Trabecular bone score and bone mineral density as indices of skeletal fragility in endogenous Cushing's syndrome

OBJECTIVE

Endogenous Cushing's syndrome (CS) is a known cause of secondary osteoporosis. Vertebral fractures (VFs) in endogenous CS may occur despite normal bone mineral density (BMD). Trabecular bone score (TBS) is a relatively new, non-invasive technique to assess bone microarchitecture. The objective of our study was to analyse the BMD and bone microarchitecture using TBS in endogenous CS and compare it with a group of age and sex-matched healthy controls, and also analyse the factors predicting BMD and TBS.

DESIGN

Cross-sectional study of cases and controls.

PATIENTS AND MEASUREMENTS

We included 40 female patients with overt endogenous CS, out of which 32 were adrenocorticotropic hormone (ACTH)-dependent CS and 8 were ACTH-independent. We also included 40 healthy, female controls. Both patients and controls were subjected to an assessment of biochemical parameters and BMD and TBS.

RESULTS

Patients with endogenous CS had significantly lower BMD at the lumbar spine, femoral neck, and total hip and significantly lower TBS than healthy controls (all p < .001), while no significant difference was noted in the distal radius BMD (p = .055). In endogenous CS, a large proportion of patients, n = 13 (32.5%) had normal BMD for age (BMD Z-score ≥ -2.0) with low TBS (L₁ -L₄ TBS ≤ 1.34). TBS correlated negatively with HbA1c (p = .006), and positively with serum T4 (p = .027).

CONCLUSION

TBS should be considered an important complementary tool in addition to BMD for the routine assessment of skeletal health in CS.

A practical guidance on the use of intravenous insulin infusion for management of inpatient hyperglycemia: Intravenous Insulin Infusion for Management of Inpatient Hyperglycemia

BACKGROUND

We aim to provide a practical guidance on the use of intravenous insulin infusion for managing inpatient hyperglycemia.

METHODS AND RESULTS

This document was formulated based on the review of available literature and personal experience of authors. We have used various case scenarios to illustrate variables which should be taken into account when deciding adjustments in infusion rate, including but not restricted to ambient blood glucose level and magnitude of blood glucose change in the previous hour.

CONCLUSION

The guidance can be generalized to any situation where dedicated protocols are lacking, trained manpower is not available and resource constraints are present.

Pyomyositis Complicated by Deep Venous Thrombosis - A Unique Case of Reverse Lemierre's Syndrome

We report a case of a young individual who presented with fever and swelling of right upper and lower limbs for 3 weeks. Subsequently he developed shortness of breath and decreased urine output and had to be mechanically ventilated. Ultrasound screening of the lower limb had shown deep venous thrombosis (DVT) and thus the diagnosis of pulmonary thromboembolism (PTE) seemed probable. However the workup for PTE was negative and patient's fever continued and his condition deteriorated. Evaluation for an infective locus led to the diagnosis of pyomyositis and DVT appeared to have developed secondary to the muscle inflammation as a part of Reverse Lemierre's syndrome. Thus this case highlights the importance of considering this diagnosis in a similar setting and not to ascribe every case of respiratory failure in a background of DVT to be due to PTE.