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Indo American Journal of Pharmaceutical Research, 2015 ISSN NO: 2231-6876

A CASE REPORT ON CORTICOSTEROIDS INDUCED CUSHING'S SYNDROME AND

NSAIDS INDUCED ACUTE BRONCHITIS

R. Siddarama*, Y. Hrushikesh Reddy, Gangula Amareswara Reddy, P Gowtham, H Shree Hari, R

Phanindra Nayak, M. Javeed Baig P Rami Reddy Memorial College of Pharmacy, Kadapa, Andhra Pradesh, India – 516003.

Corresponding author

R Siddarama

Department of Clinical Pharmacy,

P Rami Reddy Memorial College of Pharmacy,

Kadapa, Andhra Pradesh, India - 516003

siddaramapharmd22@gmail.com

+917306209795

Copy right © 2015 This is an Open Access article distributed under the terms of the Indo American journal of Pharmaceutical

Research, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ARTICLE INFO ABSTRACT

Article history

Received 15/04/2015

Available online

30/04/2015

Keywords

Corticosteroids,

NSAIDs,

Cushing’s Syndrome,

Acute Bronchitis,

ADR Analysis,

Re-Challenge

And De-Challenge.

Corticosteroids are the steroid hormones, which are mainly used in the treatment of

rheumatoid arthritis, osteoarthritis, rheumatic fever, gout, allergic reactions, renal disease,

haematological disorders and shock. The use of glucocorticoids in supra physiological doses

for more than 2-3 weeks causes a number of undesirable effects. Most of the adverse effects

are extension of pharmacological actions such as hyperglycaemia, Cushing syndrome,

oedema, hypertension, CCF, steroid myopathy, glaucoma, various fungal infections etc.

Diclofenac is a Non-Steroidal Anti Inflammatory Drug; it is high potent anti-inflammatory

and analgesic drug. The mechanism of acute bronchitis due to the diclofenac still not known

but increased production of leukotrienes may cause bronchitis. Here we report a 45 years old

female patient was experienced moon face, pedal oedema, increased RBS, LDL, total

cholesterol, abdominal striae, acute bronchitis and increased blood presser due to the

prolonged using of corticosteroids and NSAIDs since 2 years regularly.

Please cite this article in press as R Siddarama et al. A Case Report on Corticosteroids Induced Cushing's Syndrome And Nsaids

Induced Acute Bronchitis. Indo American Journal of Pharm Research.2015:5(04).

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INTRODUCTION

Cushing syndrome is defined as abnormality in high blood levels of cortisol or other exogenous compounds of

glucocorticoids. This can be iatrogenic or endogenous cortisol secretion, due to the either an adrenal tumour or hyper secretion of

adrenocorticotropic hormone by the pituitary gland [1]. The pathophysiological mechanism differs depending upon the cause of

Cushing syndrome [2]. The commonly occurring cause for Cushing syndrome is administration of exogenous glucocorticoid

hormones on prolonged use and especially used in the treatment of lymph proliferative disorders at levels of higher doses [3]. the most

common systemic side effects of administration of glucocorticoids for prolonged use which includes Cushing’s syndrome,

hypertension, cataract, skin atrophy, dyslipidaemia, hypo-thalamo-pituitary-adrenal axis suppression, failure to thrive, glaucoma,

striae and a predisposition to life-threatening infections [4].

CASE REPORT

A 45 Years old female patient was admitted in general medicine department RIMS, Kadapa with the chief complaints of

facial puffiness, swelling of limbs, abdominal distension and striaes, shortness of breath and with gradually progressing fever since 1

month. and Present history of the patient shows that the decreased urine output and constipation since 1 month. As she was a known

patient with rheumatoid arthritis, she was prescribed with corticosteroids (prednisolone) and Non-Steroidal Anti-inflammatory drugs

(diclofenac) and was on regular treatment for past 2 years. on general examination the patient was conscious and coherent but on

physical appearance was looking weak, pale and her vitals were as follows BP-150/90 mm of Hg, PR-84bpm, CVS-S1,S2+ ,RS-

Wheezing’s+, CNS- no abnormality present, P/A- distension+, striated.

