Many Possible Problems, Including Osteoporosis


Question

-I have a limited consultative practice in integrative medicine. This case involves a 57 yo physically active, lean male with some interesting problems including recent diabetes, elevated somatomedin-C, osteoporosis and other health issues.

Elevated Somatomedin-C : 243 ng/mL (ref range: 81-225); no obvious signs of acromegaly. (Pt has congenital short stature (62")). (pt asked for this test because of fatigue and his concern that it might be related to decreased growth hormone with aging).

Recent onset diabetes : Both parents had type 2 diabetes and obesity - because of this pt has tried to eat healthy, maintain nl weight and exercise. Wt is stable at 125#, Ht 62". His fasting glucose historically was between 90-100, but 7 mos ago had a level of 120 on a routine blood chem. Pt began to follow his AM fasting glucose and found it to be consistently in that range. He asked that I start Metformin and is currently on 500 mg bid. Despite that, his FG has remain elevated in the range of 120-150 and has crept upward . Hb A1C was initially 5.8, last level was 5.4. Fasting insulin was 38.8 uIU/mL.

Osteoporosis : DXA Bone Density from 1 yr ago -- LS: .892, T-score -2.7, Z-score -1.8; Hips: .983, T-score -.8, Z-score 0.

Recent N-Telopeptide/Creat Ratio 73 (Ref Range: 3-51); Pt takes Vit D and has a Vit D 25-Hydrox of 76.3 ng/mL. Ca is nl. Parathyroid hormone 51 (RR: 14-72). The patient has lost 2" in height over the last decade or so -- that prompted the DXA scan.

Possible Hypothyroidism: Has been seen by an FP who told pt he was hypothyroid and placed pt on natural porcine thyroid (30) and iodine (225 mcg). Most recent lab results from this FP: Free T4 - 1.32 (had been .79), Free T3 - 2.7, TSH 3.5, Reverse T3 elevated at 363 (RR 90-350).

Recent increase in H/H: Historically Hct has been 41-44. In last 18 mos has increased from 41 to 49. Indices unchanged. Does not take Fe.

Pt's other history includes mild atherosclerosis, longstanding well-controlled hypertension, atherogenic lipid profile controlled with Niaspan, elevated homocysteine (13), recent elevation of HS CRP, prior low levels of albumin, total protein, copper and zinc (now nl after supplementation); previous hx of lymes 18 yrs ago (CDC diagnosis), prior Hep B (non-active).

Other labs: Total testosterone (305, 475 on two occasions), Free testosterone 16.6 (RR 7.2-24), Estradiol 17 Beta 18.5 (RR 7.6-42), DHEA 118 (RR 52-295)

The patient has tremendous vitality but states he has felt fatigued compared to his baseline energy and dates this decline back to a flulike illness 3 yrs ago -- immediately after recovery from what was probably influenza, he had engaged in a brief winter camping/backcountry ski trip and upon his return home was profoundly fatigued and felt chilled for several weeks. This episode prompted his first medical evaluation in many years. While the patient's energy has increased, he still feels it is abnormal for him. He believes this may be due to chronic Lyme disease.

The patient has a fair degree of medical knowledge. Given the range of potential endocrine abnormalities, I referred him to an endocrinologist at our local medical school but he has decided instead to be seen by an endocrinologist at Mayo Medical Clinic. I don't have a problem with that approach, but it will be several months before he can get that evaluation. In the meantime, I wonder what your experts think. David Moss, MD

Response

Assuming that this is a valid DXA study, a diagnostic classification of osteoporosis is correct. Considering his historical height loss of 2 inches, I would also suggest that lateral imaging of the spine be done to evaluate for prevalent vertebral fractures. If he has any type of fracture, including an asymptomatic vertebral fracture, then his diagnosis becomes severe osteoporosis; more importantly, it suggests that the future risk of fracture is very high. He should have a thorough evaluation for secondary causes of osteoporosis, much of which has already been done. It would be helpful to include a 24-hour urine for calcium to evaluate for hypo- or hypercalciuria, both of which could have important implications regarding the pathogenesis of his osteoporosis. A serum protein electrophoresis and kappa/lamda light chains would assess the possibility of multiple myeloma. Note that diabetes mellitus type 1 and type 2 are considered risk factors for osteoporosis, and that treatment of diabetes with a TZD may be associated with increased risk of fracture. Any treatable secondary causes that are identified should be managed appropriately. He meets the National Osteoporosis Foundation guidelines for initiation of pharmacological therapy to reduce fracture risk. A follow-up DXA 1-2 years after starting treatment would be helpful to evaluate for treatment effect. E. Michael Lewiecki, MD, FACP, FACE

We also offered a note that Niospan has been reported to lower T4 and T3 levels without affecting TSH, and that treatment with desiccated thyroid typically is associated with a lower T4 and normal T3 when the TSH is normal. L De Groot, MD