Endocrine Abstracts

A 62-year-old lady was referred to our Department with a nine-month history of facial swelling, easy bruising, and centripetal weight gain. She had a longstanding history of depression, hypertension, and osteoarthritis. She was taking citalopram, buspirone, atenolol and bendrofluazide. A few months earlier she had received bilateral intra-articular knee injections at her local hospital for arthritic pain. On examination she had thin skin with multiple bruises, facial puffiness and supra-clavicular and dorso-cervical fat pads. Urinary free cortisol and plasma ACTH were undetectable. Short (baseline and 60 min cortisol values 39 and 181 nmol/l respectively) and prolonged (peak cortisol 1332 nmol/l) synacthen tests were consistent with secondary hypoadrenalism. A urinary steroid profile did not indicate presence of exogenous glucocorticoids.

The patient was commenced on hydrocortisone. Following liaison with the rheumatologists it transpired that over a three-month period, 9 months prior to presentation the patient had received four, 40 mg intra-articular triamcinolone acetonide (TCA) injections. On this basis a diagnosis of iatrogenic Cushing’s syndrome (ICS) with concomitant adrenal suppression was made. Accordingly over a 15-month follow-up period the patient’s Cushingoid features resolved. Serial synacthen tests have similarly shown recovery of the hypothalamo-pituitary–adrenal axis which however 20 months following the last TCA injections remains incomplete (last peak cortisol 470 nmol/l).

TCA is a fluorinated hydrocortisone licensed for use in inflammatory and allergic disorders. The development of ICS following a single topical (intra-articular, intra-dermal, epidural) and systemic (intra-muscular) TCA injection has been reported in both adults and children. Cushingoid features typically manifest 14–28 days after the initial injection and adrenal suppression has been reported to last for up to 9 months with one patient developing acute adrenal insufficiency. Our case highlights that clinicians should be aware that although rare, side effects (including prolonged adrenal suppression) are possible with all local steroid applications.