Endocrine Abstracts

Corticosteroids have been widely used within the management of wide spectrum of conditions. It is well known that long-term use of exogenous glucocorticoids leads to the suppression of the hypothalamic– pituitary–adrenal axis. Even a 5-day course of oral high-dose steroid therapy can cause adrenal suppression. Similarly, high-dose steroid therapy - administered intranasally, inhaled or applied topically to skin can cause adrenal suppression. Depending on administration form, the percentage of patients with adrenal insufficiency varied from 52.2% for intra-articular corticosteroids to 4.2% for nasal corticosteroids. Hence topical route is preferred over oral or parenteral route and administered for shortest possible duration. It is extremely unusual to develop adrenal insufficiency with corticosteroid eye drop usage. In fact, a study specifically designed to establish whether hypothalamic-pituitary-adrenal axis suppression is possible secondary to long-term topical ophthalmic corticosteroid use in patients undergone penetrating keratoplasty (PKP) found no evidence that using continuous long-term corticosteroid eye drops after PKP experienced adrenal suppression. I present a young boy, born with Bilateral Peter’s anomaly, a condition is characterized by central, paracentral, or complete corneal opacity as well as Bilateral congenital glaucoma. He was treated glaucoma tube implant surgery, Bilateral penetrating keratoplasties (full thickness corneal transplants) followed by Dexamethasone 0.1% eye drops twice a day to prevent rejection. By age 9 yrs, he displayed Cushingoid features and possibility of adrenal insufficiency was raised. Hence dexamethasone eye drops were withheld for 1 week. In the interim, Parents were educated regarding possibility of developing adrenal crisis and provided with emergency hydrocortisone supply. One week later, short synacthen test was arranged which revealed Serum Cortisol of < 10 nmol/l at at 0,30 and 60 minutes. His ACTH < 5 (ref 7.2 – 63.3 ng/l) and Adrenal Antibody was negative. Since then further assessment of hypothalamic–pituitary–adrenal axis have consistently revealed complete adrenal suppression. He continues to require dexamethasone eyes drops to treat his ophthalmic condition and is treated with hydrocortisone replacement therapy to treat his adrenal insufficiency.

Learning points: • Long-term use of glucocorticoids leads to the suppression of the hypothalamic–pituitary–adrenal axis which is known as glucocorticoid-induced or iatrogenic adrenal insufficiency.

• Possibility of iatrogenic Adrenal insufficiency should be considered in the differential diagnosis in all patients receiving long term corticosteroid therapy in any form. A thorough clinical as well medication history is of paramount importance in suspecting as well as arriving at the correct diagnosis.