Diagnosing the unrecognized systemic absorption of intra-articular and epidural steroid injections

To present a case series of patients who were misdiagnosed with endocrine disorders because of failure to recognize the systemic absorption of intra-articular and epidural steroids and to discuss the utility of performing a urine screen to detect synthetic glucocorticoids.

In this case series, we describe the clinical, laboratory, and imaging findings of 3 patients referred to our clinic, each with a presumed endocrine disorder.

Patient 1 was a 54-year-old woman with weakness, loss of appetite, and a hormonal profile suggestive of hypopituitarism. Patient 2 was a 49-year-old woman with chronic fatigue and history of physical abuse, whose history and test results were compatible with growth hormone deficiency secondary to head trauma. Patient 3 was a 46-year-old woman who was diagnosed with endogenous Cushing syndrome despite normal 24-hour urinary cortisol excretion. In each case, we subsequently elicited a history of intra-articular or epidural glucocorticoid injections, and a urine screen documented the presence of synthetic glucocorticoids. Systemic absorption of the injected steroids was thus determined to be the cause of the symptoms and abnormal laboratory findings in each case.

The potential for harm from intra-articular and epidural glucocorticoid administration is underrecognized by physicians, leading to expensive investigation, false diagnoses, and unnecessary treatment. A urine screen for synthetic glucocorticoids is a valuable adjunct towards appropriate diagnosis.