array:24 [
  "pii" => "S2173574312000743"
  "issn" => "21735743"
  "doi" => "10.1016/j.reumae.2011.11.010"
  "estado" => "S300"
  "fechaPublicacion" => "2012-09-01"
  "aid" => "401"
  "copyright" => "Elsevier España, S.L.. All rights reserved"
  "copyrightAnyo" => "2011"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "sco"
  "cita" => "Reumatol Clin. 2012;8:278-9"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 6510
    "formatos" => array:3 [
      "EPUB" => 54
      "HTML" => 5639
      "PDF" => 817
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S1699258X11003718"
      "issn" => "1699258X"
      "doi" => "10.1016/j.reuma.2011.11.004"
      "estado" => "S300"
      "fechaPublicacion" => "2012-09-01"
      "aid" => "401"
      "copyright" => "Elsevier España, S.L."
      "documento" => "article"
      "crossmark" => 0
      "subdocumento" => "sco"
      "cita" => "Reumatol Clin. 2012;8:278-9"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 15773
        "formatos" => array:3 [
          "EPUB" => 170
          "HTML" => 12078
          "PDF" => 3525
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Caso cl&#237;nico</span>"
        "titulo" => "Enfermedad de Cushing como causa de osteoporosis grave&#46; Un reto cl&#237;nico"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "278"
            "paginaFinal" => "279"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Cushing&#39;s disease as a cause of severe osteoporosis&#58; A clinical challenge"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figura 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 1322
                "Ancho" => 2167
                "Tamanyo" => 248951
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A&#41; Fracturas vertebrales dorsales severas o grado 3 &#40;flechas&#41;&#44; en medio fractura moderada o de grado 1-2&#46; B&#41; B Fractura esternal del tercio superior de cuerpo esternal&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Nadia Abdel-Kader, Mario H&#46; Cardiel, Victoria Navarro Compan, Juan Piedra Priego, Ana Gonz&#225;lez"
            "autores" => array:5 [
              0 => array:2 [
                "nombre" => "Nadia"
                "apellidos" => "Abdel-Kader"
              ]
              1 => array:2 [
                "nombre" => "Mario H&#46;"
                "apellidos" => "Cardiel"
              ]
              2 => array:2 [
                "nombre" => "Victoria"
                "apellidos" => "Navarro Compan"
              ]
              3 => array:2 [
                "nombre" => "Juan"
                "apellidos" => "Piedra Priego"
              ]
              4 => array:2 [
                "nombre" => "Ana"
                "apellidos" => "Gonz&#225;lez"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2173574312000743"
          "doi" => "10.1016/j.reumae.2011.11.010"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000743?idApp=UINPBA00004M"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X11003718?idApp=UINPBA00004M"
      "url" => "/1699258X/0000000800000005/v1_201305061926/S1699258X11003718/v1_201305061926/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2173574312000573"
    "issn" => "21735743"
    "doi" => "10.1016/j.reumae.2012.04.006"
    "estado" => "S300"
    "fechaPublicacion" => "2012-09-01"
    "aid" => "429"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "sco"
    "cita" => "Reumatol Clin. 2012;8:280-3"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 4329
      "formatos" => array:3 [
        "EPUB" => 59
        "HTML" => 3570
        "PDF" => 700
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
      "titulo" => "Maculopathy in Patient With Systemic Lupus Erythematosus Treated With Hydroxychloroquine"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "280"
          "paginaFinal" => "283"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Maculopat&#237;a en paciente con lupus eritematoso sist&#233;mico tratado con hidroxicloroquina"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0015"
          "etiqueta" => "Fig&#46; 3"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr3.jpeg"
              "Alto" => 1248
              "Ancho" => 1493
              "Tamanyo" => 174326
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Angiography of the right eye&#46; Microaneurysms are seen in inferior temporal region and a small temporal macula area &#40;arrows&#41;&#46; Hypo-and hyperfluorescent images of the fovea &#40;asterisk&#41; are not modified during the angiogram&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Francisco Jorge Rodr&#237;guez-Hurtado, Jos&#233; Antonio S&#225;ez-Moreno, Jos&#233; Manuel Rodr&#237;guez-Ferrer"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Francisco Jorge"
              "apellidos" => "Rodr&#237;guez-Hurtado"
            ]
            1 => array:2 [
              "nombre" => "Jos&#233; Antonio"
              "apellidos" => "S&#225;ez-Moreno"
            ]
            2 => array:2 [
              "nombre" => "Jos&#233; Manuel"
              "apellidos" => "Rodr&#237;guez-Ferrer"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S1699258X12000617"
        "doi" => "10.1016/j.reuma.2011.12.012"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12000617?idApp=UINPBA00004M"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000573?idApp=UINPBA00004M"
    "url" => "/21735743/0000000800000005/v1_201305061645/S2173574312000573/v1_201305061645/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2173574312001323"
    "issn" => "21735743"
    "doi" => "10.1016/j.reumae.2012.08.001"
    "estado" => "S300"
    "fechaPublicacion" => "2012-09-01"
    "aid" => "444"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "ssu"
    "cita" => "Reumatol Clin. 2012;8:270-7"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 29166
