Scutelnicu A, Panaitescu A M, Ciobanu A M, Gica N, Botezatu R, Peltecu G, Gheorghiu M L
"Filantropia" Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania.
"C.I.Parhon" National Institute of Endocrinology - Neuroendocrinology, Bucharest, Romania.
Acta Endocrinol (Buchar). 2020 Oct-Dec;16(4):511-517. doi: 10.4183/aeb.2020.511.
Glucocorticoids (GC) are largely used for their anti-inflammatory and immunosuppressive effects. Until recently "local" administration (inhalation, topical, intra-articular, ocular and nasal) was considered devoid of important systemic side effects, but there is no administration form, dosing or treatment duration for which the risk of iatrogenic Cushing's syndrome (CS) and consequent adrenal insufficiency (AI) can be excluded with certainty.
We present the case of a pregnant woman who developed overt CS with secondary AI in the second trimester of pregnancy. She had low morning plasma cortisol 6.95 nmol/L (normal non-pregnant range 166 - 507) and low ACTH level 1.54 pg/mL (normal range 7.2 - 63.3), suggestive for iatrogenic CS. A thorough anamnesis revealed chronic sinusitis long-term treated with high doses of intranasal betamethasone spray (6 - 10 applications/day, approximately 10 mg betamethasone/week, for 5 months). After decreasing the dose and switching to an alpha-1 adrenergic agonist spray, the adrenal function recovered in a few weeks without manifestations of AI. The patient underwent an uneventful delivery of a normal baby. A review of the literature showed that only a few cases with exogenous CS and consequent AI caused by intranasal GC administration were described, mostly in children, but none during pregnancy.
Long-term high doses of intranasal GC may induce iatrogenic CS and should be avoided. Low levels of ACTH and cortisol should prompt a detailed anamnesis looking for various types of glucocorticoid administration.
糖皮质激素（GC）因其抗炎和免疫抑制作用而被广泛使用。直到最近，“局部”给药（吸入、局部、关节内、眼部和鼻腔给药）被认为没有重要的全身副作用，但没有哪种给药形式、剂量或治疗持续时间能够确定排除医源性库欣综合征（CS）及随之而来的肾上腺功能不全（AI）的风险。
我们报告一例孕妇，在妊娠中期出现明显的CS及继发性AI。她清晨血浆皮质醇水平低，为6.95 nmol/L（非妊娠正常范围为166 - 507），促肾上腺皮质激素（ACTH）水平低，为1.54 pg/mL（正常范围为7.2 - 63.3），提示医源性CS。详细的病史询问发现她患有慢性鼻窦炎，长期使用高剂量鼻内倍他米松喷雾剂治疗（每天6 - 10次，约每周10 mg倍他米松，持续5个月）。在减少剂量并改用α-1肾上腺素能激动剂喷雾剂后，肾上腺功能在几周内恢复，未出现AI表现。患者顺利分娩一名正常婴儿。文献回顾显示，仅有少数关于鼻内GC给药导致外源性CS及随之而来的AI的病例报道，大多为儿童病例，孕期未见报道。
长期高剂量鼻内使用GC可能诱发医源性CS，应避免使用。ACTH和皮质醇水平低时应详细询问病史，查找各种糖皮质激素的使用情况。
