American Journal of Medical Case Reports
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American Journal of Medical Case Reports. 2016, 4(4), 130-133
DOI: 10.12691/ajmcr-4-4-5
Open AccessCase Report

Cushing Syndrome Following Single Steroid Injection: A Case Report and Review of the Literature

Mohamad Motawea1, , Heba Mosaad2, Nabil M. Aladeeb3 and Ahmed M. Abd El-khalek4

1Lecturer of Internal Medicine, Specialized Medical Hospital, Faculty of Medicine, Mansoura University, Egypt. Senior registrar of internal medicine, Al-Khaji National Hospital, Alkhafji, KSA

2Lecturer of clinical pathology and pharmacology, Faculty of Medicine, Mansoura University, Egypt

3Lecturer of clinical pharmacology, Faculty of Medicine, Mansoura University, Egypt

4Lecturer of diagnostic radiology, Faculty of Medicine, Mansoura University, Egypt

Pub. Date: April 27, 2016

Cite this paper:
Mohamad Motawea, Heba Mosaad, Nabil M. Aladeeb and Ahmed M. Abd El-khalek. Cushing Syndrome Following Single Steroid Injection: A Case Report and Review of the Literature. American Journal of Medical Case Reports. 2016; 4(4):130-133. doi: 10.12691/ajmcr-4-4-5


Iatrogenic Cushing’s syndrome (ICS) is a well-known adverse effect of glucocorticoids. It usually develops after prolonged exposure to excessive amounts of synthetic glucocorticoids. The manifestations of ICS are generally dose and time dependent. We will report on our own case of ICS followed by a review/highlight of published cases of ICS following single steroid injection. The development of ICS after a single and low dose of synthetic glucocorticoid is an exceptional event and only a few patients have been reported to date in the literature. Here we will report on the case of a twenty-one -year-old female patient who developed ICS with striae rubra which appeared fifteen days after irrational use of a single intramuscular injection of betamethasone (Diprofos). Endocrinological evaluation confirmed hypothalamic-pituitary-adrenal axis suppression. Her striae showed gradual fading over the next two months leaving only thin white striae similar to stretch marks. We performed a review of the literature using a computer search in the Science Direct, Google Scholar, and National Library of Medicine from 1950 to January 2016 for ICS following single injection of synthetic glucocorticoids using the terms ‘single injection’, ‘iatrogenic’, ‘betamethasone’, ‘triamcinolone’, ‘hydrocortisone’ ‘dexamethasone’ ‘adrenal suppression’ ‘Cushing case report’ and ‘Cushing’s syndrome’. Nine case reports of ICS were found in both children and adults following a single steroid injection. There are multiple factors affecting the response to steroids that make one develop Cushing’s syndrome while the others do not. Governments in developing countries must make more serious efforts to enforce the existing laws that prohibit the irrational use of steroids.

Iatrogenic Cushing’s syndrome Betamethasone hypothalamic-pituitary-adrenal axis suppression Diprofos Cushing case report

