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van Houten P, de Rooy J, van der Geest I, Netea-Maier R, van de Ven A. Spontaneous bone infarction of the distal femur in a patient with Cushing's disease: a case report. Bone Rep 2021; 14:100756. [PMID: 33665239 PMCID: PMC7905338 DOI: 10.1016/j.bonr.2021.100756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/13/2021] [Accepted: 02/13/2021] [Indexed: 12/03/2022] Open
Abstract
Avascular necrosis of the femoral head is a well-known complication of treatment with high dosage glucocorticoids and has been described in a few patients with Cushing's syndrome. In this case report, we describe the, to our knowledge, first case of a patient with endogenous Cushing's syndrome with a bone infarction located in the distal femur. In patients with Cushing's syndrome and bone pain, the diagnosis of bone infarction should be considered as it can occur as a rare complication of hypercortisolism.
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Affiliation(s)
- Pepijn van Houten
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jacky de Rooy
- Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ingrid van der Geest
- Department of Orthopedic Oncologic Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Romana Netea-Maier
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Annenienke van de Ven
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Centre, Nijmegen, the Netherlands
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Salazar D, Esteves C, Ferreira MJ, Pedro J, Pimenta T, Portugal R, Carvalho D. Avascular femoral necrosis as part of Cushing syndrome presentation: a case report. J Med Case Rep 2021; 15:287. [PMID: 34034798 PMCID: PMC8152328 DOI: 10.1186/s13256-021-02882-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 04/22/2021] [Indexed: 12/30/2022] Open
Abstract
Background The clinical characteristics and complications of Cushing syndrome (CS) are well known and described in the literature. Nevertheless, rare, atypical presentations may go unnoticed. Osteonecrosis is a well-documented complication of glucocorticoid therapy. However, endogenous hypercortisolism is a rare, but relevant, cause of bone avascular necrosis. We describe the case of a woman with CS undiagnosed for 2 years after presenting with femoral avascular necrosis. Case presentation A 38-year-old Caucasian woman was referred for evaluation of secondary amenorrhea, associated with oral contraception withdrawal in the context of deep venous thrombosis (DVT). She had a previous right hip arthroplasty for treatment of avascular necrosis of the femoral head, diagnosed after 3 years of progressive right hip pain and limited mobility. She also had high blood pressure (HBP) of 5 years’ duration, and reported weight gain (4 kg in 2 years). There was no history of infertility (gravida 2, para 2). Physical examination revealed buffalo hump, truncal obesity, facial plethora, muscular atrophy and proximal myopathy, and easy bruising (under anticoagulant treatment for DVT). Workup showed abnormal overnight dexamethasone suppression test (DST) (serum cortisol 21.5 µg/dL; normal < 1.8 µg/dL), elevated 24-hour urinary free cortisol (UFC) (728.9 µg/day; reference range 36.0–137.0 µg/day), and suppressed plasma adrenocorticotropic hormone (ACTH) (< 1.0 pg/mL), findings consistent with ACTH-independent CS. Urinary metanephrines and catecholamines were normal, and the remaining analytical study showed no major changes, apart from glycated hemoglobin (HbA1c) of 6.8%. Adrenal computed tomography (CT) scan showed a 25 mm lesion in the left adrenal gland, with density non-suggestive of adenoma. The patient underwent unilateral adrenalectomy and started steroid replacement. Histology revealed an adrenal cortex adenoma. Three months after surgery the patient presented with resolution of HBP and hypercortisolism (UFC 37.4 µg/day; reference range 36.0–137.0 µg/day). Conclusion In some cases, CS signs may go unnoticed and the diagnosis postponed. Avascular necrosis is a rare presenting feature of endogenous hypercortisolism, and, if left untreated, complete collapse of the femoral head may ensue, rendering the need for hip replacement in up to 70% of patients. Suspicion and recognition of atypical features is therefore important in avoiding complications and delay in treatment of CS.
