Impaired recovery of hypothalamic-pituitary-adrenal axis function and hypoglycemic seizures after high-dose inhaled corticosteroid therapy in a toddler.
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.
Kennedy
Mary Jayne
MJ
Department of Pharmacy, Children's Hospital, Columbus, Ohio, USA. mjkennedy@cmh.edu
Carpenter
Janice M
JM
Lozano
Rolando A
RA
Castile
Robert G
RG
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
D000730:Androstadienes; D018926:Anti-Allergic Agents; D005938:Glucocorticoids; D000068298:Fluticasone; D006854:Hydrocortisone