Adrenal insufficiency and growth failure secondary to iatrogenic inhaled and intranasal corticosteroids - a case report.

Introduction: Chronic glucocorticoid therapy by systemic and inhaled forms is the most common cause of adrenal insufficiency. There is no administrative form, dosing, duration or underlying disease for which it is more common, although higher dose and prolonged use have highest risk. Clinical case characteristics: A 11-year-old girl was brought with cough and cold for a week, fever, vomiting and headache for one day. She had been diagnosed to have asthma and allergic rhinitis 7 years ago. She was started on Mometasone 120mcg nasal spray OD, used for 4 years and Budesonide 64mcg nasal spray BD for 1 year. She was also put on Formoterol 6mcg + Mometasone 200mcg MDI, used for 4 years, and Formoterol 6mcg + Budesonide 200mcg MDI, used for 1 year. No significant birth or family history. On examination, child was severely stunted and wasted, with height and weight below - 3 standard deviations on IAP growth chart. She was hemodynamically stable, head to toe and systemic examination was normal. Outcome: She was found to have severe hyponatremia, which was corrected. Due to significant past history of chronic usage of intranasal and inhaled corticosteroids, adrenal insufficiency was suspected and serum cortisol levels done, which were low. ACTH stimulation test was administered and serum cortisol levels tested at 30 minutes and 60 minutes, remained below the reference range after the test. Hence the child was diagnosed to have adrenal insufficiency. Pediatric endocrinology reference taken and steroids tapered over several weeks. Serum cortisol levels monitored during follow up were normal. Conclusion: Clinicians must have a high index of suspicion, especially in patients with nonspecific symptoms after cessation of high-dose or long-term steroids and consider testing for cortisol levels. Patient education, monitoring and regular follow up is a key feature of management of this condition. [ABSTRACT FROM AUTHOR]