Cushing’s Disease Presenting with Lower Extremity Insufficiency Fracture, and Complicated by Cavernous sinus Syndrome and Pituitary Macroadenoma Infarction Following Bilateral Inferior Petrosal Sampling

Osteoporosis is a common manifestation of Cushing’s syndrome, and fractures, particularly of vertebra and ribs, are frequent complications. Lower extremity insufficiency fractures, in the absence of other overt Cushingoid features, are a rarely reported presenting feature of endogenous Cushing’s syndrome. Adrenocorticotrophic hormone (ACTH) dependent Cushing’s syndrome accounts for the majority of endogenous Cushing’s syndrome, and includes ACTH-secreting pituitary adenomas, ectopic ACTH production and corticotrophin releasing hormone (CRH)-producing tumors. Bilateral Inferior Petrosal Sinus Sampling (BIPSS) is the gold standard to confirm ACTH excess of pituitary origin and lateralization within the gland. It is generally regarded as an accurate and safe procedure, and serious adverse effects are rare. We report a case of Cushing’s Disease presenting with a metatarsal fracture with minimal other clinical signs of hypercortisolism, and a novel case of cavernous sinus syndrome and pituitary macroadenoma infarction complicating BIPSS, with subsequent temporary improvement of hypercortisolism.