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[1]  Iglesias P., González J., Díez J. J. Acute and persistent iatrogenic Cushing’s syndrome after a single dose of triamcinolone acetonide. J Endocrinol Invest 28(11): 1019-1023, 2005.
[2]  Girre C, Vincens M, Gompel A, Fournier PE. Iatrogenic Cushing's syndrome caused by an acute overdose of triamcinolone. Therapie, 42(3): 317-318, 1987.
[3]  Tempark T, Phatarakijnirund V, Chatproedprai S, Watcharasindhu S, Supornsilchai V, Wananukul S. Exogenous Cushing's syndrome due to topical corticosteroid application: case report and review literature. Endocrine 38(3): 328-334, 2010.
[4]  Pranab Kumar Sahana, Nilendu Sarma, Nilanjan Sengupta, Prashant Subhash Somani. A Florid Case of Iatrogenic Cushing's Syndrome Induced by Topical Steroid with Osteoporosis and Hypogonadism. Indian J Dermatol 60(4): 420, 2015.
[5]  Deep Dutta, Shivaprasad KS, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury. Iatrogenic Cushing’s Syndrome Following Short-Term Intranasal Steroid Use. J Clin Res Pediatr Endocrinol 4(3): 157-159, 2012.
[6]  Ozlem Celik, Mutlu Niyazoglu, Hikmet Soylu, Pinar Kadioglu. Iatrogenic Cushing’s syndrome with inhaled steroid plus antidepressant drugs. Multidiscip Respir Med 7: 26, 2012.
[7]  Raveendran A.V. Inhalational Steroids and Iatrogenic Cushing’s Syndrome. Open Respir Med J 8: 74-84, 2014.
[8]  Sapna Sadarangani, Melody L. Berg, William Mauck, Stacey Rizza. Iatrogenic Cushing Syndrome Secondary to Ritonavir-Epidural Triamcinolone Interaction: An Illustrative Case and Review. Interdisciplinary Perspectives on Infectious Diseases. Volume 2014 (2014), Article ID 849432, 7 pages.
[9]  Danielle Levine, Sonia Ananthakrishnan, Amit Garg. Iatrogenic Cushing syndrome after a single intramuscular corticosteroid injection and concomitant protease inhibitor therapy (agents inhibiting cytochrome p450). J Am Acad Dermatol 65(4): 877-878, 2011.
[10]  Triamcinolone, DRUGDEX System. Version 5.1, Thomson Healthcare, Greenwood Village, Colo, USA.
[11]  Jansen TLTHA, Van Roon EN. Four cases of a secondary Cushingoid state following local triamcinolone acetonide (Kenacort®) injection. Neth J Med 60: 151-153, 2002.
[12]  Augspurger RR, Wettlaufer JN. Cushing’s syndrome: complication of triamcinolone injection urethral strictures in children. J Urol 123: 932-933, 1980.
[13]  Teelucksingh S, Balkaran B, Ganeshmoorthi A, Arthur P. Prolonged childhood Cushing’s syndrome secondary to intral-esional triamcinolone acetonide. Ann Trop Paediatr 22: 89-91, 2002.
[14]  Kumar S, Singh RJ, Reed AM, Lteif AN. Cushing’s syndrome after intra-articular and intradermal administration of triam-cinolone acetonide in three pediatric patients. Pediatrics 13: 1820-1824, 2004.
[15]  Tomé MA, Peñalva A, Casanueva FF. Suppression of the pituitary-adrenal axis after iatrogenic Cushing’s syndrome by epidural triamcinolone injection. 11th Meeting of the European Neuroendocrine Association (ENEA) 2004; Cp (abstract).
[16]  Stephen M. Tuel, Jay M. Meythaler, Leland L. Cross. Cushing's syndrome from epidural methylprednisolone. J pain 40: 81-84, 1990.
[17]  Grierson M. J., Harrast M. A., “Iatrogenic Cushing syndrome after epidural steroid injections for lumbar radiculopathy in an HIV-infected patient treated with ritonavir: a case report highlighting drug interactions for spine interventionalists,” PM R 4(3): 234-237, 2012.
[18]  Yombi J. C., Maiter D., Belkhir L., Nzeusseu A., Vandercam B., “Iatrogenic Cushing's syndrome and secondary adrenal insufficiency after a single intra-articular administration of triamcinolone acetonide in HIV-infected patients treated with ritonavir,” Clin Rheumatol 27 (2): 79-82, 2008.
[19]  Ramanathan R., Pau A. K., Busse K. H., Zemskova M, Nieman L, Kwan R, Hammer JH, Mican JM, Maldarelli F. “Iatrogenic cushing syndrome after epidural triamcinolone injections in an HIV type 1-infected patient receiving therapy with ritonavir-lopinavir,” Clin Infect Dis 47 (12): 97-98, 2008.
[20]  Danaher P. J., Salsbury T. L., Delmar J. A., “Metabolic derangement after injection of triamcinolone into the hip of an HIV-infected patient receiving ritonavir,” Orthopedics 32 (6), 450, 2009.
[21]  Dort K., Padia S., Wispelwey B., Moore C. C., “Adrenal suppression due to an interaction between ritonavir and injected triamcinolone: a case report,” AIDS Res Ther 8: 6-10, 2009.
[22]  Levine D., Ananthakrishnan S., Garg A., “Iatrogenic Cushing syndrome after a single intramuscular corticosteroid injection and concomitant protease inhibitor therapy,” J Am Acad Dermatol 65 (4): 877-878, 2011.
[23]  Albert N. E., Kazi, J. Santaro, and R. Dougherty, “Ritonavir and epidural triamcinolone as a cause of iatrogenic Cushing’s syndrome,” Am J Med Sci 344 (1): 72-74, 2012.
[24]  Fessler D., Beach J., Keel J., Stead W., “Iatrogenic Hypercortisolism Complicating triamcinolone acetonide injections in patients with HIV on ritonavir-boosted protease inhibitors,” Pain Physician 15(6): 489-493, 2012.
[25]  Maviki M., Cowley P., Marmery H., “Injecting epidural and intra-articular triamcinolone in HIV-positive patients on ritonavir: beware of iatrogenic Cushing’s syndrome,” Skeletal Radiol 42 (2): 313-315, 2013.
[26]  Schwarze-Zander C., Klingmüller D., Klumper J., Strassbag P., Rockstroh J. K. “Triamcinolone and ritonavir leading to drug-induced Cushing syndrome and adrenal suppression: description of a new case and review of the literature,” Infection 41(6): 1183–1187, 2013.
[27]  Hall J. J., Hughes C. A., Foisy M. M., Houston S., Shafran S. “Iatrogenic Cushing syndrome after intra-articular triamcinolone in a patient receiving ritonavir-boosted darunavir,” Int J STD AIDS 24(9): 748-752, 2013.
[28]  Hui JYH, Woo PCY, Lo SS, Chan JCS. Over the counter medication and its effects. Lancet 359: 1120, 2002.
[29]  Kshirsagar MJ, Langade D, Patil S, Patki PS. Prescribing patterns among medical practitioners in Pune, India. Bull World Health Organ 76(3): 271-275, 1998.
[31]  Fell P. J. Kinetic studies of cortisol and synthetic corticosteroids in man. Clinical Endocrinology 1: 65-72, 1972.
[32]  Chunhui He, Hongwei Fan, Jie Tan, Jianjun Zou, Yubing Zhu, Kun Yang, Qin Hu. Pharmacokinetics of betamethasone and betamethasone 17-monopropionate in Chinese healthy volunteers after intramuscular injection of betamethasone phosphate/betamethasone dipropionate. Arzneimittel-forschung 61(7): 417-420, 2011.
[33]  Hirano K, Ichihashi T, HY. Studies on the absorption of practically water-insoluble drugs following injection. II. Intramuscular absorption from aqueous suspensions in rats. Chem Pharm Bull (Tokyo) 29: 817-827, 1981.
[34]  Daley-Yates PT, Price AC, Sisson JR, Pereira A, Dallow N. Beclomethasone dipropionate: absolute bioavailability, pharmacokinetics and metabolism following intravenous, oral, intranasal and inhaled administration in man. Br J Clin Pharmacol 51: 400-409, 2001.