OBJECTIVE: To present an unusual case of Cushing syndrome in a pediatric patient caused by a single depot triamcinolone injection. METHODS: A case report followed by a literature review are presented. RESULTS: A 13-year-old male presented with rapid weight gain, elevated blood pressure, headaches, and diffuse purplish striae. Lab results revealed a low 24-hour urinary free cortisol of <3 μg (reference range is 4.0 to 56 μg/24 hours), a low midnight salivary cortisol of <50 ng/dL (reference range is <100 ng/dL), a low adrenocorticotropic hormone of <5 pg/mL (reference range is 6 to 55 pg/mL), and a lower than expected testosterone of 86 ng/dL. The values were not consistent, and upon further questioning the family admitted the patient had received a "Jesus shot" from a practitioner which was sold as a cure all. Upon further investigation, it was determined that this injection contained both dexamethasone and depot triamcinolone. The triamcinolone in this injection was quantified and remained measureable for over 4 months following injection. CONCLUSION: The cause of Cushing syndrome symptoms with adrenal suppression was exogenous glucocorticoid, specifically depot triamcinolone. Exogenous glucocorticoids can create adrenal suppression, contributing to life-threatening adrenal crises with illness or stress. Recovery of our patient's adrenal axis was demonstrable within a few months. This case highlights the potentially devastating effects of glucocorticoid treatment for unclear medical indications. Further, it raises concerns about the potential unintended consequences of such therapies and the importance for providers to raise additional questions whenever the clinical presentation and laboratory investigation are inconsistent.
OBJECTIVE: To present an unusual case of Cushing syndrome in a pediatric patient caused by a single depot triamcinolone injection. METHODS: A case report followed by a literature review are presented. RESULTS: A 13-year-old male presented with rapid weight gain, elevated blood pressure, headaches, and diffuse purplish striae. Lab results revealed a low 24-hour urinary free cortisol of <3 μg (reference range is 4.0 to 56 μg/24 hours), a low midnight salivary cortisol of <50 ng/dL (reference range is <100 ng/dL), a low adrenocorticotropic hormone of <5 pg/mL (reference range is 6 to 55 pg/mL), and a lower than expected testosterone of 86 ng/dL. The values were not consistent, and upon further questioning the family admitted the patient had received a "Jesus shot" from a practitioner which was sold as a cure all. Upon further investigation, it was determined that this injection contained both dexamethasone and depot triamcinolone. The triamcinolone in this injection was quantified and remained measureable for over 4 months following injection. CONCLUSION: The cause of Cushing syndrome symptoms with adrenal suppression was exogenous glucocorticoid, specifically depot triamcinolone. Exogenous glucocorticoids can create adrenal suppression, contributing to life-threatening adrenal crises with illness or stress. Recovery of our patient's adrenal axis was demonstrable within a few months. This case highlights the potentially devastating effects of glucocorticoid treatment for unclear medical indications. Further, it raises concerns about the potential unintended consequences of such therapies and the importance for providers to raise additional questions whenever the clinical presentation and laboratory investigation are inconsistent.
Authors: Lynnette K Nieman; Beverly M K Biller; James W Findling; John Newell-Price; Martin O Savage; Paul M Stewart; Victor M Montori Journal: J Clin Endocrinol Metab Date: 2008-03-11 Impact factor: 5.958