title: Outbreak of exogenous Cushing's syndrome due to unlicensed medications.
abstract: OBJECTIVE
  Despite the widespread medical use of glucocorticoids, reports of factitious administration of these hormones have been uncommon. We herein report an outbreak of Cushing's syndrome in Tehran among the addicts using Tamgesic (a brand of Buprenorphine) to help them through the narcotic withdrawal stage, without knowledge of the glucocorticoid content of the black-market drug.
  
  
  METHODS
  Case histories of 19 patients with a final diagnosis of iatrogenic Cushing's syndrome were reviewed. Liquid chromatography/mass spectrometry (LC-Mass) method was used to evaluate glucocorticoid existence in the brand. High performance liquid chromatography was used to determine plasma dexamethasone level.
  
  
  RESULTS
  No buprenorphine was present in the vials. Each Tamgesic vial contained 0.4 mg of Dexamethasone disodium phosphate; Heroin was also found in them. The duration of injection abuse and the total dexamethasone intake was 4.5 (1-18) months and 2.6 (0.8-8) mg/day, respectively. Median plasma dexamethasone concentration was 5.8 nmol/l, with a range of 5-8.7. Physical findings of the cases were not different from those of the classic endogenous Cushing's syndrome but their serum cortisol and urinary free cortisol were suppressed. Severe life-threatening complications were demonstrated in five cases.
  
  
  CONCLUSIONS
  Surreptitious use of steroids resulting in Cushing's syndrome may be more common in opium addicts; a high degree of suspicion is needed to uncover this disorder. Whenever facing a cushingoid appearance in addicts, the possibility of using black market drugs with corticosteroid contents should be kept in mind.
authors.affiliation: Research Institute for Endocrine Sciences, Shahid Beheshti University, Tehran, Iran. azizi@erc.ac.ir
authors.forename: Fereidoun
authors.initials: F
authors.lastname: Azizi
authors.forename: Adel
authors.initials: A
authors.lastname: Jahed
authors.forename: Mehdi
authors.initials: M
authors.lastname: Hedayati
authors.forename: Mahnaz
authors.initials: M
authors.lastname: Lankarani
authors.forename: Hadi Shahrad
authors.initials: HS
authors.lastname: Bejestani
authors.forename: Fatemeh
authors.initials: F
authors.lastname: Esfahanian
authors.forename: Nargues
authors.initials: N
authors.lastname: Beyraghi
authors.forename: Alireza
authors.initials: A
authors.lastname: Noroozi
authors.forename: Farzad
authors.initials: F
authors.lastname: Kobarfard
mesh_terms: D000328:Adult; D002047:Buprenorphine / Q000008:administration & dosage* / Q000009:adverse effects*; D003480:Cushing Syndrome / Q000139:chemically induced*; D003907:Dexamethasone / Q000009:adverse effects* / Q000097:blood; D004340:Drug Contamination; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D007049:Iatrogenic Disease; D008297:Male; D008875:Middle Aged; D009293:Opioid-Related Disorders / Q000188:drug therapy*; D009892:Opium; D013375:Substance Withdrawal Syndrome / Q000188:drug therapy
chemical_list: D002047:Buprenorphine; D003907:Dexamethasone; D009892:Opium; D006854:Hydrocortisone