A 14-year-old female with perinatally acquired HIV on boosted protease inhibitor (PI) therapy with atazanavir and ritonavir rapidly developed cushingoid features with excessive weight gain and moon facies within 2 weeks of receiving inhaled fluticasone/salmeterol for asthma treatment. Soon after discontinuing PIs and inhaled steroid, she required hospitalization for dyspnea, headache, muscle weakness, and extreme fatigue requiring hydrocortisone replacement therapy for presumed adrenal insufficiency. Cushing syndrome and adrenal suppression were very likely caused by elevated steroid systemic concentrations resulting from the cytochrome p450 interaction between the protease inhibitors and fluticasone. The Naranjo probability scale score of 5 suggests that the event was probably drug related. This is the first case report of fluticasone and PI-induced Cushing syndrome and adrenal suppression in a pediatric patient without a history of recent or concomitant treatment with systemic steroid therapy. Additionally, this case is unique as it is the most rapid (<2 weeks) presentation documented, thus far. Health care professionals should be conscious of this important drug-drug interaction in HIV-infected children and adolescents and be aware that rapid onset of hypercortisolism and adrenal suppression are possible.

OBJECTIVE:To assess the effect of antenatal corticosteroids on very low birth weight (VLBW) infants through 36 weeks' postconceptional age. STUDY DESIGN:Data were collected prospectively on all VLBW (Յ1500 gm) infants (n ϭ 670) admitted to a single newborn intensive care unit from 1991 to 1996. Mortality rate and the frequency of medical morbidities attributable to prematurity were compared between VLBW infants who received antenatal corticosteroid therapy and those who did not. RESULTS:Antenatal steroid therapy was associated with a significantly lower rate of mortality ( p ϭ 0.02) and of mortality due to respiratory causes ( p ϭ 0.01). Although the frequency of chronic lung disease (oxygen requirement at 36 weeks' postconceptional age) was not significantly different between the groups ( p ϭ 0.48), the frequency of infants surviving without chronic lung disease was significantly greater in the steroid-exposed group ( p ϭ 0.02). There were no significant differences between the groups in the frequency of sepsis, necrotizing enterocolitis, length of hospital stay, or retinopathy of prematurity requiring surgery. CONCLUSION:In our study, antenatal corticosteroid therapy was associated with a beneficial effect on mortality and respiratory morbidity for VLBW infants and was not associated with any known increased risks.In 1972, Liggens and Howie 1 first reported the use of antenatal corticosteroid therapy (ANS) for the prevention of respiratory distress syndrome (RDS) in premature infants. Meta-analysis of subsequent studies conducted in the 1970s and 1980s noted not only a lower frequency of RDS but also an increased neonatal survival rate, a decrease in the frequency of intraventricular hemorrhage (IVH), and no clear-cut evidence of adverse effects. 2 Despite published data demonstrating the efficacy of ANS, Ͻ20% of women in the United States in preterm labor received ANS in 1992. 3 Although ANS use has increased since the panel of the 1994 National Institutes of Health Consensus Conference on the Effect of Corticosteroids for Fetal Maturation and Perinatal Outcomes recommended the use of corticosteroids for the majority of women in premature labor, ϳ45% of women in preterm labor did not receive ANS in 1996. 3 Although the primary focus of most published clinical studies of ANS has been the prevention of RDS, animal and human data indicate that corticosteroids induce maturation of other organ systems besides the lung. 4 Our study focused on assessing the efficacy of ANS in reducing the frequency of neonatal morbidities associated with prematurity, other than RDS. We specifically looked at chronic lung disease (CLD), IVH, cystic periventricular leukomalacia (PVL), patent ductus arteriosus (PDA), surgery for retinopathy of prematurity, and mortality. We also reviewed the association of corticosteroids with necrotizing enterocolitis (NEC) and neonatal sepsis. METHODSAll very low birth weight (VLBW) infants admitted to the newborn intensive care unit at the University of New Mexico Hospital between May of 1991 and Ju...

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