Clinical Images: Vertebral compression fractures and striae in Cushing's disease

Our patient, a 22‐year‐old man with a history of obesity, essential tremor, and fatty liver, presented with 2 months of progressively worsening back pain. He also had a history of recently worsening hypertension and had several previous emergency department visits for back pain, where he was also noted to be hypokalemic. The hypertension and hypokalemia persisted despite angiotensin‐converting enzyme inhibitor and mineralocorticoid receptor antagonist use. Because of the patient's severe non‐traumatic back pain, magnetic resonance imaging (MRI) of the spine was performed. This showed multilevel vertebral compression fractures (A), for which the patient underwent kyphoplasty and was started on calcium and vitamin D supplementation. The patient was also noted to have diffuse striae (B) and facial fullness, raising the suspicion for Cushing's syndrome. Striae are dermal scars resulting from tears in the dermis and occur in a variety of conditions associated with inhibition of dermal collagen formation, including glucocorticoid excess. Confirmatory test results included an elevated 24‐hour urine cortisol level, an abnormal 1‐mg dexamethasone suppression test result, an elevated serum adrenocorticotropic hormone (ACTH) level, and a pituitary MRI scan significant for a 0.4 × 1.1 × 0.6–cm hypoenhancing lesion within the posterior aspect of the adenohypophysis, leading to the diagnosis of Cushing's disease. Inferior petrosal sinus sampling was consistent with a central source of ACTH. Ultimately, the patient underwent transsphenoidal resection of his pituitary tumor. On pathology, immunoperoxidase staining of the resected tumor elucidated anterior pituitary cells expressing keratin, ACTH, growth hormone, and prolactin. In the months following the resection, the patient's symptoms, electrolyte abnormalities, and weight greatly improved; he experienced no further fractures; and he was able to stop antihypertensive medications.

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