      "formatos" => array:3 [
        "EPUB" => 84
        "HTML" => 27596
        "PDF" => 1486
      ]
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>"
      "titulo" => "Raynaud&#44; Digital Ulcers and Calcinosis in Scleroderma"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "270"
          "paginaFinal" => "277"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Raynaud&#44; &#250;lceras digitales y calcinosis en esclerodermia"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Alejandro Nitsche"
          "autores" => array:1 [
            0 => array:2 [
              "nombre" => "Alejandro"
              "apellidos" => "Nitsche"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S1699258X12000903"
        "doi" => "10.1016/j.reuma.2012.02.006"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12000903?idApp=UINPBA00004M"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312001323?idApp=UINPBA00004M"
    "url" => "/21735743/0000000800000005/v1_201305061645/S2173574312001323/v1_201305061645/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>"
    "titulo" => "Cushings Disease as a Cause of Severe Osteoporosis&#58; A Clinical Challenge"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "278"
        "paginaFinal" => "279"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Nadia Abdel-Kader, Mario H&#46; Cardiel, Victoria Navarro Compan, Juan Piedra Priego, Ana Gonz&#225;lez"
        "autores" => array:5 [
          0 => array:4 [
            "nombre" => "Nadia"
            "apellidos" => "Abdel-Kader"
            "email" => array:1 [
              0 => "greendoggy&#64;hotmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">¿</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Mario H&#46;"
            "apellidos" => "Cardiel"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Victoria"
            "apellidos" => "Navarro Compan"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Juan"
            "apellidos" => "Piedra Priego"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Ana"
            "apellidos" => "Gonz&#225;lez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Servicio de Reumatolog&#237;a&#44; Hospital Universitario Virgen Macarena&#44; Sevilla&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Reumatolog&#237;a&#44; Hospital Dr&#46; Miguel Silva Hospital&#44; Morelia&#44; Mexico"
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Enfermedad de Cushing como causa de osteoporosis grave&#46; Un reto cl&#237;nico"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1320
            "Ancho" => 2167
            "Tamanyo" => 176158
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Severe stage 3 dorsal vertebral fractures &#40;arrows&#41;&#44; moderate stage 1&#8211;2 dorsal fracture&#46; &#40;B&#41; Fracture of the upper sternal body&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Secondary osteoporosis has been associated with different diseases and drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> These include endocrine diseases&#44; cancer&#44; kidney damage&#44; gastrointestinal and rheumatic diseases&#46; Steroids are also a well-recognized cause of bone mass loss&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> According to some studies&#44; 20&#37;&#8211;30&#37; of postmenopausal women and over 50&#37; of men have a second cause of osteoporosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Endogenous Cushing&#39;s syndrome is characterized by excessive production of steroids&#44; the most common cause being Cushing&#39;s disease due to a pituitary adenoma secreting ACTH&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A female&#44; 41&#44; attended the emergency department with generalized musculoskeletal pain&#44; especially in the chest&#44; spine and groin&#46; Initial radiographs showed multiple fractures of the upper third of the sternal body&#44; two severe stage 3 dorsal vertebral fractures and a third stages 1&#8211;2 dorsal fracture&#44; with another on the ischiopubic ramus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46; On examination hypertension and cushingoid features&#44; such as round face and ce obesity were later found&#46; Laboratory studies showed that cortisol and baseline ACTH determination were elevated&#46; The baseline cortisol was 319<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;normal between 50 and 250<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; and ACTH of 57&#46;4<span class="elsevierStyleHsp" style=""></span>pg&#47;ml when it is normally undetectable or less than 10<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#44; with a decreased gonadotropin level&#46; The levels of urinary free cortisol and cortisol were also elevated at night&#58; 847<span class="elsevierStyleHsp" style=""></span>nmol&#47;l and 290&#46;7<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; respectively&#46; The nocturnal cortisol under normal conditions is negligible&#46; A cranial MRI showed a questionable image in the pituitary&#44; so catheterization of inferior petrosal sinus was performed to study the source of ACTH overproduction&#46; There was a central-peripheral gradient of ACTH and increased focus on the left half of the hypophysis&#46; A second MRI detected a nodule of 6&#46;3<span class="elsevierStyleHsp" style=""></span>mm in the posterior left area of the pituitary&#46; Following these results the patient was diagnosed as having Cushing&#39;s disease due to a pituitary microadenoma&#46; The patient was treated from the surgical standpoint with a hemihypophysectomy of the microadenoma&#44; and infused intravenously &#40;iv&#41; with zoledronic acid 5<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>iv<span class="elsevierStyleMonospace">&#47;</span>year as a treatment for severe