Metabolic derangement after injection of triamcinolone into the hip of an HIV-infected patient receiving ritonavir.

Iatrogenic Cushing syndrome with secondary adrenal insufficiency is a rare but recognized complication of intra-articular corticosteroid injection. Recent reports suggest that the risk of this serious complication is significantly higher in human immunodeficiency virus (HIV)-infected patients receiving ritonavir-based antiretroviral regimens. This article describes a case of a 44-year-old HIV-infected man taking ritonavir who required admission to the intensive care unit (ICU) for hyperosmolar hyperglycemic state following injection of triamcinolone acetonide 80 mg into his right hip for osteoarthritis. Within 3 days of the injection, he developed polydipsia, polyphagia, polyuria, fatigue, and malaise and lost 10 lbs. Laboratory evaluation revealed a blood glucose of 766 mg/dL, and serum pH was 7.36 (normal, 7.31-7.41). After 3 days in the ICU, he was discharged on detemir insulin 15 units subcutaneously daily and sliding scale insulin aspart. Seven weeks after the injection, his detemir insulin had been titrated to 41 units daily, and his serum triamcinolone acetonide concentration was 0.39 mcg/dL (normal, <0.03 mcg/dL). His morning plasma cortisol level was 1.6 mcg/dL (normal, 4-24 mcg/dL), and his adrenocorticotropic hormone concentration was <5 pg/mL (normal, 7-50 pg/mL), consistent with suppression of his hypothalamic-pituitary-adrenal axis. We believe that systemic absorption of triamcinolone and decreased metabolism of triamcinolone due to ritonavir caused this profound and persistent hyperglycemia and hypothalamic-pituitary-adrenal axis suppression. This case highlights the need for heightened awareness of potential interactions to avoid important adverse effects in patients who receive intra-articular corticosteroids.

Acute colonic pseudo-obstruction (Ogilvie syndrome) after arthroplasty in the lower extremity.

BACKGROUND: Acute colonic pseudo-obstruction, also known as Ogilvie syndrome, is an uncommon postoperative complication of total hip and total knee arthroplasty that is characterized by massive colonic dilatation and the potential for substantial morbidity and mortality. METHODS: We conducted a retrospective case-control study of 1170 total hip and knee arthroplasties performed by one surgeon from 1995 to 2002, and identified eighteen patients with Ogilvie syndrome. Radiographs and medical records were analyzed for risk factors and treatment effectiveness. RESULTS: Eleven (1.6%) of 708 patients who had a total hip arthroplasty and seven (1.5%) of 462 patients who had a total knee arthroplasty had Ogilvie syndrome develop postoperatively. Seventeen of these patients had preoperative conditions and/or had received medications identified as risk factors for Ogilvie syndrome. The use of patient-controlled analgesia was associated with an earlier development of symptoms. Colonic decompression was performed in seven patients and was associated with a significantly shorter hospital stay (p = 0.019). CONCLUSIONS: Acute colonic pseudo-obstruction was equally prevalent after total hip and total knee arthroplasties. Most patients who had Ogilvie syndrome had risk factors that could be identified preoperatively. Knowledge of these risk factors can enable the physician to anticipate which patients may have Ogilvie syndrome develop and, therefore, to be vigilant for its development and judicious in the use of patient-controlled analgesia. We also found that decompressive colonoscopy reduced the risk of perforation and decreased the length of hospitalization for the patients in whom Ogilvie syndrome developed.