Endocrine Abstracts

Introduction: Osteoporosis is a metabolic bone disease, characterized by reduction and changes in the bone mass quantity and quality, leading to an increased risk of fractures. It can be divided in primary (postmenopausal or senile), secondary and idiopathic. In the presence of osteoporotic fractures, particularly in men before the age of 65, it is essential to investigate the presence of secondary causes in order to establish an etiological therapy.

Case Report: A 62-year-old man was referred to an outpatient consultation for fractured osteoporosis after suffering spontaneous rib fractures during a coughing episode. He had history of arterial hypertension, diabetes mellitus, smoking, depressive disorder and an adrenal nodule under surveillance for 9 years. He was chronically medicated with metformin, enalapril, lercanidipine, nebivolol, hydrochlorothiazide, atorvastatin and fluoxetine.Physical examination revealed a mildly Cushingoid phenotype and deformation of the left tibia without local inflammatory signs. The analytical evaluation reveled bone alkaline phosphatase 97.6 (n< 22.9 μg/l), serum cortisol 22.8 μg/dl and after 1 mg of dexamethasone 4.5 μg/dl, urinary cortisol 388 μg/24 h (n< 213.7), ACTH 8.7 (N: 7 – 63 pg/ml), hemoglobin A1c 8.1%, calcium 9.3 mg/dl, phosphorus 3.7 mg/dl, Vitamin D 10 ng/ml and PTHi 117 (N: 12-65 pg/ml).DXA revealed T-scores -1.6 CL and -1.5 CF, while bone scintigraphy showed uptake of 3 right posterior rib arches (C8,9,10) and homogeneous uptake of the proximal two-thirds of the left tibia and distal extremity of the left femur. MRI confirmed the diagnosis of Paget’s Bone Disease of the left tibia and femur.Adrenal MRI revealed a dimensional increase (from 12 to 27 mm) of the right adrenal nodule. Treatment with zoledronic acid associated with calcium and vitamin D supplementation was initiated, as well as optimization of antidiabetic therapy with empagliflozin. He underwent laparoscopic right adrenalectomy, and histology revealed nodular hyperplasia of the adrenal cortex.

Discussion and Conclusions: In the reported case, the patient had several risk factors for low bone mass and fragility fractures, namely diabetes mellitus, functional hypercortisolemia, secondary hyperparathyroidism, Paget’s bone disease and smoking. A multifactorial therapeutic approach was essential in order to reduce its high fracture risk.