Exogenous Cushing syndrome with inhaled fluticasone in a child receiving lopinavir/ritonavir.

OBJECTIVE: To describe a case of Cushing syndrome in a child during concurrent use of inhaled fluticasone propionate, nasal mometasone, and a highly active antiretroviral regimen including lopinavir/ritonavir. CASE SUMMARY: A 9-year-old boy with HIV infection and asthma developed moon facies, increased facial hair, and increased weight after fluticasone propionate inhalation (1 puff; 220 microg) therapy was begun. His antiretroviral regimen contained the protease inhibitor combination lopinavir/ritonavir at a dose of 216/54 mg twice daily, and he had been stable for the previous 5 years. He had also been receiving intranasal mometasone for 11 months for the management of allergic rhinitis. Serum cortisol and adrenocorticotropic hormone levels were consistent with adrenal suppression. These physical findings and symptoms and laboratory values normalized after discontinuation of the fluticasone propionate. The Naranjo probability scale indicated that a probable interaction occurred between lopinavir/ritonavir and fluticasone propionate, leading to subsequent adrenal suppression. DISCUSSION: Protease inhibitors are associated with numerous drug interactions due to inhibition of the CYP3A4 isoenzyme. Pharmaceutical agents used to treat comorbidities in HIV-infected individuals often can interact with protease inhibitors, leading to toxic drug concentrations or untoward effects. Inhaled corticosteroids such as fluticasone propionate are often necessary to treat asthma in young children and are metabolized by CYP3A4. Interactions between protease inhibitors and inhaled fluticasone propionate have been reported in the adult population, but reports are limited in the pediatric literature. CONCLUSIONS: This case raises awareness of the interaction between fluticasone propionate and lopinavir/ritonavir and adverse effects in children receiving both medications.

Congenital HIV infection and precocious puberty.

Reported endocrine problems related to human immunodeficiency virus (HIV) infection in children are primarily growth deceleration and delayed pubertal development. We report here an African-American male with congenital HIV infection who developed precocious puberty that was diagnosed at 4-9/12 years of age.

Skin and subcutaneous infections.

Cutaneous infections most commonly are caused by Staphylococcus aureus and GABHS. Life-threatening complications can occur and are preventable with early diagnosis and specific therapy. Dermatophytoses frequently are seen in children and immune-compromised adults with poor hygiene. Sporotrichosis and nontuberculous mycobacteria are ubiquitous and can cause indolent granulomatous lesions. Vesicular and fleshy lesions are manifestations of cutaneous viral infections due to HSV, varicella-zoster virus, molluscum, and human papillomavirus.