Low Bone Density Is Not Always Osteoporosis!

Presentation Number: SAT 311
Date of Presentation: April 1st, 2017

Amena Iqbal*1, Boby G Theckedath2, Janice L Gilden3 and Alvia Moid4
1Rosalind Franklin University of Medicine /Chicago Medical School and Captain James A. Lovell Federal Health Care Center, North Chicago, IL, Lincolnwood, IL, 2Rosalind Franklin University of Medicine and Science/ Chicago Medical School, and Captain James A. Lovell Federal Health Care Center, North Chicago, IL, 3Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL, 4Captain James A. Lovell Federal Health Care Center and Rosalind Franklin University of Medicine and Science Chicago Medical School, North Chicago, IL

Abstract

Background:Most metabolic bone disease is assumed to be osteoporosis and evaluation for other causes is not common. Although celiac disease with malabsorption occurs in both pediatric and adult patients, it can present with minor and subclinical manifestations of the disease. Furthermore, osteomalacia may be the sole manifestation of celiac disease. We present an interesting case of a young male patient who was referred to Endocrinology for treatment of “osteoporosis” after L4 compression fracture of the spine and discovered to have ostemalacia from this malabsorptive disease.

Clinical case: A 32 year old young male with no significant past medical history was referred for evaluation of osteopenia on Bone density (DXA), ordered due to a traumatic L4 lumbar spine compression fracture suffered while playing dodgeball. He denies steroid use, personal or family history of bone disorders. He did admit to having loose stools intermittently for the past few years.

Physical Examination: Normal except for BMI of 22.83 kg/m2. No signs of tetany. Laboratory Tests : Hgb 14g/dL (13-17) , Calcium 7.5 mg/dL(8.5-10.1) , Phosphate 3.3 mg/dL (2.5-4.9) , Magnesium 2 mg/dL (1.8-2.4) ,Vitamin D 25ng/mL (30-100), PTH 29 pg/ mL (12.4-76.8), Iron 45 ug/dL(65-175) , TIBC 334 ug/dL (250-450), Iron saturation 13% (10-50), folate 16.1 ng/mL(8.7-55.4), Cr 0.99 mg/dL(0.67-1.17), (eGFR = 109.8 ml/min).

Alkaline phosphatase 134 U/L (45-117), TSH 2.30 uIU/mL ( 0.358-3.74) , ESR 16 mm/HR (0-15), CRP 1 mg/dL(0.0-0.9) , SPEP/UPEP normal , Calcium 24 hr urine <5mg/24hr (42 - 353) . Dual-energy x-ray absorptiometry (DXA) : Anterior lumbar spine BMD 0.828, T- score -2.4, Femoral neck BMD 0.695, T- score -1.7 and total hip BMD 0.764, T- score -1.8 .

Due to iron deficiency anemia and Vitamin D deficiency, the differential diagnosis included syndromes of malabsorption. Upper gastrointestinal endoscopy showed Duodenitis, followed by a biopsy of duodenum which showed severe villous blunting, consistent with celiac disease. Celiac titers: Anti-tissue transglutaminase IgA antibodies TTG IgA >100 U/mL (<5) and Gliadin IgA 97 Units (<20 Antibody not detected), Gliadin IgG 84 Units (>or=20 Antibody detected), and suggested celiac disease. Oral Vitamin D calcium and iron supplements, and gluten free diet were advised.

Conclusion:  The diagnosis of celiac disease was made in an asymptomatic patient for hypocalcemia and osteomalacia, due to evaluation for the etiology of metabolic bone disease, following a traumatic fracture, which prompted a DEXA scan. Celiac disease, an uncommon autoimmune disease characterized by small intestinal damage typically associated with loss of absorptive villi causing malabsorption, osteomalacia and fracture as the first presenting findings is rare. Therefore, malabsorptive causes of metabolic bone disease should be considered in these cases so that proper treatment is administered. 

 

Nothing to Disclose: AI, BGT, JLG, AM