The patient underwent reduction and fixation, and the hips were regularly monitored. She was started on vitamin D, calcium, and phosphate replacement. Three months later, the patient was still experiencing hip pains and was unable to ambulate without support.
persistent symptoms so dexa scan , TBS, repeat vit D , also bone biopsy with double labeled tetracycline may be needed should be considered in this condition for alternative cause of his symptoms like co-existence of osteoporosis
in
osteoporosis there is decreased bone mass, incomplete trabecula but the ratio
of bone mineral to bone matrix is normal while this ratio is low in
osteomalacia also there is thick osteoid with defect mineralization in biopsy
and thin cortical bone with bowing of long one
D- Would you recommend any further investigations and why?
E- Discuss the rationale of bone biopsy in this case.
Still symptomatic, she may need histological evaluation; to assess treatment response vs alternative diagnosis
F- Compare the key features between osteomalacia and osteoporosis.
D- Would you recommend any further investigations and why?
Bone profile, PTH, BTMs
DXA
Bone biopsy
E- Discuss the rationale of bone biopsy in this case.
The patient is receiving the appropriate medical treatment but is still symptomatic and not improving. We need to look for an underlying cause for his mineralization defect.
F- Compare the key features between osteomalacia and osteoporosis.Osteomalacia is a mineralization defect leading to a bone architecture defect due to a low bone mineral-to-bone matrix ratio.
Osteoporosis decreases bone strength and mass while maintaining bone architecture as the bone mineral-to-bone matrix ratio is normal.
D:VD ,Serum Ca and phosphorus
DEXA scan ,hip Xray
E:it is the most accurate way but invasive
F osteomalacia du to lack of VD lack of mineralization of bone but osteoporosis loss of bony mass
D- Would you recommend any further investigations and why?yes, I would recommend hip xray .DEXA scan.
serum phosphate, calcium vitamin d
E- Discuss the rationale of bone biopsy in this case.Although it is good to do an anterior iliac crest bone biopsy, it is not routine due to invasive procedures.
F- Compare the key features between osteomalacia and osteoporosis. Osteomalacia causes soft bones due to a lack of vitamin D. and is a disorder of decreased mineralization, which results in bone breaking down faster than it can reform. In osteoporosis, bone mass decreases over time, leading to weakened and brittle bones that are susceptible to fracture.
Would you recommend any further investigations and why?
Postoperative complications like pain, muscle weakness or loosening of hip prosthesis) should be considered for this patient, So, Xray of the hip is recommended. serum calcium phosphorus and 25 OH vitamin D should be ordered for this case and evaluate further causes if still hypocalcemia or hypophosphatemia despite adequate supplementation. The patient should be screened for osteoporosis by DEXA scan if there is no obvious cause for his pain.
E. Discuss the rationale of bone biopsy in this case.
Anterior iliac crest bone biopsy with double tetracycline labelling and histomorphometric assessment is the most accurate way to diagnose osteomalacia. However, it is infrequently performed clinically because it is invasive and because the diagnosis can usually be made from a combination of clinical (eg, bone pain and tenderness, fractures, and/or muscle weakness); laboratory findings, which depend on the cause and radiological findings.
Osteomalacia is characterised by osteoid accumulation with a thickening of osteoid seams associated with a decreased mineralization rate and an elongation of the mineralization lag time. Double labels may be undetectable and appear diffused. A decreased mineralization rate alone is not specific to osteomalacia, it may be a sign of osteoblast activity diminution with a reduced matrix apposition. An increase in osteoid thickness with a normal mineralization rate may reflect an increased apposition rate.(3)
F. Compare the key features between osteomalacia and osteoporosis.
In osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal. Osteoporosis is operationally defined as a high T score less than -2.5 SD by DEXA scan. Patients with osteomalacia usually have osteoporosis. In osteomalacia, the ratio of bone mineral to bone matrix is low. Osteoporosis results from a combination of low peak bone mass along with either decreased bone formation and/or increased bone resorption. Osteomalacia is a state of impaired mineralization secondary to severe vitamin D deficiency, hypophosphatemia or profound hypocalcemia.
