steroids

Case‐Based Introduction to Steroid-Related Adrenal Issues

  • Case 1 – 10-year-old girl with severe persistent asthma

    • Co-morbid GERD → required Nissen fundoplication.

    • Controller therapy before crisis:

    • High-dose mometasone/formoterol 200/5\;\mu g\;\text{BID}

    • Omalizumab SQ.

    • Additional “yellow-zone” plan from Colorado team: budesonide/formoterol PRN (PURIM).

    • 2018–early 2019: ≥2 oral steroid bursts (dexamethasone & prednisone taper).

    • Feb 2019 nocturnal episode: dyspnea, visual disturbance, HA, dizziness, clammy, diarrhea, palpitations → adult ER (initial low BP, resolved) then children’s ED.

    • Extensive work-up: CT head, CXR, EKG, MRI brain ± contrast, LP → unremarkable; ENDO labs clinched diagnosis:

    • AM cortisol < 1 µg/dL.

    • ACTH < 5 pg/mL (low despite expected HPA rebound → acute exogenous suppression).

    • ACTH stimulation test:

      • Baseline cortisol 1.2\;\mu g/dL

      • 30 min 7\;\mu g/dL, 60 min 6\;\mu g/dL (expected ≥ 18\;\mu g/dL).

    • → Dx: Secondary adrenal insufficiency (AI) from steroid therapy.

    • Treated with physiologic hydrocortisone; weaned off after several months; repeat stim normal → cleared.

    • 2020: brief systemic steroids for pneumonia/asthma; AM cortisol acceptable; no further AI.

  • Clinical pearls from Case 1

    • AI can masquerade as vague malaise (“weak & dizzy all over”).

    • Bold/ more common symptoms: fatigue, dizziness, nausea/vomiting/diarrhea, abdominal pain, poor weight gain, arthralgias/myalgias, striae.

    • Emergent red flags: hypotension, hypoglycemia → adrenal crisis → \uparrow\;\text{mortality}.

Who Needs Screening for Adrenal Suppression?

  • Literature + CHOP pathway:

    • Any systemic glucocorticoid ≥ 2 weeks (peds) or ≥ 3 weeks (adults) → risk of HPA suppression.

    • Repeated or chronic bursts in the preceding 12 mo.

    • Cushingoid appearance.

  • Screening test of choice: fasting AM serum cortisol (draw by 08:00).

    • Kids:

    • \ge10\;\mu g/dL → normal.

    • <3\;\mu g/dL → almost always abnormal.

    • 3–10\;\mu g/dL → grey zone.

    • Adults: “normal” threshold closer to 18\;\mu g/dL.

    • Consider simultaneous ACTH.

    • Abnormal/indeterminate → ACTH (