Endocrine Abstracts

Background: Iatrogeny is the most common cause of Cushing syndrome (CS), with most reported cases due to prolonged use of oral, parenteral or, rarely, topical corticosteroid preparations. Few cases of CS (and consecutive adrenal insufficiency (AI)) due to intranasal corticoids have been reported and the vast majority were documented in pediatric patients.

Case reports: We present two cases of iatrogenic CS due to chronic intranasal administration of over-the-counter intranasal betamethasone in adults.

Patient A: 20-year-old female presenting for a second opinion, having been diagnosed with idiopathic AI 6 months earlier (whilst evaluated for mild hair loss). At that point, substitution with hydrocortisone was recommended, as well as topic minoxidil for hair growth restoration. At presentation in our clinic, she had ceased hydrocortisone administration for one week; lab tests showed low plasmatic 0800 h cortisol (3.27 μg/dl) and adequately elevated ACTH (52.8 pg/ml). We discontinued all medication and reevaluated the patient one month later, when physical examination revealed red striae on the inner thighs. Lab tests once again revealed low ACTH (1.95 pg/ml), low plasmatic 0800 h cortisol (<1 μg/dl) and suboptimal response to Synacthen (1 mg). The patient eventually recalled she had been using intranasal betamethasone 0.5 mg/ml several times/day in the past 2 years for chronic rhinitis. She had fortuitously stopped the medication for one month before the first evaluation in our clinic, but resumed treatment afterwards. The diagnosis of iatrogenic CS (with secondary AI) was made, betamethasone was discontinued and substitution treatment was indicated until restoration of adrenal function.

Patient B: Alarmed by his daughter’s diagnosis, father of patient A presented in our clinic for evaluation one month later. He reported chronic use of both betamethasone 0.5 mg/ml (4–8 times/day in the past 6 years) and beclomethasone 100 μg (4 times/day in the past 8 months). He discontinued betamethasone 8 days prior to presentation and was intensely symptomatic (fatigued, nauseous, with diffuse muscular and osteoarticular pain and blood pressure of 100/60 mmHg (vs. previous hypertensive state)). Blood tests revealed low 0800 h cortisol (2.76 μg/dl) and inadequately normal ACTH (26.18 pg/ml). Substitution therapy was advised, but the patient refused. He continued beclomethasone, as indicated by his pneumologist. Hypertension medication was discontinued and gradually reintroduced as adrenal function recovered in the next 4 months.

Conclusions: Nasal over-the-counter preparations are often not perceived as relevant medication by patients. Still, betamethasone is a potent long-lasting corticosteroid and its capacity of inducing CS should not be overlooked, even in intranasal form.