Supplementary Material for: Iatrogenic Cushing syndrome and secondary adrenal insufficiency in a child due to topical ocular corticosteroids: A case report

Introduction: Iatrogenic Cushing Syndrome (ICS) can be caused by synthetic glucocorticoids administered through various routes. ICS caused by corticosteroid eye drops is an exceptional event, being more frequent in pediatric age. Herein, we describe a case of iatrogenic Cushing syndrome (ICS) associated with secondary adrenal insufficiency (SAI) caused by ocular topical corticosteroid treatment. Case presentation: An 11-year-old girl was referred to our ocular inflammation department due to idiopathic, chronic, non-hypertensive, non-granulomatous bilateral anterior uveitis, treated with topical dexamethasone (eye drops, 1mg/ml) for one year. During the past year, the child and her mother observed a gradual change in her physical appearance, particularly noting the development of a cushingoid facial appearance. Laboratory data revealed morning serum adrenocorticotropic hormone (ACTH) of 3.6 ng/L [7.2-63.3] and morning serum cortisol of 0.20 μg/dL [6.2-19.4]. She was treated with methotrexate (15 mg/week, orally), and the topical corticosteroid regimen was progressively tapered and discontinued after three months. Nine months after the patient discontinued corticosteroid eyedrops, her cushingoid face disappeared, and her laboratory data improved. Regarding the ophthalmological examination, the uveitis remained in remission with methotrexate, with no new episodes of intraocular inflammation. Conclusion: Although rare, ophthalmologists must be aware of ICS and SAI and prioritize using the least potent corticosteroid for the shortest duration necessary. Additionally, clinicians should avoid abrupt cessation of long-term corticosteroid therapy, as this can precipitate an adrenal crisis in the presence of adrenal insufficiency.