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Iatrogenic cushing syndrome secondary to ritonavir-epidural triamcinolone interaction: an illustrative case and review.
[cushing syndrome]
HIV
positive
patients
on
ritonavir-containing
antiretroviral
therapy
(
ART
)
can
develop
iatrogenic
Cushing
syndrome
(
IACS
)
and
adrenal
insufficiency
as
a
result
of
drug-drug
interactions
with
inhaled
or
intranasal
glucocorticoid
therapy
.
Reports
related
to
epidural
triamcinolone
injections
are
relatively
uncommon
but
increasingly
reported
.
We
describe
a
48
-
year
-old
woman
with
immunologically
and
virologically
well-controlled
HIV
on
ritonavir-based
ART
,
who
developed
headache
,
dizziness
,
and
candida
and
herpes
simplex
virus
(
HSV
)
ulcerative
esophagitis
7
days
after
receiving
an
epidural
triamcinolone
injection
for
cervical
radicular
pain
.
Iatrogenic
Cushing
syndrome
and
relative
adrenal
insufficiency
were
suspected
and
proven
.
The
patient
's
ART
was
changed
to
a
non-
HIV
protease
inhibitor-
(
PI-
)
containing
program
,
her
symptoms
improved
,
and
she
did
not
require
hydrocortisone
replacement
.
In
this
paper
,
we
review
the
literature
on
IACS
and
relative
secondary
adrenal
insufficiency
from
epidural
triamcinolone
injections
in
HIV
patients
on
ritonavir-containing
ART
regimens
.
A
high
index
of
clinical
suspicion
is
needed
for
diagnosis
.
Prevention
of
drug-drug
interactions
by
taking
a
thorough
medication
history
for
patients
on
ritonavir-containing
ART
regimens
before
prescribing
any
form
of
corticosteroid
is
crucial
and
effective
and
sustained
interdisciplinary
communication
in
the
care
of
such
patients
.
Diseases
Validation
Diseases presenting
"pain"
symptom
achondroplasia
acute rheumatic fever
adrenal incidentaloma
adrenomyeloneuropathy
aniridia
aromatase deficiency
carcinoma of the gallbladder
cholangiocarcinoma
coats disease
congenital diaphragmatic hernia
congenital toxoplasmosis
cushing syndrome
cutaneous mastocytosis
cystinuria
dedifferentiated liposarcoma
dentin dysplasia
dracunculiasis
dystrophic epidermolysis bullosa
epidermolysis bullosa simplex
erdheim-chester disease
erythropoietic protoporphyria
esophageal adenocarcinoma
esophageal carcinoma
esophageal squamous cell carcinoma
fabry disease
familial mediterranean fever
focal myositis
hirschsprung disease
hodgkin lymphoma, classical
holt-oram syndrome
junctional epidermolysis bullosa
kabuki syndrome
kindler syndrome
lamellar ichthyosis
liposarcoma
locked-in syndrome
lymphangioleiomyomatosis
malignant atrophic papulosis
neuralgic amyotrophy
oligodontia
oral submucous fibrosis
papillon-lefèvre syndrome
phenylketonuria
pleomorphic liposarcoma
primary hyperoxaluria type 1
proteus syndrome
pyomyositis
scrub typhus
sneddon syndrome
systemic capillary leak syndrome
thoracic outlet syndrome
trochlear dysplasia
typhoid
von hippel-lindau disease
waldenström macroglobulinemia
well-differentiated liposarcoma
wolf-hirschhorn syndrome
This symptom has already been validated