A Different Kind of Epidemic

There seems to be an epidemic of steroid use in the northeastern DR Congo. We found out recently that one of our diabetic patients with a non-healing foot wound, persistent vomiting and lowish blood pressure had been taking prednisolone for several years for headaches. Prednisolone mimics the action of cortisol, which is produced by our adrenal glands and which has many different effects in the body. When one takes prednisolone or other steroids for long periods of time, the adrenal gland stops producing its own cortisol. If someone takes too high doses for too long, one can develop diabetes, high blood pressure, obesity, osteoporosis, cataracts and other problems. Could our patient have developed diabetes because of her chronic use of prednisolone? If one stops taking steroids abruptly after chronic use, severe illness and even shock with persistently low blood pressure can result. The treatment for this is restarting the steroids, usually in the form of high dose intravenous hydrocortisone and then slowly tapering the dose. Within hours after starting hydrocortisone, our diabetic stopped vomiting.

We had a similar case recently. One of our patients who had been hospitalized for weeks with severe fatigue, edema (puffiness) of his face, and other vague complaints, developed hypotension. While teaching the nursing students how to take histories and do physical exams, Anna learned that he had chronically used dexamethasone—another steroid—for headaches. We started hydrocortisone and with 24 hours the patient was a new man, sitting up in bed, more responsive, with a normal blood pressure.

Yesterday we received a new patient transferred from another hospital where he had been treated for 10 days for low blood pressure. He was on the verge of shock with low blood pressure and tachycardia when he arrived. We assumed this was septic shock (shock due to an infection) and started fluids and antibiotics. He had severe abdominal pain and I was concerned about ruptured appendicitis or a typhoid perforation, but I found no abnormalities when I echoed his abdomen.  I had noticed that his face was a bit puffy when he arrived but didn’t think much of it. Today I noticed it again and asked him about steroid use. Surprise, surprise—he has used dexamethasone chronically for pain control and he abruptly stopped the medication a month ago. While he might very well have an infection, I think his persistent hypotension is due to adrenal insufficiency (and his history of high blood pressure in the past is probably due to his dexamethasone use as well).

I saw two very obese patients today—one presenting with shortness of breath and palpitations concerning for heart failure, the other admitted for abdominal pain and found to have HIV. Both of them have had significant weight gain in the past year. They also both take steroids chronically for musculoskeletal complaints.

Stretch marks and developing "moon facies"--this man has been taking around 10 mg of dexamethasone daily for 2 years to treat chronic pain

This is what happens without an FDA, with pharmacies that do not require prescriptions. Steroids are amazing medications and can be very helpful in reducing inflammation, but with chronic use they can become monsters. When we moved here I knew I would be combatting malaria, HIV, schistosomiasis, as well as diabetes and hypertension. I did not know that I would be seeing so often the fallout of unsupervised medication use. How does one change such a vast system of unregulated provision of medications? I have no idea…