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METABOLIC BONE DISEASE
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The term metabolic bone disease denotes those conditions producing diffusely decreased bone density and diminished bone strength It is categorized by histologic appearance: osteoporosis (bone matrix and mineral both decreased) and osteomalacia (bone matrix intact, mineral decreased) Osteoporosis and osteomalacia often coexist in the same patient
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A Symptoms and Signs
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Osteoporosis is usually asymptomatic until fractures occur It may present as backache of varying degrees of severity or as a spontaneous fracture or collapse of a vertebra Loss of height is common Once osteoporosis is identified, a carefully directed history and physical examination must be performed to determine its cause (Table 26 10)
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B Laboratory Findings
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Serum calcium, phosphate, and PTH are normal The alkaline phosphatase is usually normal but may be slightly elevated, especially following a fracture Vitamin D deficiency is very common and serum determination of 25-hydroxyvitamin D should be obtained for every individual with low bone density Serum 25-hydroxyvitamin D levels below 20 ng/mL are considered frank vitamin D deficiency Lesser degrees of vitamin D deficiency (serum 25-hydroxyvitamin D levels between 20 ng/mL and 30 ng/mL) may also increase the risk for hip fracture (See Osteomalacia, below) Testing for thyrotoxicosis and hypogonadism may be required Celiac
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Asymptomatic to severe backache from vertebral fractures Spontaneous fractures often discovered incidentally on radiography; loss of height Serum PTH, calcium, phosphorus, and alkaline phosphatase usually normal
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Endocrine Disorders
CMDT 2008
Table 26 10 Etiologies of osteoporosis1
Hormone deficiency Estrogen (women) Androgen (men) Hormone excess Cushing s syndrome or corticosteroid administration Thyrotoxicosis Hyperparathyroidism Immobilization and microgravity Tobacco Alcoholism Malignancy, especially multiple myeloma Medications Excessive vitamin D intake Excessive vitamin A intake Heparin therapy Genetic disorders Aromatase deficiency Type I collagen mutations Osteogenesis imperfecta Idiopathic juvenile and adult osteoporosis Ehlers-Danlos syndrome Marfan s syndrome Homocystinuria Miscellaneous Celiac disease Anorexia nervosa Protein-calorie malnutrition Vitamin C deficiency Hyponatremia (chronic) Copper deficiency Liver disease Rheumatoid arthritis Uncontrolled diabetes mellitus Systemic mastocytosis
Table 26 11 Indications for measuring bone density
Long-term (> 1 month) corticosteroid (> 6 mg prednisone) therapy Chronic diseases associated with osteoporosis Alcoholism Anorexia nervosa Hypogonadism of any cause: women or men Hyperparathyroidism Hyperthyroidism Liver disease Low body mass index (BMI < 19 kg/m2) Immobilization (eg, paraplegia) Inflammatory bowel disease Protein calorie malnutrition Renal failure Chronic disorders associated with osteomalacia Hypocalcemia Hypophosphatemia Malabsorption Nephrotic syndrome Renal failure Vitamin D deficiency Family history of osteoporosis or hip fracture Fracture following minimal or no trauma Fracture following minimal trauma Loss of height or thoracic kyphosis (dowager s hump) Radiologic suspicion for low bone density Radiologic diagnosis of vertebral crush deformity
See Table 26 12 for causes of osteomalacia
disease may be screened for with serum immunoglobulin A (IgA) endomysial antibody and tissue transglutaminase antibody determinations
C Bone Densitometry
Dual energy x-ray absorptiometry (DXA) is used to determine the bone density of the lumbar spine and hip This test delivers negligible radiation, and the measurements are quite accurate Bone densitometry should be performed on all patients who are at risk for osteoporosis or osteomalacia (Table 26 11) Bone densitometry cannot distinguish osteoporosis from osteomalacia; in fact, both are often present Also, the bone mineral density does not directly measure bone quality and is only fairly successful at predicting fractures Vertebral bone mineral density may be misleadingly high in compressed vertebrae and in patients with extensive arthritis DXA also overestimates the bone mineral density of taller persons and underestimates the bone mineral density of smaller persons Quantitative CT delivers more radiation but is more accurate in the latter situations Bone mineral density in typically expressed in gm/cm2, for which there are different normal ranges for each bone and for each type of DXA-measuring machine The T score is a simplified way of reporting bone density in which the patient s bone mineral density is compared to the young normal mean and expressed as a standard deviation score The World Health Organization has established criteria for defining osteoporosis in postmenopausal white women, based on T score: T score 10: Normal T score 10 to 25: Osteopenia ( low bone density ) T score < 25: Osteoporosis T score < 25 with a fracture: Severe osteoporosis This classification is somewhat arbitrary and there really is no bone mineral density fracture threshold; instead, the frac-
ture risk increases about twofold for each standard deviation drop in bone mineral density In fact, most women with fragility fractures have bone densities above 25 Surveillance DXA bone densitometry is recommended for postmenoapausal women with a frequency according to their T scores: obtain DXA every 5 years for T scores 10 to 15, every 3 5 years for scores 15 to 20, and every 1 2 years for scores under 20 The Z score is used to express bone density in premenopausal women, younger men, and children, The Z score is a statistical term that is used for expressing an individual s bone density as standard deviation from age-matched, racematched, and sex-matched means
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