osteoporosis&#44; with great improvement of bone pain&#46; After surgery&#44; cortisol levels were normalized with baseline cortisol levels of 152<span class="elsevierStyleHsp" style=""></span>ng&#47;ml and urinary cortisol of 107<span class="elsevierStyleHsp" style=""></span>nmol&#47;l&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Although osteoporosis is a cardinal manifestation of Cushing&#39;s<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> syndrome&#44; there are few publications in this respecto&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The incidence of Cushing&#39;s syndrome of endogenous origin is 2&#8211;4 cases per million inhabitants&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Its diagnosis requires a high clinical suspicion&#44; as most of the symptoms of this syndrome are highly prevalent in the general population &#40;hypertension&#44; glucose intolerance&#44; central obesity&#44; osteoporosis&#41; and none of these is specific&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Fractures occur in 19&#37;&#8211;50&#37; in patients with Cushing&#39;s disease&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In the last 5 years&#44; we have only found two case reports of fractures secondary to osteoporosis due to Cushing&#39;s<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> disease&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Our patient presented with spontaneous fractures as a sentinel manifestation of Cushing&#39;s disease&#44; and in this case the causal diagnosis of osteoporosis had highly relevant prognostic and therapeutic implications&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0020" class="elsevierStylePara elsevierViewall">We must always consider the possibility of secondary osteoporosis after the appearance of a spontaneous fracture&#44; especially in men and premenopausal and perimenopausal women&#44; where the frequency of secondary osteoporosis is near&#47;greater than 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Protection of human and animal subjects</span>&#46; The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Confidentiality of Data</span>&#46; The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Right to privacy and informed consent</span>&#46; The authors have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence is in possession of this document&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Disclosures</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no disclosures to make&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:2 [
          "identificador" => "xres125906"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec113200"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres125905"
          "titulo" => "Resumen"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec113201"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case Report"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusions"
        ]
        8 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Ethical disclosures"
        ]
        9 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Disclosures"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-08-09"
    "fechaAceptado" => "2011-11-16"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec113200"
          "palabras" => array:3 [
            0 => "Cushing&#39;s disease"
            1 => "Fractures"
            2 => "Secondary osteoporosis"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec113201"
          "palabras" => array:3 [
            0 => "Enfermedad de Cushing"
            1 => "Fracturas"
            2 => "Osteoporosis secundaria"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Secondary osteoporosis is a frequently underestimated bone disorder&#46; It is a secondary cause of bone loss that affects more than half of men and premenopausal and perimenopausal women&#44; and about one-fifth of postmenopausal women&#46; We herein report an uncommon case of multiple fractures due to secondary osteoporosis caused by Cushing&#39;s disease&#46; In this case the appearance of fractures in a 41 years old woman was the sign of alarm that ultimately led us to the diagnosis&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La osteoporosis secundaria est&#225; frecuentemente infraestimada en el estudio de la osteoporosis&#46; Existe una causa segunda de osteoporosis en cerca o m&#225;s de la mitad de hombres y mujeres premenop&#225;usicas&#44; y en torno a un quinto de las mujeres posmenop&#225;usicas&#46; Presentamos a una mujer de 41 a&#241;os&#44; con dolor &#243;seo por fracturas m&#250;ltiples&#44; cuyo diagn&#243;stico final fue enfermedad de Cushing&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Abdel-Kader N&#44; et al&#46; Enfermedad de Cushing como causa de osteoporosis grave&#46; Un reto cl&#237;nico&#46; Reumatol Clin&#46; 2012&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.reuma.2011.11.004">doi&#58;10&#46;1016&#47;j&#46;reuma&#46;2011&#46;11&#46;004</span></p>"
      ]
    ]
    "multimedia" => array:1 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1320
            "Ancho" => 2167
            "Tamanyo" => 176158
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Severe stage 3 dorsal vertebral fractures &#40;arrows&#41;&#44; moderate stage 1&#8211;2 dorsal fracture&#46; &#40;B&#41; Fracture of the upper sternal body&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:8 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Secondary osteoporosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "E&#46; Stein"
                            1 => "E&#46; Shane"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Endocrinol Metab Clin North Am"
                        "fecha" => "2003"
                        "volumen" => "32"
