ESPE Abstracts

Background: Adrenal insufficiency (AI) is mainly due to congenital disorders in children. Acquired causes can be autoimmune, inflammatory, infectious but mainly drug induced especially due to prolonged exposure to excess glucocorticoids. Daily dose, duration, timing, as well as the route of administration can all play a role in. We present two patients with different clinical presentations.

Case 1: A 8 year- old-girl referred for obesity. She was on local steroids for widely spread psoriasis for more than 2 years: twice daily. On examination: weight: 45 kg, Height: 129 cm (+0.51 SDS), BMI:27 (+3.58 SDS) cushingoid obesity, red striae on the armpits /on the abdomen, hirsutism and high blood pressure. Investigations revealed low cortisol level: 17 nmol/L (N>144 nmol/L) with a peak cortisol <100 nmol/l on ACTH stimulation. Acquired adrenal insufficiency was diagnosed and replacement therapy by hydrocortisone 10 mg/m² was initiated along with blood pressure management and dietary measures in addition to laser sessions for hirsutism. Adrenal function recovered after 2 years, the treatment was then discontinued.

Discussion: The use of synthetic glucocorticoids remains widely prevalent in medical practice for treating various acute and chronic conditions. The oral route is the most commonly used. As for topical steroids, the cutaneous absorption depends on the exposure area, the presence of a skin permeability enhancer. Regardless of the administration route, deficiency in glucocorticoids occurs due to alteration of ACTH secretion caused by long term treatment. The symptoms are nonspecific and can stay non diagnosed. The diagnosis currently relies on the realization of a Low Dose Short Synacthen Test (LD-SST). Hydrocortisone is preferably used as replacement therapy in adrenal insufficiency because its short duration of action allows the HPA axis to recover. The progressive reduction of treatment serves a dual purpose: preventing adrenal insufficiency linked to persistent suppression of the HPA axis and to avoid a recurrence of the initial condition. The best preventive treatment remains to avoid giving glucocorticoids or to administer them as sparingly and for as short a time as possible.

Conclusion: Our patients illustrate well drug induced adrenal insufficiency which can be insidious and easily misdiagnosed or leading to acute adrenal insufficiency in some cases. Recovery is possible after early diagnosis and treatment.