We present a 15-year-old girl and an 11-year-old boy who were prescribed dexamphetamine for treatment of Attention Deficit Hyperactivity Disorder (ADHD), and who subsequently presented with symptoms indicative of Cushing's syndrome. It turned out that both children had taken high doses of dexamethasone instead of dexamphetamine due to an error made by the pharmacist. The diagnosis of exogenous Cushing's syndrome is easily made. However, it is a serious condition with possibly severe and persistent complications. The substitution of dexamethasone for dexamphetamine has been described before. Both doctors and pharmacists should be aware of this possible error.
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