                        "paginaInicial" => "115"
                        "paginaFinal" => "134"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12699295"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Secondary causes of osteoporosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Lorraine"
                            1 => "M&#46;D&#46; Fitzpatrick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4065/77.5.453"
                      "Revista" => array:6 [
                        "tituloSerie" => "Mayo Clin Proc"
                        "fecha" => "2002"
                        "volumen" => "77"
                        "paginaInicial" => "453"
                        "paginaFinal" => "468"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12004995"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Secondary osteoporosis&#58; a review of the recent evident"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46;E&#46; Painter"
                            1 => "M&#46; Kleerekoper"
                            2 => "P&#46;M&#46; Camacho"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4158/EP.12.4.436"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endocr Pract"
                        "fecha" => "2006"
                        "volumen" => "12"
                        "paginaInicial" => "436"
                        "paginaFinal" => "445"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16901802"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence&#44; etiology and clinical findings of Cushing&#39;s syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Lahera Vargas"
                            1 => "C&#46; Varela Da Costa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1575-0922(09)70191-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endocrinol Nutr"
                        "fecha" => "2009"
                        "volumen" => "56"
                        "paginaInicial" => "32"
                        "paginaFinal" => "39"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19627706"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis and complications of Cushing&#39;s s&#237;ndrome&#58; a consensus statement"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46; Arnald"
                            1 => "A&#46; Angeh"
                            2 => "A&#46;B&#46; Atkinson"
                            3 => "X&#46; Bertagna"
                            4 => "F&#46; Cavagnini"
                            5 => "G&#46; Chrousos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Clin Endocrinol Met"
                        "fecha" => "2003"
                        "volumen" => "88"
                        "paginaInicial" => "5593"
                        "paginaFinal" => "5602"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Severe impairment of bone mass and turnover in Cushing&#39;s disease&#58; comparison between chidhood-onset and adulthood-onset disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46; Di Somma"
                            1 => "R&#46; Pivonello"
                            2 => "S&#46; Loche"
                            3 => "A&#46; Faggiano"
                            4 => "P&#46; Marzullo"
                            5 => "A&#46; Di Sarno"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Endocrinol &#40;Oxford&#41;"
                        "fecha" => "2002"
                        "volumen" => "56"
                        "paginaInicial" => "153"
                        "paginaFinal" => "158"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A juvenile case of Cushing&#39;s disease incidentally discovered with multiple bone fractures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Yoshihara"
                            1 => "Y&#46; Okubo"
                            2 => "A&#46; Tanabe"
                            3 => "A&#46; Sata"
                            4 => "M&#46; Nishimaki"
                            5 => "T&#46; Kawamata"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intern Med"
                        "fecha" => "2007"
                        "volumen" => "46"
                        "paginaInicial" => "583"
                        "paginaFinal" => "587"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17473494"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hormone-induced spontaneous femoral neck fracture in a 28-year-old female patient"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Bale"
                            1 => "C&#46; Bollheimer"
                            2 => "J&#46; Sch&#246;lmerich"
                            3 => "A&#46; Sch&#228;ffler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Klin &#40;Munich&#41;"
                        "fecha" => "2009"
                        "volumen" => "104"
                        "paginaInicial" => "244"
                        "paginaFinal" => "248"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/21735743/0000000800000005/v1_201305061645/S2173574312000743/v1_201305061645/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "17376"
    "tipo" => "SECCION"
    "es" => array:2 [
      "titulo" => "Case Report"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "es"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/21735743/0000000800000005/v1_201305061645/S2173574312000743/v1_201305061645/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000743?idApp=UINPBA00004M"
]
Share
Journal Information
Vol. 8. Issue 5.
Pages 278-279 (September - October 2012)
Visits
15102
Vol. 8. Issue 5.
Pages 278-279 (September - October 2012)
Case Report
Full text access
Cushings Disease as a Cause of Severe Osteoporosis: A Clinical Challenge
Enfermedad de Cushing como causa de osteoporosis grave. Un reto clínico
Visits
15102
Nadia Abdel-Kadera,
Corresponding author
greendoggy@hotmail.com

