Case of the week

Prof : Faiza Qari

A 65 year old female was diagnosed to have osteoporosis (T score of -2.5 in the lumbar spineT score of -2.5 in the lumbar spine). Her physician sent off a PTH and serum calcium.

The PTH was high and the calcium was normal. The physician started her on alendronate 70 mg weekly.

He contemplated sending the patient to ENT surgeon for parathyroid-ectomy, but decided to get your opinion first.

You obtain a history of loss of height and rib fracture after falling against the dining table.

She had a mild stroke a few years ago, she fully recovered but she developed seizure disorder for which she takes phenytoin.

She lives alone and does not get out much because of arthritis and some gait imbalance for which she uses a walker around the house.

Physical examination shows kyphosis and tenderness to fist percussion over the thoracic spine, with some pain on compression of the ribs.

Mild symmetric weakness is noted in the proximal muscles.

You appropriately diagnosed her illness and treated her.

Q1 What clues from the history and physical exam helped you in making your diagnosis?

Loss of heightRib fracturePhenytoinLack of sun exposureGait disturbances

Q1 Cont..

KyphosisTenderness over the thoracic spineProximal muscles weaknessBMD: T score -2.5Elevated PTHNormal calcium

Q2 What further tests do you want to order?

Calcium-albuminPhosphate- creatinine25 hydroxy vitamin D Intact PTH24 hours urine collection for calcium

Q3 Which test is diagnostic?

25 hydroxy vitamin D

Q4 How should this patient be treated? Vitamin D3 50,000 units once per week for

six to eight weeks, and then 800 to 1000 IU daily.

Intramuscular cholecalciferol (300,000 IU) in one or two doses per year is also an option

Calcium 1200 mg/day

Q5 How would you monitor treatment?

25OHD concentrations should be measured approximately three months after initiating therapy.

Hypercalcemia (1st sign of toxicity)

Q6 Is it necessary to screen the general population for this condition?

It is not necessary.

All adults who do not have regular effective sun exposure should consume at least 800 IU VitD3 daily

In patients who are home-bound, known or suspected malabsorption, and in those being evaluated for osteoporosis, it is appropriate to measure serum 25OHD