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Cushing's disease presenting with avascular necrosis of the hip: an orthopedic emergency
C A Koch1, C Tsigos, N J Patronas
1Developmental Endocrinology Branch, National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-1862, USA.
Insights
Avascular necrosis (AVN) of the hip can be an early sign of Cushing
Area of Science:
- Endocrinology
- Orthopedics
- Radiology
Background:
- Nontraumatic avascular necrosis (AVN) of the hip is typically linked to exogenous glucocorticoids.
- Endogenous hypercortisolism, such as Cushing's syndrome (CS), is a rare cause of AVN.
Observation:
- A 30-year-old woman with Cushing's disease presented with early-stage AVN of the hip.
- Initial plain X-rays were negative, but MRI confirmed stage 2 AVN.
- Orthopedic intervention with core decompression was performed before a CS diagnosis.
Findings:
- The patient's femoral head recovered fully following early core decompression.
- MRI is crucial for diagnosing early AVN, as radiographs can be falsely negative.
- This case highlights AVN as a potential initial manifestation of CS.
Implications:
- Early diagnosis and treatment of AVN are critical for a favorable prognosis.
- Core decompression should be promptly initiated for suspected AVN, even before CS diagnosis.
- Recognizing the link between AVN and CS is vital for timely endocrine management and orthopedic outcomes.
Abstract:
Nontraumatic avascular necrosis (AVN) of the hip is commonly caused by exogenous glucocorticoid administration, whereas it has rarely been associated with endogenous hypercortisolism. We report a 30-yr-old woman with Cushing's disease whose presenting manifestation was early AVN of the hip. Although plain x-ray was negative, magnetic resonance imaging (MRI) of the hip showed stage 2 AVN. Her orthopedic disease was considered an emergency, and thus, it was treated with core decompression before the diagnosis of Cushing's syndrome (CS) was pursued further. The femur recovered fully, as demonstrated by her improved clinical picture and a subsequent MRI. AVN carries a poor prognosis, if not treated early. The diagnostic procedure of choice is MRI, because plain radiographs are falsely negative in early stages. This case illustrates that AVN can be the presenting manifestation of CS; to prevent irreversible effects on the femoral head, core decompression should not be delayed for the purpose of evaluation and treatment of CS.