Investigations:

On laboratory examination of the patient, results were found to be as follows, Blood profile: Hb-10 gm%, TC-9000cells/mm3

, Differential count- polymorphs-55% , Lymphocytes- 43%, Esinophills-2%.Random Blood Sugar-143mgs/dl, Blood urea-20mgs/dl,

Total Cholesterol-254mgs/dl, HDL-50mgs/dl, LDL-182 mgs/dl, VLDL-24mgs/dl, TG-118mgs/dl. Liver Function test: serum

creatinine-0.8mgs/dl, Total Bilirubin-1.5mgs/dl, Direct Bilirubin-0.8mgs/dl, alkaline phosphatase-80IU/L, SGOT-41U/L, SGPT-

35U/L, Total Protiens-7.2g/dl. TSH-1.5micro IU/ml. USG Abdomen- Hepatomegaly with fatty changes and chest x-ray- acute

bronchitis. So based on subjective and objective evaluation patient have experienced Cushing’s syndrome and acute bronchitis due to

the prolonged usage of corticosteroids(prednisolone) and NSIDS(diclofenac). Clinical evaluation was done and patient was treated

symptomatically with parenteral diuretics(lasix 40mg iv bid), parenteral anti-ulcer drug (pantaprazole 40mg iv bid), parenteral

bronchodilator(deriphylline 110mg iv bid)oral vitamin supplements (calcium 100mg od) and syrup purgative (lactulose 10ml bid).

ADR Analysis

Causality assessment:

After collecting the past and current history from the patient, ADR Analysis was done by using naranjos scale, WHO-UMC,

karch and lasagna scales shown in Table: 1. the most suspected drug to produce Cushing’s syndrome and acute bronchitis were due to

the Corticosteroids and NSAID'S. Here we also performed severity, predictability and preventability scales shown in Table 2.

Re-challenge:

Patient had similar complaints in the past, so for confirmatory purpose we reintroduced the same amount of the drugs

(prednisolone-60mg bd and diclofenac-50mg bd) 1 month back. Then she was experienced with facial puffiness, swelling of both

limbs(shown in figure; 1), abdominal distension, abdominal striae, increased RBS(143mg/dl), LDL(182mg/dl), total

cholesterol(254mg/dl), blood pressure(150/90mmof hg) and acute bronchitis (shown in figure: 2).

De-challenge:

After complete evaluation of the re-challenge information the suspected drugs were stopped administrating.

Figure-1: Facial puffiness, swelling of both limbs.

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Figure - 2: Acute bronchitis.

Table1: Causality assessment of suspected drugs.

S.NO ADR SCALES

(CAUSALITY ASSESSMENT)

SUSPECTED DRUGS CAUSING ADR

PREDNISOLONE DICLOFENAC

1. Naranjo's scale Definite ADR (score - 9) Definite ADR (score - 9)

2. WHO-UMC Scale Certain Certain

3 Karch and lasagna Definite ADR Definite ADR

Table2: Severity, Predictability and Preventability scales.

CAUSALITY ASSESSMENT SUSPECTED DRUGS CAUSING ADR

PREDNISOLONE DICLOFENAC

Severity Moderate level 4(b) Severe, level 5

Predictability Predictable type-A Predictable type- B

Preventability Not Preventable Not Preventable

DISCUSSION

Cushing syndrome results from a set of clinical presentation caused by hyper-cortisolism [5]. Cushing syndrome may be due

to the endogenous causes such as ectopic ACTH production, pituitary tumour, and exogenous causes like exogenously administration

of corticosteroids. The most common cause of Cushing syndrome is exogenous administration of glucocorticoids than the Endogenous

Cushing syndrome [6]. Cushing syndrome can be broadly divided into two types depending upon the plasma level of ACTH: ACTH

dependent Cushing syndrome and ACTH–independent Cushing syndrome. Cushing’s syndrome due to exogenous corticosteroids

administration is variably described as steroid- induced Cushing’s syndrome, exogenous Cushing’s, or iatrogenic Cushing syndrome

[7]. The common clinical presentations of Cushing’s syndrome are obesity, which implies in the face, neck, spinal canal, trunk, and

abdomen [8]. Fat deposition, in the temporal fossae, cheeks result in "moon" face and in the back of neck results in "buffalo hump".

The enlarging trunk, breasts, and abdomen due to stretching of the fragile skin it may leads to development of broad, reddish-purple

striae. The red-purple livid striae are most commonly found over the abdomen, but are also present on the arms, upper thighs and

breasts. This striaes are greater than 1 cm in width which is typical, and almost pathognomonic [9]. In the patients with Cushing

syndrome, 50% of them may develop Psychiatric abnormalities in such patients. Common psychiatric abnormalities which comprise:

lethargy, paranoia, agitated depression, overt psychosis, insomnia, irritability, anxiety, emotional liability, and panic attacks [10].

CONCLUSION Corticosteroids are having more ADRs (adverse drug reaction) profile. So, proper information about side effects should be

provided to the patients and precautions should be taken and regularly monitor the patients’ blood cortisol levels who are receiving the

oral corticosteroids.

CONFLICT OF INTERESTS The authors have declared that they have no conflict of interest.

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