A 23‐year‐old woman with a history of recently diagnosed diabetes mellitus (DM) type 2 and hypertension (HTN) and recent significant weight gain presented to the ED with a 2‐month history of extreme low back pain with associated LE weakness (R>L), bilateral LE hypesthesia, and occasional urine incontinence. Physical exam in the ED showed exquisite sacral tenderness, L5‐S1 weakness, and Cushingoid features. Initial thoracic and lumbar CT scans suggested accumulation of fat in the epidural space, and a subsequent MRI confirmed epidural lipomatosis extending from T4 to T9. Cushing's disease was confirmed with elevated 24‐hour urinary cortisol level. Suppression of plasma cortisol following a high‐dose dexamethasone test suggested an ectopic ACTH source as the cause of hypercortisolism. After several chest CTs, a 1.7‐cm pulmonary nodule was identified in the right upper lobe. Removal of this nodule identified an ACTH‐producing bronchial carcinoid, likely responsible for the patient's hypercortisolism. Following removal, control of the patient's HTN and DM improved dramatically, she lost 100 pounds over a few months, and her low back pain significantly improved.
A rare condition, epidural lipomatosis, is the abnormal accumulation of fat in the extradural space. Accumulated fat compresses neural elements, resulting in radiculopathy, as well as neurological changes at the involved segments. This condition has been associated with exogenous and endogenous glucocorticoid sources and with obesity. The combination of hypercortisolism and obesity were likely contributory to the development of epidural lipomatosis in this patient.
This unusual case suggests that imaging is an essential part of the workup for any patient with back pain associated with neurological deficits. Epidural lipomatosis, associated with low back pain and neurological changes, is an example of a disease process for which imaging is important for diagnosis.
A. Arens, none; J. Grigoriev, none.