A 9-year-old female presents to the clinic with facial edema that has progressively worsened over a period of a few weeks.
The patient’s facial swelling had become more pronounced during the 3 days prior to the clinic visit, prompting the mother to bring her daughter to the pediatrician. The patient also was noted to be hypertensive with a blood pressure of 140/110 mm Hg. She denied fevers, headache, change in appetite or weight, chest pain, palpitations, shortness of breath, constipation, diarrhea, changes in urine, or swelling in the extremities.
The patient’s past medical history was significant for Tetralogy of Fallot with pulmonary atresia. Her only medication is aspirin, 81 mg once a day. Her past surgical history was significant for left aortopulmonary shunt in June 2009; complete repair of Tetralogy of Fallot with pulmonary atresia in September 2009; reimplementation of right upper lobe aortopulmonary collateral in June 2011; and pulmonary valve replacement in January 2017.
Following that procedure, a 25-cm keloid developed over the median sternotomy wound. The patient subsequently had a scar revision surgery, five-and-a-half weeks prior to the current presentation, in order to remove this keloid. During this procedure, she received a single injection of Kenalog-40 (triamcinolone acetonide). A dose of 10 mL was dispensed by the pharmacy; however, the actual amount administered was not reported. Her family history was noncontributory.
On initial presentation to the clinic, the patient’s vital signs were significant for a blood pressure of 130/94 mm Hg and a heart rate of 113 beats per minute. She was afebrile. On physical exam, her face demonstrated symmetric bilateral edema, characteristic of the Cushingoid moon facies (Figures 1 to 3). Cardiac exam was significant for a grade 3/6 holosystolic heart murmur. Her lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended with normoactive bowel sounds. There was no peripheral edema noted. Because of her cardiac history and physical exam findings, she was sent to the emergency department (ED) for further evaluation.
The patient’s last echocardiogram performed 4 months prior to clinic presentation demonstrated mild pulmonary valve stenosis; no pulmonary valve regurgitation; right ventricular dilation; normal right and left ventricular systolic function; and a right pleural effusion. In the ED, her chest x-ray showed a mildly enlarged cardiac silhouette, unchanged from previous imaging. Mild pulmonary edema also was noted. Her renal ultrasound was normal.
A complete blood count (CBC) showed a white blood cell (WBC) count of 12.4 μL/L (neutrophils, 69.9; lymphocytes, 20.7); hemoglobin of 14.6 g/dL; hematocrit of 43.8%; and platelets of 272 μL/L. Urinalysis was negative without hematuria or proteinuria. Electrolytes were within normal limits. Blood urea nitrogen was measured at 12 mg/dL and creatinine was 0.650 mg/dL. Glucose was 95 mg/dL. Brain natriuretic peptide (BNP) was normal at 4.7 pg/mL. Metanephrine and normetanephrine were within normal limits at 42 pg/mL and 48 pg/mL, respectively. The C-reactive protein (CRP) was normal. Antinuclear antibody (ANA) was negative. The C3 and C4 complement were 141 mg/dL (normal, 90-180 mg/dL) and 21.9 mg/dL (normal, 10-40 mg/dL), respectively. Nighttime cortisol level was <0.5 μg/dL. Adrenocorticotropic hormone (ACTH) was low at 6 pg/mL (normal, 9-57 pg/mL). Salivary cortisol was <0.010 mcg/dL. Allergy panel was negative.
1. Klein J, Vuguin P, Hyman S. Cushing syndrome. Pediatr Rev. 2014:35(9):405-407.
2. Stratakis CA. Cushing syndrome in pediatrics. Endocrinol Metab Clin North Am. 2012;41(4):793-803.
3. Güemes M, Murray P, Brain C, et al. Management of Cushing syndrome in children and adolescents: experience of a single tertiary centre. Eur J Pediatr. 2016;175(7):967-976.
4. Lila AR, Sarathi V, Jagtap VS, Bandgar T. Menon P, Shah NS. Cushing's syndrome: stepwise approach to diagnosis. Indian J Endocrinol Metab. 2011;15 suppl 4:S317-S321.
5. Namburu RP, Karthik TS, Reddy P. Iatrogenic Cushing's syndrome in an infant. J Clin Diagn Res. 2013;7(2):353-354.
6. Zil EAA, Janjua OH, Latif A, Aadil M. Case of iatrogenic Cushing's syndrome by topical triamcinolone. J Ayub Med Coll Abbottabad. 2018;30(1):121-123.
7. Orton S, Censani M. Iatrogenic Cushing's syndrome due to intranasal usage of ophthalmic dexamethasone: a case report. Pediatrics. 2016;137(5):e20153845.
8. Tiwari A, Goel M, Pal P, Gohiya P. Topical-steroid-induced iatrogenic Cushing syndrome in the pediatric age group: a rare case report. Indian J Endocrinol Metab. 2013;17(suppl 1):S257-S258.
9. Keil MF. Quality of life and other outcomes in children treated for Cushing syndrome. J Clin Endocrinol Metab. 2013;98(7):2667-2678.
10. Morelli Coppola M, Salzillo R, Segreto F ,Persichetti P. Triamcinolone acetonide intralesional injection for the treatment of keloid scars: patient selection and perspectives. Clin Cosmet Investig Dermatol. 2018;11:387-396.
11. Kumar S, Singh RJ, Reed AM, Lteif AN. Cushing's syndrome after intra-articular and intradermal administration of triamcinolone acetonide in three pediatric patients. Pediatrics. 2004;113(6);1820-1824.
12. Finken MJ, Mul D. Cushing’s syndrome and adrenal insufficiency after intradermal triamcinolone acetonide for keloid scars. Eur J Pediatr. 2010;169(9):1147-1149.