Lower Extremity Insufficiency Fractures in Patients with Cushing's Syndrome

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 234-256-Bone & Calcium Metabolism: Clinical Trials & Case Series
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-255
Sujani Poonuru*1, James W Findling2 and Joseph L Shaker3
1Medical College of Wisconsin, Brookfield, WI, 2Medical College of Wisconsin, Menomonee Falls, WI, 3Medical College of Wisconsin, Milwaukee, WI
Lower Extremity Insufficiency Fractures in Patients with Cushing’s Syndrome

Sujani Poonuru, James W. Findling, Joseph L. Shaker


Low bone density with an increased fracture risk is a well recognized complication of overt endogenous Cushing’s syndrome (CS).  Early recognition and treatment of CS have been shown to improve bone density and reduce fractures. We report 9 women with a median age of 59 (range 27-69) in whom a lower extremity (LE) insufficiency fracture (IF) was one of the initial clinical manifestations of CS.   

Summary of Cases:

All 9 patients had LE IF prior to the diagnosis of CS.  Eight patients had metatarsal IF and 1 had tibial IF.  One patient also had a fibular IF and another had a femoral neck IF.  Hip (n=2), rib (n=2), and pelvic (n=1) fractures also occurred prior to the diagnosis of CS.  Five patients had no overt clinical features of CS and 4 patients were described as having a “Cushingoid” appearance.  Eight of the 9 patients had hypertension, 4 had diabetes/prediabetes, and 2 had kidney stones.  The median BMI was 26.6 kg/m2 (range 23.7-48).  Biochemical evaluation showed abnormal late night salivary cortisols in 6/9 patients (normal in 3 with adrenal Cushing’s), abnormal 1 mg dexamethasone suppression test in 8/9 patients (normal in 1 with adrenal Cushing’s), and elevated 24 hour urinary free cortisol in 3/8 patients.  Eight of the 9 patients have had surgical confirmation of CS:  4 patients had adrenal Cushing’s (2 bilateral nodular hyperplasia and 2 unilateral nodules) and 4 had ACTH producing pituitary adenomas.  One patient with adrenal Cushing’s has not had surgery yet.  Amongst the 8 women > 50 years of age, 3 met WHO densitometric criteria for osteoporosis and 5 met criteria for osteopenia.   The 27 yo woman had lower than average BMD with a femoral neck Z-score of -1.3.  Prior to the diagnosis of CS, 7 patients had received bisphosphonate therapy.


Although LE IF are common in female athletes, sometimes associated with amenorrhea, there have only been 4 previously reported cases of CS who presented with IF (1-3).

Non-traumatic lower extremity insufficiency fractures with low bone density may be one of the initial manifestations of CS even in the absence of overt clinical features of hypercortisolism.

1.Licata. Med and Sci in Sports Exercise, 1992. 2.Ontell et al. Alerts, Notices, and Case reports, 1995. 3.Albon et al. British Endocrine Society Meeting 2003, P26.

Disclosure: JWF: Consultant, Abbott Laboratories, Consultant, Corcept, Investigator, Novartis Pharmaceuticals. Nothing to Disclose: SP, JLS

*Please take note of The Endocrine Society's News Embargo Policy at http://www.endo-society.org/endo2013/media.cfm