Session: SUN 234-256-Bone & Calcium Metabolism: Clinical Trials & Case Series
Poster Board SUN-255
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.
Disclosure: JWF: Consultant, Abbott Laboratories, Consultant, Corcept, Investigator, Novartis Pharmaceuticals. Nothing to Disclose: SP, JLS
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