Key points are not available for this paper at this time.
Abstract Disclosure: L. Bellavia: None. M. Pignanelli: None. D. Aqbal: None. Background: Cushing Syndrome (CS) from iatrogenic steroid administration is a well- established consequence of steroid use. It is important to recognize the potential of this condition even after a 1-time intraarticular steroid injection received months earlier. Clinical Case: A 40-year-old woman presented for evaluation of rapid weight gain, abdominal stretch marks and excess hair growth. Work-up was consistent with an ACTH-independent etiology of CS, suggestive of exogenous steroid use: ACTH undetectable ( 5 pg/mL, n6-50 pg/mL), 24 hr urinary free cortisol undetectable ( 2 ug/24 hrs, n6-42 ug/24hr), morning cortisol undetectable ( 0.5 mcg/dL, n4-22 mcg/dL). Historical review with patient included thorough review of medications and products without noted steroids. CT Abdomen pelvis completed 12 months prior for unrelated symptoms showed unremarkable adrenal glands without any masses. MRI Brain pituitary was normal. The source of her steroid exposure was still unclear, so a serum synthetic glucocorticoid screen was sent, which revealed elevated levels of Triamcinolone Acetonide (TCA) at 0.22 mcg/dL (n0.10 mcg/dL). Her pharmacy and her providers were contacted to assess for any TCA exposures, which revealed that she received 40mg of TCA intraarticular injection via ultrasound guided technique into her right hip bursa for hip bursitis 6 months prior to presentation. No other exposures to TCA were found on review. Two months after presentation (8 months after TCA exposure), she began to develop nausea, vomiting, fatigue, and weakness and was thus started on Hydrocortisone 10mg daily for developing adrenal insufficiency. Repeat testing at that time revealed a suppressed adrenal axis, with repeat morning cortisol 0.5 mcg/dL, ACTH 5 pg/mL and TCA levels of 0.15 mcg/dL. The pharmacokinetics of TCA following intraarticular injections is not well established with variable reports of synovial half-life ranging from 1 day to greater than 3 weeks, with the maximum effect of TCA on cortisol suppression observed with TCA serum levels of 0.19 mcg/dL. No other documented cases of TCA induced CS have demonstrated lasting clinical effects 8 months after TCA exposure. Conclusion: It is important to recognize the potential of rare adverse events that are attributable to the systemic absorption of intraarticular corticosteroids as their pharmacokinetics are not well known. This case raises the need for early general medical education for clinicians and patients about the potential risks of corticosteroids, administered from any route, even after isolated exposures. Reference: Dickson RR, Reid JM, Nicholson WT, Lamer TJ, Hooten WM. Corticosteroid and Cortisol Serum Levels Following Intra-articular Triamcinolone Acetonide Lumbar Facet Joint Injections. Pain Pract. 2018 Sep;18(7):864-870. doi: 10.1111/papr.12686. Epub 2018 Mar 23. PMID: 29436106. Presentation: 6/3/2024
Bellavia et al. (Tue,) studied this question.