Endocrine Abstracts

A 38-year-old farmer presented to Orthopaedics Department with backache and progressively increasing difficulty in walking for a year. MRI spine showed multiple central vertebral fractures suggestive of possible metabolic bone disease/oncogenic osteomalacia; he was hence referred to Endocrinology Department.

He was in pain. No previous history of trauma, no gastrointestinal or urinary symptoms. He however reported erectile dysfunction. On examination he was not Cushingoid, had generalized spinal tenderness and small testicles, but secondary sexual characteristics were normal. Initial evaluation showed normal FBC, U&Es but ESR 71(0–10 mm/h) and CRP 67 mg/l (<6) were high. DEXA scan revealed osteoporosis: T-scores at lumbar spine −4.1, Neck-of-Femur −4.0 and Forearm −4.0. Serum corrected calcium 9.4 mg/dl (8.8–10.6), magnesium 1.8 mg/dl (1.6–2.6), PTH 20.6 pg/ml (10–65), alkaline phosphatase 124 U/l (53–128) were normal; vitamin-D 18.5ng/ml (>30) low; urine pH 5, serum bicarbonate 24.6 mmol/l (21–31) both normal; dexamethasone-suppression test excluded cortisol-excess. 9am testosterone 30 pg/ml (50–210) was low but FSH 5.6 mIU/ml (2–10) and LH 5.1 mIU/ml (1.4–11) were inappropriately normal; prolactin 10 ng/ml (3–18), TSH 4.7 μIU/ml (0.3–5–5) and freeT₄ 1.7 ng/dl (0.3–2.3), PSA were within-limits. Pituitary Imaging was normal. Urine/ serum immunofixation were negative for light-chains, serum immunofixation was negative for monoclonal-gammopathy, urinary Bence-Jones proteins were negative and bone-marrow biopsy was negative for hematolymphoid malignancy. PET-CT done showed no neoplastic/metastatic lesions. Bone scan too suggested metabolic bone disease.

Having excluded underlying malignancy and multiple myeloma by various investigations, it was concluded that significant osteoporosis (metabolic bone disease) is possibly due to hypogonadism plus vitamin D deficiency. He was treated with calcium+vitamin D supplements, Androgen-replacement-therapy and physiotherapy. By 3 months, he made good clinical recovery, and radiological evidence of healed vertebral fractures.

Osteoporosis, characterized by decreased bone-mineral-density and increased fracture-risk, is common among females and the elderly. This case illustrates the difficulties in evaluation and management of young male patient with severe osteoporosis.