Iatrogenic cushings syndrome precipitated by fluticasone nasal drops in HIV infected patient

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A 43 year old Somali woman presented with increasing fatigue, difficulty getting out of her chair and 15kg weight gain over one month.• Past medical history included paranoid psychosis, human immunodeficiency virus (HIV) and nasal congestion due to adenotonsillar hypertrophy.She declined surgery and was commenced on inhaled Flixonase Nasule (Fluticasone 400 micrograms/unit dose) by her local GP as recommended in ENT clinic.• Her HIV infection was well controlled (viral load <50RNA copies/ml), with excellent immunological reconstitution (CD4 count >500cells/mm3).• Current medications include ritonavir/ darunovir, tenofovir, emtricitabine, flupenthixol depot, zopiclone, olanzapine, ferrous sulphate, folic acid and fluticasone nasal spray.• On presentation, she had rounded facial facies, truncal adiposity, dorsocervical fat pad and extensive purple striae over the axillae, upper chest, breasts, groin and thighs.• Her clinical presentation and results were consistent with glucocorticoid excess.• A diagnosis of iatrogenic Cushing's syndrome was made secondary to high systemic steroid levels from inhaled fluticasone, induced by concomitant Ritonavir use.• The hyperprolactinaemia was attributed to Olanzapine; a common dose-related side effect of antipsychotic treatment.• Fluticasone inhalers were slowly weaned and her symptoms, blood pressure and glucose improved.

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