The Roentgenographic Appearance of the Bones in Cushing's Syndrome

A series of 7 cases of Cushing's syndrome from the records of the Mount Sinai Hospital was studied with particular attention to the occurrence, appearance, and distribution of osteoporosis. The final diagnosis in 4 cases was carcinoma, and in 3 cases adenoma, of the adrenal cortex, as proved at operation or at autopsy. All of the patients were females. The characteristic clinical picture of Cushing's syndrome in the female, in whom most of the cases have been reported, is the deposition of fat on the trunk, vascular hypertension, amenorrhea, the development of purplish striae on the abdomen, choleric facies, varying degrees of hirsutism, acneiform eruptions on the face and trunk, decreased sugar tolerance, and osteoporosis. The syndrome apparently occurs with basophilic adenoma of the pituitary gland, tumors of the adrenal cortex and, very rarely, of the thymus, or without tumors of any of these organs (2). The association of a tumor with Cushing's syndrome occurs rarely in the adult male, regularly in the child, and commonly in the adult female (2). In all cases the basophilic cells show characteristic hyaline changes which are now regarded as the common pathological denominator (2). It may be, however, that the hyalinization represents the degenerative change following a period of overactivity of the basophils as a consequence of inactivation of certain subsidiary ductless glands (6). There is a decrease or absence of estrogens in the blood, and an increase in the urinary androgens. Androgens may inhibit the effect of the estrogens on the formation of bone, and this may account for the severity of the osteoporosis. The most important factor, however, is thought to be a negative nitrogen balance due to the increased conversion of proteins into sugars (1). Osteoporosis occurs frequently in Cushing's syndrome. Eisenhardt and Thompson (4), in a review of the literature, found that of 61 patients, ranging in age from eleven to seventy-eight years (average thirty-four years), in whom an examination of the bones had been made, 53 had definite osteoporosis, 5 showed questionable changes, and 3 had normal bones. In one of the 53 cases with osteoporosis there was delayed epiphyseal union. In our series of 7 patients, from nineteen to forty-nine years of age, 6 had osteoporosis. The skull was involved most often in our cases, but the more striking changes occurred in the spine and in the ribs. In one patient with severe changes, the long bones, especially the femora and the humeri, were involved. The osteoporosis in the skull, noted in 5 of the 7 cases, was irregular in distribution and occurred most often in the frontal and parietal regions. The osteoporotic areas were irregularly triangular or ameboid in shape, with ill-defined margins, or were roughly circular, resembling metastatic cancer. In one case (Fig. 4) there was diffuse, slightly coarse granular mottling of the calvarium not unlike that observed in a well advanced case of hyperparathyroidism.