#8: Cushingoid facies

REAL LIFE, REAL PATIENT, THIS AINT NO GAME

This ten-year-old girl is a patient of my father's in Victoria .  She and her brother suffer from typical childhood conditions.  They are very bright, active children who, like most, visit the office more frequently in the winter months.  Their mother, a family physician and an excellent photographer suggested I share this case.  She took these pictures between October, 1999 and July 2000. 

What is happening?  Obviously, Stephanie is developing Cushingoid facies.  She was prescribed fluticasone 100 mcg BID, but it appears that she was receiving closer to 400-500mcg per day.  Her brother had experienced severe asthma in the past and had been managed on higher doses and perhaps this influenced the administration at home.

What might be causing it?  Many respondents identified either exogenous or endogenous steroid intoxication as the culprit.  However, only Eldina proposed an inhaled steroid as a potential source. 

Would you recommend any tests?  None were ordered.  She is to be followed carefully as the steroid is withdrawn. 

A simple intervention seems to be resulting in a marked improvement.  Can you guess what it was?  Within a month of changing from fluticasone to montelukast, Stephanie's physiognomy had changed.  Her face appeared much less Cushingoid and her blood pressure was normal.  Her height has not changed since starting the inhaler and this is to be monitored carefully.

Don't worry, they already offed the cat.  Excellent