Iatrogenic Cushing’s Syndrome Following Intra-Articular Triamcinolone Injection in an HIV-Infected Patient on Cobicistat Presenting as a Pulmonary Embolism: Case Report and Literature Review

Figures & data

Table 1 Summary of Cases of Patients Who Developed ICS While on HAART with Pharmacological Boosters After They Received Steroid Injections

Site	Number of Cases	HPA Axis Suppression Present	HAART Pharmacological Booster
Knee	2 this case^Citation8,Citation14	Yes	RTV
Subacromial/Shoulder	5^Citation7,Citation8,Citation11,Citation20	Yes	RTV
Epidural/Spine	10^Citation7,Citation11,Citation17	Yes	RTV
			Cobicistat
Hip/Trochanteric Bursa	1^Citation7	Yes	RTV
Elbow	1^Citation18	Yes	RTV
Periradicular	1^Citation7	Yes	RTV
Orbital	1^Citation26	Yes	RTV
Cervical/Neck	2^Citation8,Citation9	Yes	RTV
Intramuscular	1^Citation7	Yes	RTV
Total Cases	25

Abbreviations: ICS, iatrogenic Cushing’s syndrome; HAART, highly active antiretroviral therapy; HPA, hypothalamic pituitary adrenal; RTV, ritonavir.

Table 2 Summary of Cases of Patients Who Developed ICS While on HAART with Pharmacological Boosters After They Had Other Non-Systemic Exposure to Steroids

Site	Number of Cases	HPA Axis Suppression Present	HAART Pharmacological Booster
Dexamethasone & Betamethasone Eye Drops	1^Citation12	Yes	RTV
Inhaled Budesonide	7^Citation22^–^Citation25,Citation27,Citation28	4 with, 2 without, 1 unknown	RTV
Oral Budesonide	1^Citation15	No	RTV
Intranasal Fluticasone	3^Citation10	Yes	RTV
Inhaled Fluticasone	26^Citation10,Citation12	Yes	RTV
			Cobicistat
Total Cases	38

Abbreviations: ICS, iatrogenic Cushing’s syndrome; HAART, highly active antiretroviral therapy; HPA, hypothalamic pituitary adrenal; RTV, ritonavir.

Figure 1 (A) Bruises on the left upper extremity, which developed after the second intra-articular injection. (B) Bruise on the left lower extremity which developed into a non-healing ulcer. (C) Cushingoid facies and facial plethora. The picture on the left was taken a week prior to the first intra-articular injection, and the second picture was taken nearly 2 months after the second injection. (D and E) Wide, violaceous striae on the chest (D) and abdomen (E).

Figure 2 Follow-up images were collected at the patients most recent outpatient appointment, 7 months after the first intra-articular injection, showing resolution of symptoms. Of note resolution of (A) Cushingoid facies, (B) extremity bruising, wide violaceous striae of the (C) chest and (D) abdomen.

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