title: Impaired recovery of hypothalamic-pituitary-adrenal axis function and hypoglycemic seizures after high-dose inhaled corticosteroid therapy in a toddler.
abstract: BACKGROUND
  Corticosteroids are the treatment of choice for children with persistent reactive airway disease. In these patients, taper and discontinuation of systemic therapy is often facilitated by transition to high-dose inhaled corticosteroid treatment.
  
  
  OBJECTIVE
  To report a case of impaired hypothalamic-pituitary-adrenal (HPA) axis recovery and adrenal crisis associated with prolonged high-dose inhaled therapy after long-term systemic corticosteroid treatment.
  
  
  METHODS
  A 32-month-old child with severe airway obstruction and wheezing was treated with long-term daily systemic (intravenous and oral) corticosteroids followed by high-dose inhaled fluticasone (440 to 1,320 microg/day). This child presented in adrenal crisis, as evidenced by severe hypoglycemia and seizures, I day after receiving the influenza vaccine. After hydrocortisone replacement and a long taper of fluticasone, the child's adrenal function returned to normal.
  
  
  RESULTS
  At the time of seizure, the serum glucose was 1 mg/dL. An electroencephalogram, computed tomographic scan, and magnetic resonance imaging of the brain were normal. Adrenal insufficiency was documented (morning serum cortisol, 0.6 microg/dL; after adrenocorticotrophic hormone stimulation, 8.4 microg/dL). Repeat evaluation 3 weeks after discontinuation of all corticosteroid therapy demonstrated normal HPA axis function.
  
  
  CONCLUSIONS
  After treatment with long-term systemic steroids, high-dose inhaled corticosteroid therapy can impair recovery of the HPA axis and place patients at risk for adrenal crisis.
authors.affiliation: Department of Pharmacy, Children's Hospital, Columbus, Ohio, USA. mjkennedy@cmh.edu
authors.forename: Mary Jayne
authors.initials: MJ
authors.lastname: Kennedy
authors.forename: Janice M
authors.initials: JM
authors.lastname: Carpenter
authors.forename: Rolando A
authors.initials: RA
authors.lastname: Lozano
authors.forename: Robert G
authors.initials: RG
authors.lastname: Castile
mesh_terms: D000280:Administration, Inhalation; D000730:Androstadienes / Q000008:administration & dosage / Q000009:adverse effects*; D018926:Anti-Allergic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D002675:Child, Preschool; D005260:Female; D000068298:Fluticasone; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D006854:Hydrocortisone / Q000008:administration & dosage; D007003:Hypoglycemia / Q000139:chemically induced*; D007030:Hypothalamo-Hypophyseal System / Q000187:drug effects*; D010913:Pituitary-Adrenal System / Q000187:drug effects*; D012640:Seizures / Q000139:chemically induced*; D016896:Treatment Outcome
chemical_list: D000730:Androstadienes; D018926:Anti-Allergic Agents; D005938:Glucocorticoids; D000068298:Fluticasone; D006854:Hydrocortisone