Corresponding author.
, Mario H. Cardielb, Victoria Navarro Compana, Juan Piedra Priegoa, Ana Gonzáleza
a Servicio de Reumatología, Hospital Universitario Virgen Macarena, Sevilla, Spain
b Servicio de Reumatología, Hospital Dr. Miguel Silva Hospital, Morelia, Mexico
This item has received
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (1)
Abstract

Secondary osteoporosis is a frequently underestimated bone disorder. It is a secondary cause of bone loss that affects more than half of men and premenopausal and perimenopausal women, and about one-fifth of postmenopausal women. We herein report an uncommon case of multiple fractures due to secondary osteoporosis caused by Cushing's disease. In this case the appearance of fractures in a 41 years old woman was the sign of alarm that ultimately led us to the diagnosis.

Keywords:
Cushing's disease
Fractures
Secondary osteoporosis
Resumen

La osteoporosis secundaria está frecuentemente infraestimada en el estudio de la osteoporosis. Existe una causa segunda de osteoporosis en cerca o más de la mitad de hombres y mujeres premenopáusicas, y en torno a un quinto de las mujeres posmenopáusicas. Presentamos a una mujer de 41 años, con dolor óseo por fracturas múltiples, cuyo diagnóstico final fue enfermedad de Cushing.

Palabras clave:
Enfermedad de Cushing
Fracturas
Osteoporosis secundaria
Full Text
Introduction

Secondary osteoporosis has been associated with different diseases and drugs.1,2 These include endocrine diseases, cancer, kidney damage, gastrointestinal and rheumatic diseases. Steroids are also a well-recognized cause of bone mass loss.2,3 According to some studies, 20%–30% of postmenopausal women and over 50% of men have a second cause of osteoporosis.2,3 Endogenous Cushing's syndrome is characterized by excessive production of steroids, the most common cause being Cushing's disease due to a pituitary adenoma secreting ACTH.4,5

Case Report

A female, 41, attended the emergency department with generalized musculoskeletal pain, especially in the chest, spine and groin. Initial radiographs showed multiple fractures of the upper third of the sternal body, two severe stage 3 dorsal vertebral fractures and a third stages 1–2 dorsal fracture, with another on the ischiopubic ramus (Fig. 1A and B). On examination hypertension and cushingoid features, such as round face and ce obesity were later found. Laboratory studies showed that cortisol and baseline ACTH determination were elevated. The baseline cortisol was 319ng/ml (normal between 50 and 250ng/ml) and ACTH of 57.4pg/ml when it is normally undetectable or less than 10pg/ml, with a decreased gonadotropin level. The levels of urinary free cortisol and cortisol were also elevated at night: 847nmol/l and 290.7ng/ml, respectively. The nocturnal cortisol under normal conditions is negligible. A cranial MRI showed a questionable image in the pituitary, so catheterization of inferior petrosal sinus was performed to study the source of ACTH overproduction. There was a central-peripheral gradient of ACTH and increased focus on the left half of the hypophysis. A second MRI detected a nodule of 6.3mm in the posterior left area of the pituitary. Following these results the patient was diagnosed as having Cushing's disease due to a pituitary microadenoma. The patient was treated from the surgical standpoint with a hemihypophysectomy of the microadenoma, and infused intravenously (iv) with zoledronic acid 5mgiv/year as a treatment for severe osteoporosis, with great improvement of bone pain. After surgery, cortisol levels were normalized with baseline cortisol levels of 152ng/ml and urinary cortisol of 107nmol/l.

