1. Case of the week Prof : Faiza Qari

2. T score of -2.5 in the lumbar spine  A 65 year old female was diagnosed to have osteoporosis (T 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.

3. 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.

4. 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.

5. Q1 What clues from the history and physical exam helped you in making your diagnosis?  Loss of height  Rib fracture  Phenytoin  Lack of sun exposure  Gait disturbances

6. Q1 Cont..  Kyphosis  Tenderness over the thoracic spine  Proximal muscles weakness  BMD: T score -2.5  Elevated PTH  Normal calcium

7. Q2 What further tests do you want to order?  Calcium-albumin  Phosphate- creatinine  25 hydroxy vitamin D  Intact PTH  24 hours urine collection for calcium

8. Q3 Which test is diagnostic? 25 hydroxy vitamin D

9. 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

10. Q5 How would you monitor treatment?  25OHD concentrations should be measured approximately three months after initiating therapy.  Hypercalcemia (1 st sign of toxicity)

11. 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