SEVERE LONGSTANDING OSTEOPENIA WITHOUT CLEAR CAUSE    12/7/2017

SEVERE LONGSTANDING OSTEOPENIA WITHOUT CLEAR CAUSE    12/7/2017

Question-I have a case for which I need help from the endoexperts.A 34 year old male patient who had several vertebral fractures and osteoporosis. When he was 17 years old he had severe back pain and was noted to have compression fractures of L4 and L5. Over several years he had multiple fractures of the vertebra (cervical, thoracic and lumbar) and issues with the hardware installed.  DEXA scan done recently showed a Z score of -4.2. Has not been on any antiresorptive treatment.
Other history: No history of kidney stones. No flushing episodes or skin rashes.
No galactorrhea. No symptoms suggestive of visual field defects.
No diarrhea, weight loss, eating disorders, jaundice, history of liver disease.
No history suggestive of any metabolic disorder in infancy. No dental issues.
Normal puberty.
Did take steroid shots in the back (7- 10) over the years.
Was on seroquel for 15 years. Was on PPI in the past.
Exam: No cushingoid features, wheel chair bound, normal facial hair.
Laboratory evaluation: Mild hypercalcemia noted on the bmp (10.3).
Vitamin D is 35  PTH 36 (10-60 pg/ml)
24 hour urinary calcium 125 (300 mg/24 hours)
Alkaline phosphatase 59 (40-129 U/lt)
TSH- 1.95(0.27-4.2 ng/dl)
Prolactin -5 (4.6-21.4)
IGF-1 135 (54-310 ng/ml)
Testosterone 543 (240-950)
Tryptase 3.3( <11.5ng/ml)
Tissue trasglutaminase <1.2 (<4 U/ml)
1 mg dexamethasone suppression test
Osteocalcin 28(9-42 ng/ml)
B-CTX 513 (93-630 pg/ml)

Is there any other cause for secondary osteoporosis that needs to be evaluated?Is there an advantage in starting the patient on teriparatide and then transition to antiresorptives or start with bisphosphoantes?  Thanking you in advance. Vishnu Garla, MD , University of Mississippi Medical Center.

RESPONSE:  This is a challenging case which most likely has a genetic etiology such as osteogenesis imperfecta.  Is there any family history of osteoporosis and any suggestion of blue sclerae?  Gene testing would provide an answer.  On the other hand there are other potential factors such as primary hyperparathyroidism, PPI use, steroid use.  I would check several serum calcium levels to help decide the parathyroid status.  A normal serum PTH does not rule out the problem.  With such severe osteoporosis an anabolic agent such as teriparatidede  or abaloparatide followed by denosumab would be the most effective treatment although the benefit for osteogenesis imperfecta is less certain.              Frederick Singer, M.D.
Addendum- No family history of osteoporosis or blue sclera.I am referring to genetics to get him tested for OI. Will follow up on the Ca levels. VG