Fig. 1.

(A) Severe stage 3 dorsal vertebral fractures (arrows), moderate stage 1–2 dorsal fracture. (B) Fracture of the upper sternal body.

(0.17MB).
Discussion

Although osteoporosis is a cardinal manifestation of Cushing's4 syndrome, there are few publications in this respecto.6 The incidence of Cushing's syndrome of endogenous origin is 2–4 cases per million inhabitants/year.4 Its diagnosis requires a high clinical suspicion, as most of the symptoms of this syndrome are highly prevalent in the general population (hypertension, glucose intolerance, central obesity, osteoporosis) and none of these is specific.4 Fractures occur in 19%–50% in patients with Cushing's disease.6 In the last 5 years, we have only found two case reports of fractures secondary to osteoporosis due to Cushing's7 disease.8 Our patient presented with spontaneous fractures as a sentinel manifestation of Cushing's disease, and in this case the causal diagnosis of osteoporosis had highly relevant prognostic and therapeutic implications.

Conclusions

We must always consider the possibility of secondary osteoporosis after the appearance of a spontaneous fracture, especially in men and premenopausal and perimenopausal women, where the frequency of secondary osteoporosis is near/greater than 50%.3

Ethical disclosures

Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this investigation.

Confidentiality of Data. The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study.

Right to privacy and informed consent. The authors have obtained the informed consent of the patients and/or subjects mentioned in the article. The author for correspondence is in possession of this document.

Disclosures

The authors have no disclosures to make.

References
[1]
E. Stein, E. Shane.
Secondary osteoporosis.
Endocrinol Metab Clin North Am, 32 (2003), pp. 115-134
[2]
A. Lorraine, M.D. Fitzpatrick.
Secondary causes of osteoporosis.
Mayo Clin Proc, 77 (2002), pp. 453-468
[3]
S.E. Painter, M. Kleerekoper, P.M. Camacho.
Secondary osteoporosis: a review of the recent evident.
Endocr Pract, 12 (2006), pp. 436-445
[4]
M. Lahera Vargas, C. Varela Da Costa.
Prevalence, etiology and clinical findings of Cushing's syndrome.
Endocrinol Nutr, 56 (2009), pp. 32-39
[5]
G. Arnald, A. Angeh, A.B. Atkinson, X. Bertagna, F. Cavagnini, G. Chrousos.
Diagnosis and complications of Cushing's síndrome: a consensus statement.
J Clin Endocrinol Met, 88 (2003), pp. 5593-5602
[6]
C. Di Somma, R. Pivonello, S. Loche, A. Faggiano, P. Marzullo, A. Di Sarno.
Severe impairment of bone mass and turnover in Cushing's disease: comparison between chidhood-onset and adulthood-onset disease.
Clin Endocrinol (Oxford), 56 (2002), pp. 153-158
[7]
A. Yoshihara, Y. Okubo, A. Tanabe, A. Sata, M. Nishimaki, T. Kawamata.
A juvenile case of Cushing's disease incidentally discovered with multiple bone fractures.
Intern Med, 46 (2007), pp. 583-587
[8]
M. Bale, C. Bollheimer, J. Schölmerich, A. Schäffler.
Hormone-induced spontaneous femoral neck fracture in a 28-year-old female patient.
Med Klin (Munich), 104 (2009), pp. 244-248

Please cite this article as: Abdel-Kader N, et al. Enfermedad de Cushing como causa de osteoporosis grave. Un reto clínico. Reumatol Clin. 2012. doi:10.1016/j.reuma.2011.11.004

Copyright © 2011. Elsevier España, S.L.. All rights reserved
Download PDF
Idiomas
Reumatología Clínica (English Edition)
Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?