Iatrogenic Cushing syndrome in a child due to erroneous compounding of omeprazole containing glucocorticoid: A case report and literature review

Q Jordens; L Sevenants; F de Zegher; D Mekahli; K Casteels

doi:10.1016/j.arcped.2023.02.001

Iatrogenic Cushing syndrome in a child due to erroneous compounding of omeprazole containing glucocorticoid: A case report and literature review

Arch Pediatr. 2023 May;30(4):247-250. doi: 10.1016/j.arcped.2023.02.001. Epub 2023 Mar 27.

Authors

Q Jordens¹, L Sevenants¹, F de Zegher², D Mekahli³, K Casteels⁴

Affiliations

¹ Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium.
² Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
³ Department of Pediatric Nephrology, University Hospital of Leuven, Leuven, Belgium; PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
⁴ Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium. Electronic address: kristina.casteels@uzleuven.be.

PMID: 36990933
DOI: 10.1016/j.arcped.2023.02.001

Abstract

A 3-month-old infant was examined for inconsolable crying with polydipsia, polyuria, and rapid weight gain. Unexpectedly, the symptoms resolved spontaneously during hospitalization but were aggravated 2 weeks after discharge, with the patient presenting a Cushingoid appearance. Investigations ruled out diabetes mellitus and nephrogenic diabetes insipidus but indicated adrenocortical suppression by exogenous glucocorticoids, which were discovered via toxicologic analysis of her previously compounded omeprazole suspension. After discontinuing the omeprazole suspension, the infant recovered fully and the laboratory results normalized. This case shows us that the assumption of appropriate medication intake may conceal unexpected medication errors. Following this case, the current literature on the benefits and risks of compounding and its impact on patient health is discussed.

Keywords: Cushing syndrome; Glucocorticoid; Medication error; Pediatric.

Publication types

Review
Case Reports

MeSH terms

Child
Cushing Syndrome* / chemically induced
Cushing Syndrome* / complications
Cushing Syndrome* / diagnosis
Diabetes Insipidus, Nephrogenic* / complications
Diabetes Insipidus, Nephrogenic* / diagnosis
Female
Glucocorticoids / adverse effects
Humans
Iatrogenic Disease
Infant
Polydipsia / diagnosis

Substances

Glucocorticoids