Cushing's syndrome from epidural methylprednisolone

Iatrogenic Cushing's syndrome has been reported after the use of nasal, aerosol, oral, and intramuscular steroid preparations. Presented is a case of Cushing's syndrome due to an epidural injection of methylprednisolone. A 24-year-old man had left arm pain after an occupational injury. Electromyography revealed C7 radioculopathy and cervical laminectomy was performed. Postoperatively, the patient noted improvement, however, he had recurrence of his symptoms within 1 month. Significant pain in the left arm, accompanied by swelling, persisted despite non-steroidal anti-inflammatory and anti-depressant medications. Repeat electromyography showed a resolving C7 with increased polyphasic potentials. Reflex sympathetic dystrophy was diagnosed and the patient received 3 stellate ganglion blocks with relief of the swelling, but only temporary relief of pain. He then underwent epidural injection of 60 mg of methylprednisolone. A cushingoid appearance was noted approximately 1 month later. Serum cortisol was undetectable, there was no adrenal response to synthetic ACTH, and urinary-free cortisol was below normal at 12. The patient eventually underwent a second surgical procedure for his pain and required steroid coverage. His pain subsequently showed slow improvement. Urinary-free cortisol normalized 4 months after onset; however, the patient's cushingoid appearance persisted for 12 months.