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Affiliation(s)
- Daniela Salazar
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, 4200-319, Porto, Portugal. .,Faculty of Medicine of University of Porto, Porto, Portugal. .,Institute for Research and Innovation in Health, University of Porto, Porto, Portugal.
| | - César Esteves
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, 4200-319, Porto, Portugal
| | - Maria João Ferreira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, 4200-319, Porto, Portugal.,Faculty of Medicine of University of Porto, Porto, Portugal.,Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
| | - Jorge Pedro
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, 4200-319, Porto, Portugal.,Faculty of Medicine of University of Porto, Porto, Portugal.,Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
| | - Tiago Pimenta
- Department of Surgery of Centro Hospitalar, Universitário de São João, Porto, Portugal
| | - Raquel Portugal
- Department of Pathology of Centro Hospitalar, Universitário de São João, Porto, Portugal
| | - David Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, 4200-319, Porto, Portugal.,Faculty of Medicine of University of Porto, Porto, Portugal.,Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
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Belmahi N, Boujraf S, Larwanou MM, El Ouahabi H. Avascular necrosis of the femoral head: An exceptional complication of cushing's disease. Ann Afr Med 2019; 17:225-227. [PMID: 30588938 PMCID: PMC6330779 DOI: 10.4103/aam.aam_75_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Avascular necrosis (AVN) of the femoral head is a well-recognized complication of steroid treatment. Exogenous glucocorticoids' administration and alcoholism are the most common nontraumatic etiologies. AVN secondary to endogenous hypercortisolism (HC) is rare; very few case reports are available on this complication. We describe a 28-year-old female that has presented an AVN with Cushing's syndrome. Biochemical investigations confirmed HC. Magnetic resonance imaging (MRI) showed a pituitary adenoma that was resected transsphenoidally. The postoperative failure directed to radiosurgery treatment. Then, the patient then expressed a significant clinical improvement while developing adrenocorticotropic deficiency; hence, steroids were indicated. During the discovery of Cushing disease, the patient presented also limping and progressive pain in right hip. The pelvis MRI showed an AVN of the right femoral head. The patient underwent a total replacement of the right hip sine presenting an extensive AVN. This case elucidates that AVN could be an early manifestation of Cushing's disease.
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Affiliation(s)
- Nadia Belmahi
- Department of Endocrinology and Diabetology, University Hospital of Fez, Fez, Morocco
| | - Saïd Boujraf
- Department of Biophysics and Clinical MRI Methods, Faculty of Medicine and Pharmacy, University of Fez, Fez, Morocco
| | | | - Hanan El Ouahabi
- Department of Endocrinology and Diabetology, University Hospital of Fez, Fez, Morocco
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Uppal J, Burbridge B, Arnason T. Bilateral osteonecrosis of the hip in panhypopituitarism. BMJ Case Rep 2019; 12:12/2/bcr-2018-227471. [PMID: 30765453 DOI: 10.1136/bcr-2018-227471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Osteonecrosis, also known as avascular necrosis, is a condition that causes significant morbidity and loss of function. It is a common complication seen with supraphysiological steroid use. Early diagnosis is critical as it impacts prognosis. We report a 20-year-old man who developed bilateral osteonecrosis of the hip following 6 years of low-dose steroid replacement therapy for panhypopituitarism secondary to a transsphenoidal resection of a growth hormone-secreting pituitary macroadenoma. The patient presented with several weeks of right-sided hip pain and significant loss of function. X-ray and MRI showed bilateral osteonecrosis of the hips with the right side more severely affected than the left. He was initiated on analgesics and bisphosphonates and underwent right hip total arthroplasty followed 1 year later by left hip arthroplasty. Postsurgery, the patient is mobilising well and his pituitary hormones are well balanced. He continues on low-dose glucocorticoid replacement which will continue lifelong.
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Affiliation(s)
- Jasmene Uppal
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brent Burbridge
- Department of Radiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Terra Arnason
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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