Indian Pediatrics

, Volume 56, Issue 3, pp 242–243 | Cite as

Secondary Adrenal Insufficiency due to Intra-articular Glucocorticoid Injections

  • Malgorzata WojcikEmail author
  • Anna Ruszala
  • Dominika Janus
  • Jerzy B Starzyk
Case Report



The most common cause of hypothalamic-pituitary-adrenal axis suppression is systemic glucocorticoids administration.

Case characteristics

A 14- year-old boy with juvenile idiopathic arthritis receiving repeated intra-articular steroids for last 3 years developed fever, fatigue, nausea and abdominal pain. Stimulation with lowdose Synathen revealed low adrenal reserve, suggesting secondary adrenal insufficiency.


Temporary hydrocortisone substitution therapy improved condition.


Intra-articular steroids may cause potentially life-threatening suppression of the hypothalamic-pituitary-adrenal axis.


Adrenal insufficiency Corticosteroids Fever Juvenile idiopathic arthritis 


  1. 1.
    Charmandari E, Nicolaides NC, Chrousos GP, Adrenal insufficiency. The Lancet. 2014;383:2152–67.CrossRefGoogle Scholar
  2. 2.
    Weitoft T, Ronnblom I. Glucocorticoid resorption and influence on the hypothalamicpituitary–adrenal axis after intra–articular treatment of the knee in resting and mobile patients. Ann Rheum Dis. 2006;65:955–7.CrossRefGoogle Scholar
  3. 3.
    Lazarevic MB, Skosey JL, Djordjevic–Denic G, Swedler WI, Zgardic I, Myones BA. Reduction of cortisol levels after single intra–articular and intramuscular steroid injection. Am J Med. 1955;99:370–3.CrossRefGoogle Scholar
  4. 4.
    Mader R, Lavi I, Luboshitzky R. Evaluation of the pituitary–adrenal axis function following single intraarticular injection of methylprednisolone. Arthritis Rhematism. 2005;52:924–8.CrossRefGoogle Scholar
  5. 5.
    Lipworth BJ. Systemic adverse effect of inhaled corticosteroid therapy: A systematic review and metaanalysis. Arch Intern Med. 1999;159:941–55.CrossRefGoogle Scholar
  6. 6.
    Smith RW, Downey K, Gordon M, Hudak A, Meder R, Barker S, et al. Prevalence of hypothalamic–pituitaryadrenal axis suppression in children treated for asthma with inhaled corticosteroid. Paediatr Child Health. 2012;17:34–9.CrossRefGoogle Scholar
  7. 7.
    Armstrong RD, English J, Gibsn T, Marks V. Serum methyloprednisolone levels following intra–articular injection of methyloprednisolone acetate. Ann Rheum Dis. 1981;40:571–4.CrossRefGoogle Scholar
  8. 8.
    Derendorf H, Mollman H, Vortman G, van der Ouweland FA, van de Putte LB, Gevers G, et al. Pharmacokinetics of rimexolone after intra–articular administration. J Clin Pharmacol. 1990;30:476–9.CrossRefGoogle Scholar
  9. 9.
    Kazlauskeite R, Evans AT, Villabona CV, Abdu TA, Ambrosi B, Atkinson AB, et al. For the Consortium for Evaluation of Corticotropin Test in Hypothalamic–Pituitary Adrenal Insufficiency: A meta–analysis. J Clin Endocrinol Metab. 2008;93:4245–53.CrossRefGoogle Scholar
  10. 10.
    Habib G, Jabbour A, Artul S Hakim G. Intra–articular methylprednisolone acetate injection at the knee joint and the hypothalamic–pituitary–adrenal axis: A randomized controlled study. Clin Rheumatol. 2014;33:99–103.CrossRefGoogle Scholar

Copyright information

© Indian Academy of Pediatrics 2019

Authors and Affiliations

  • Malgorzata Wojcik
    • 1
    Email author
  • Anna Ruszala
    • 1
  • Dominika Janus
    • 1
  • Jerzy B Starzyk
    • 1
  1. 1.Department of Pediatric and Adolescent Endocrinology, Institute of Pediatrics, Jagiellonian University Medical CollegeChildren’s University HospitalKrakowPoland

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