[Secondary adrenal insufficiency after local injections of triamcinolone acetonide]

Abstract

History and admission findings: Two women, aged 74 and 57 years, were admitted for endocrinological work-up. The 74-year-old women had clinical signs of adrenal insufficiency after she had been given one triamcinolone acetonide intra-articular injection 3 months before. The 57-year-old women who had over several years been repeatedly received local triamcinolone acetonide injections for degenerative changes in her cervical spine for several years and needed reoperative investigation. Physical examination was unremarkable in both patients: they had no signs of Cushing's syndrome.

Investigations: Serum cortisol and plasma adrenocorticotropic hormone (ACTH) were reduced in both patients. Endocrinological tests in the 74-year-old patient showed reduced free cortisol excretion in the urine, normal cortisol response in the ACTH test and subnormal cortisol stimulation during the corticotropin-releasing-hormone test and the insulin tolerance test. Magnetic resonance imaging of the sella was normal. The 57-year-old patient had a reduced cortisol response.

Diagnosis, treatment and course: The results of endocrinological tests in both patients were consistent with secondary adrenal insufficiency after local injection of triamcinolone acetonide. In the 74-year-old patient substitution treatment with hydrocortisone was started and resulted in rapid improvement of the symptoms. Perioperative intravenous substitution was advised for the 57-year-old patient .

Conclusions: Locally administered synthetic glucocorticoids can be associated with systemic adverse effects, such as secondary adrenal insufficiency. Clinically significant secondary adrenal failure can be produced not only by long-term administration of triamcinolone acetonide, but possibly also if it is injected just once.