High prevalence of hookah smoking among secondary school students in a disadvantaged community in Johannesburg.

The daily dose of budesonide used in our cases varied from 200 μg to 1 200 μg. Adherence to medication was assessed by verbal report and medication demonstration by the caregiver. In case 2 the child was given medication by a trained nurse in a children’s home and medication was boarded for us to review. Dosing of inhaled budesonide in children with obstructive lung disease is based on clinical response to treatment. Recommended dosing ranges from a low dose of 100 200 μg/d to higher doses of >400 μg/d. With the exception of case 1 these children were on moderate doses of budesonide only and in case 3 initially a low dose of fluticasone (50 μg/d). The fact that the children may have been overdosed cannot be entirely excluded. However, it appears that adrenal axis suppression can occur at standard recommended doses of budesonide and fluticasone when used concomitantly with ritonavir. This relationship requires further investigation. The older nucleoside reverse transcriptase inhibitors (NRTIs) such as zidovudine and stavudine remain first-line therapy in our and other resource-limited settings. These drugs are associated with lipodystrophy and truncal obesity. It is important to consider Cushing’s syndrome as a differential diagnosis and that the diagnosis of adrenal suppression is not missed.