in patients being treated with CYP3A4 inhibitors. Due to its differing physicochemical properties, beclometasone may be considered as the safest therapeutic alternative.

Anabolic Androgenic Steroids Induced Iatrogenic Cushing Syndrome in a Patient with Relapse of Antitubercular Drugs Induced Hepatitis

Anabolic Androgenic Steroids Induced Iatrogenic Cushing Syndrome in a Patient with Relapse of Antitubercular Drugs Induced Hepatitis

Topical Corticosteroid-Induced Iatrogenic Cushing Syndrome in an Adolescent: A Case Report

Cushing syndrome (CS) is an endocrinological disorder characterized by increased blood cortisol level. It is either due to an excessive endogenous release of steroids (e.g., pituitary adenoma or adrenal hyperplasia) or exogenous administration of steroids. Iatrogenic Cushing syndrome is the most common form of Cushing syndrome. The vast majority of cases are due to oral or parenteral steroid preparations, which are commonly prescribed for pulmonary, renal, hematological or autoimmune diseases. Prolonged use of topical corticosteroids, particularly in children, may cause Cushing syndrome and suppression of the hypothalamo-pituitory-adrenal (HPA) axis, which is less common than that of oral or parenteral route. Iatrogenic CS due to the overuse of topical corticosteroids is rarely reported. There are only few cases that reported young children having Cushing syndrome secondary to misuse of topical corticosteroids.

A Case of Iatrogenic Cushing's Syndrome

A Case of Iatrogenic Cushing's Syndrome

Iatrogenic Cushing syndrome in a child due to erroneous compounding of omeprazole containing glucocorticoid: A case report and literature review

A 3-month-old infant was examined for inconsolable crying with polydipsia, polyuria, and rapid weight gain. Unexpectedly, the symptoms resolved spontaneously during hospitalization but were aggravated 2 weeks after discharge, with the patient presenting a Cushingoid appearance. Investigations ruled out diabetes mellitus and nephrogenic diabetes insipidus but indicated adrenocortical suppression by exogenous glucocorticoids, which were discovered via toxicologic analysis of her previously compounded omeprazole suspension. After discontinuing the omeprazole suspension, the infant recovered fully and the laboratory results normalized. This case shows us that the assumption of appropriate medication intake may conceal unexpected medication errors.Following this case, the current literature on the benefits and risks of compounding and its impact on patient health is discussed.

Current and future perspectives on clinical management of classic 21-hydroxylase deficiency.

Optimizing the glucocorticoid dosage has been a major concern in classic 21OHD (21-hydroxylase deficiency) treatment, as it is essential to adjust it meticulously to the needs of the individual patient. Insufficient glucocorticoid treatment will cause adrenal insufficiency, including life-threatening adrenal crisis, while excess of androgen could cause precocious pubertal growth in children, virilization in female patients, and infertility in male and female adult patients. Meanwhile, overtreatment with glucocorticoids causes iatrogenic Cushing's syndrome which could result in growth impairment, obesity, osteoporosis, and hypertension. The dilemma of 21OHD treatment is that glucocorticoid supplementation therapy at physiological dosage does not sufficiently suppress ACTH, consequently leading to adrenal androgen excess. Accordingly, the window for the appropriate glucocorticoid treatment would have to be substantially narrower than that of other types of adrenal insufficiency without androgen excess, such as adrenal hypoplasia. For the appropriate management of classic 21OHD, the physician has to be well versed in the physiology of the adrenal cortex, growth, and reproductive function. Comprehensive understanding of patients' requirements according to their life stage and sex is essential. Furthermore, female patients with 46,XX need to be cared for as differences in sex development (DSD) with careful psychological management. In this review, we aimed to comprehensively summarize the current status of classic 21OHD treatment, including the initial treatment during the neonatal period, management of adrenal insufficiency, maintenance therapy of each life stage, and the importance of clinical management as DSD for 46,XX female patients. The recently developed agents, Chronocort, and Crinecerfont, are also discussed.

Methyl-Prednisolone and Betamethasone Induced Iatrogenic Cushing Syndrome - A Rare Case Report

Methyl-Prednisolone and Betamethasone Induced Iatrogenic Cushing Syndrome - A Rare Case Report