A rare case report of iatrogenic Cushing syndrome with multisystem involvement due to prolonged steroid injections: a diagnostic challenge.

Introduction and importance: Iatrogenic Cushing syndrome is a multisystemic endocrinological disorder. It is caused by prolonged exposure to exogenous corticosteroids and remains an underdiagnosed endocrine disorder, particularly in low-resource settings where unsupervised self-administration and misuse of Over The Counter (OTC) steroid injections is common. Case presentation: We present a 57-year-old woman with a 20-year history of type 2 diabetes mellitus who presented to the notice of a clinician with multifocal recurrent left arm, leg, and breast cellulitis; diarrhea; bilateral pedal edema; and atrial fibrillation. The history of the patient was long-term treatment with insulin and frequent self-administered steroid injections for self-treated musculoskeletal pain, not prescribed. Despite classic Cushingoid features, her laboratory findings paradoxically revealed hypocortisolism and suppressed gonadotropins, consistent with hypothalamic pituitary adrenal (HPA) axis suppression. Management consisted of steroid withdrawal under observation, broad-spectrum antibiotics in cellulitis, hyperglycemia control with aggressive insulin, and supportive care. Clinical discussion: This case demonstrates the diagnostic challenge of exogenous Cushing syndrome, in which biochemical findings of low cortisol can mask clinical hypercortisolism. It underscores the systemic complications which include metabolic decompensation, infection susceptibility, and cardiovascular disease due to unregulated steroid use. Of interest is that the case demonstrates the public health significance of uncontrolled steroid access in low- and middle-income nations like Pakistan, where over-the-counter misuse mainly contributes to underdiagnosed iatrogenic Cushing syndrome. Conclusion: Clinicians should consider iatrogenic Cushing syndrome in patients with unexplained multisystem problems. Regulatory control of over-the-counter steroid access and patient education are crucial to preventing such cases.