Cargando…

Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy

SUMMARY: We present a case of iatrogenic Cushing’s syndrome, induced by treatment with fluticasone furoate (1–2 dd, 27.5 µg in each nostril) in a pediatric patient treated for congenital HIV. The pediatric patient described in this case report is a young girl of African descent, treated for congenit...

Descripción completa

Detalles Bibliográficos
Autores principales: van den Berg, S A A, van ‘t Veer, N E, Emmen, J M A, van Beek, R H T
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Bioscientifica Ltd 2017
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5404706/
https://www.ncbi.nlm.nih.gov/pubmed/28458904
http://dx.doi.org/10.1530/EDM-16-0158
_version_ 1783231638736470016
author van den Berg, S A A
van ‘t Veer, N E
Emmen, J M A
van Beek, R H T
author_facet van den Berg, S A A
van ‘t Veer, N E
Emmen, J M A
van Beek, R H T
author_sort van den Berg, S A A
collection PubMed
description SUMMARY: We present a case of iatrogenic Cushing’s syndrome, induced by treatment with fluticasone furoate (1–2 dd, 27.5 µg in each nostril) in a pediatric patient treated for congenital HIV. The pediatric patient described in this case report is a young girl of African descent, treated for congenital HIV with a combination therapy of Lopinavir/Ritonavir (1 dd 320/80 mg), Lamivudine (1 dd 160 mg) and Abacavir (1 dd 320 mg). Our pediatric patient presented with typical Cushingoid features (i.e. striae of the upper legs, full moon face, increased body and facial hair) within weeks after starting fluticasone furoate therapy, which was exacerbated after increasing the dose to 2 dd because of complaints of unresolved rhinitis. Biochemical analysis fitted iatrogenic Cushing’s syndrome, with a repeatedly low cortisol (<0.03 µM, ref 0.14–0.60 µM) and low ACTH (9 pg/mL, ref 9–52 pg/mL) without signs of adrenal insufficiency. No other biochemical abnormalities that could point to adrenal or pituitary dysfunction were detected; electrolytes, thyroid and gonadal function, and IGF-1 were within the normal range. Pharmacogenetic analysis revealed that the pediatric patient carried the CYP3A4 *1B/*1G and CYP3A5 *3/*3 genotype (associated with a partial and complete loss of enzyme activity, respectively) which is associated with the development of iatrogenic Cushing’s syndrome in patients treated for HIV due to the strong inhibition of CYP3 enzymes by Ritonavir. Upon discontinuation of fluticasone treatment, the pediatric patient improved both clinically and biochemically with normalisation of cortisol and ACTH within a couple of weeks. LEARNING POINTS: Fluticasone therapy may induce iatrogenic Cushing’s syndrome in a patient treated with anti-retroviral therapy. Pharmacogenetic analysis, in particular CYP3A genotyping, provides useful information in patients treated for HIV with respect to possible future steroid treatment. Fluticasone furoate is not detected in the Siemens Immulite cortisol binding assay.
format Online
Article
Text
id pubmed-5404706
institution National Center for Biotechnology Information
language English
publishDate 2017
publisher Bioscientifica Ltd
record_format MEDLINE/PubMed
spelling pubmed-54047062017-04-28 Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy van den Berg, S A A van ‘t Veer, N E Emmen, J M A van Beek, R H T Endocrinol Diabetes Metab Case Rep Unusual Effects of Medical Treatment SUMMARY: We present a case of iatrogenic Cushing’s syndrome, induced by treatment with fluticasone furoate (1–2 dd, 27.5 µg in each nostril) in a pediatric patient treated for congenital HIV. The pediatric patient described in this case report is a young girl of African descent, treated for congenital HIV with a combination therapy of Lopinavir/Ritonavir (1 dd 320/80 mg), Lamivudine (1 dd 160 mg) and Abacavir (1 dd 320 mg). Our pediatric patient presented with typical Cushingoid features (i.e. striae of the upper legs, full moon face, increased body and facial hair) within weeks after starting fluticasone furoate therapy, which was exacerbated after increasing the dose to 2 dd because of complaints of unresolved rhinitis. Biochemical analysis fitted iatrogenic Cushing’s syndrome, with a repeatedly low cortisol (<0.03 µM, ref 0.14–0.60 µM) and low ACTH (9 pg/mL, ref 9–52 pg/mL) without signs of adrenal insufficiency. No other biochemical abnormalities that could point to adrenal or pituitary dysfunction were detected; electrolytes, thyroid and gonadal function, and IGF-1 were within the normal range. Pharmacogenetic analysis revealed that the pediatric patient carried the CYP3A4 *1B/*1G and CYP3A5 *3/*3 genotype (associated with a partial and complete loss of enzyme activity, respectively) which is associated with the development of iatrogenic Cushing’s syndrome in patients treated for HIV due to the strong inhibition of CYP3 enzymes by Ritonavir. Upon discontinuation of fluticasone treatment, the pediatric patient improved both clinically and biochemically with normalisation of cortisol and ACTH within a couple of weeks. LEARNING POINTS: Fluticasone therapy may induce iatrogenic Cushing’s syndrome in a patient treated with anti-retroviral therapy. Pharmacogenetic analysis, in particular CYP3A genotyping, provides useful information in patients treated for HIV with respect to possible future steroid treatment. Fluticasone furoate is not detected in the Siemens Immulite cortisol binding assay. Bioscientifica Ltd 2017-04-06 /pmc/articles/PMC5404706/ /pubmed/28458904 http://dx.doi.org/10.1530/EDM-16-0158 Text en © 2017 The authors http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_GB This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_GB) .
spellingShingle Unusual Effects of Medical Treatment
van den Berg, S A A
van ‘t Veer, N E
Emmen, J M A
van Beek, R H T
Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy
title Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy
title_full Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy
title_fullStr Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy
title_full_unstemmed Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy
title_short Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy
title_sort fluticasone furoate induced iatrogenic cushing syndrome in a pediatric patient receiving anti-retroviral therapy
topic Unusual Effects of Medical Treatment
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5404706/
https://www.ncbi.nlm.nih.gov/pubmed/28458904
http://dx.doi.org/10.1530/EDM-16-0158
work_keys_str_mv AT vandenbergsaa fluticasonefuroateinducediatrogeniccushingsyndromeinapediatricpatientreceivingantiretroviraltherapy
AT vantveerne fluticasonefuroateinducediatrogeniccushingsyndromeinapediatricpatientreceivingantiretroviraltherapy
AT emmenjma fluticasonefuroateinducediatrogeniccushingsyndromeinapediatricpatientreceivingantiretroviraltherapy
AT vanbeekrht fluticasonefuroateinducediatrogeniccushingsyndromeinapediatricpatientreceivingantiretroviraltherapy