Osteomalacia is characterised by low vitamin D, low serum calcium, phosphorus, and high PTH and serum alkaline phosphatase. Notably, 25(OH)D levels may be low in patients with osteoporosis and a subset of these patients may also have secondary elevations of PTH.(4)
Would you recommend any further investigations and why?lab: PTH, alkaline phosphatase
radiology: DXA scan, high resolutin quantitative ct
bone biopsy
Discuss the rationale of bone biopsy in this case. the patient does not respond to to ttt
he has fragility fracture
Compare the key features between osteomalacia and osteoporosis
osteomalacia is cause by bone demineralization while osteoporosis means decrease bone mass, both make patient at risk of fracture
osteoporosis has female predomenance while osteomalacia has equal distribution.
osteoporosis is usually painless, while in osteomalacia pain is a predominant feature.osteoporosis ass. with normal calcium, phosphorus and vit D. While osteomalacia is ss.with decreased all. osteomalacia is frequently ass. with ms.weakness
ttt of osteoporosis is antiresorptive, while in osteomalacia is mineral and vit D
D- Would you recommend any further investigations and why?S.Ca ,s.P, s.Mg, PTH , ALP,DEXA scan
E- Discuss the rationale of bone biopsy in this case.Although it is the gold standard for diagnosing osteomalasia , it’s invasive, painful and require expert personnel.
F- Compare the key features between osteomalacia and osteoporosis.Osteoporosis/decrease bone mass
osteomalacia / demineralization
D.pth level , dexa scan .
E. Bone biopsy would be done because of persistent of symptoms and high risk of fracture. It will help us to differentiate between osteoporosis and osteomalacia or maybe mixed condition.
F.Osteoporosis: loss of bone density and strength, which lead to fracture particularly in old postmenopausal women. Ratio of bone mineral to bone matrix is normal.
Osteomalacia: is resulted by vitamin D deficiency resulting in soft and weak bones. Ratio of bone mineral to matrix is low
D- PtH and dexa scan mg level bone biopsy
e- fracture need to do biopsy
f- osteoporosis— decrase bone mass
osteomalacia — demineralization
D- Would you recommend any further investigations and why?
E- Discuss the rationale of bone biopsy in this case.
F- Compare the key features between osteomalacia and osteoporosis.
-bone mass decreases, but the ratio of bone mineral to bone matrix is normal.
-the ratio of bone mineral to bone matrix is low.
D- Would you recommend any further investigations and why?
DXA scan , PTH
E- Discuss the rationale of bone biopsy in this case.
The presence of the frequent fracture and no resolution of symptoms
F- Compare the key features between osteomalacia and osteoporosis.
Osteoporosis show decreased bone formation and volume, decrease in number of osteoclast and osteoblast, thin ostieod seams and minimal peritrabecular or no bone fibrosis
Osteomalacia : demineralization and wide ostieod seams
D- Would you recommend any further investigations and why?
E- Discuss the rationale of bone biopsy in this case.
F- Compare the key features between osteomalacia and osteoporosis.
D- Would you recommend any further investigations and why?
*PTH (could have PHPT)
*Vit D ( can be still deficient )
*? Bone biopsy
*bALP, Ca, PO4
*Bence-Johns protein in urine (may have MM as well)
E- Discuss the rationale of bone biopsy in this case.
With the normal renal function, I may NOT proceed for bone biopsy. If patient has hyperparathyroidism it would be obvious biochemically. Otherwise DEXA will reveal if she has osteoporosis.
F- Compare the key features between osteomalacia and osteoporosis.
In osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal.
In osteomalacia, the ratio of bone mineral to bone matrix is low, i.e there is normal matrix but it is under mineralized.
The patient should be screened for osteoporosis by DEXA scan if there is no obvious cause for his pain. Although bone biopsy is the most accurate way to diagnose osteomalacia. However, it is infrequently performed clinically because it is invasive and because the diagnosis can usually be made from a combination of clinical (eg, bone pain and tenderness, fractures, and/or muscle weakness); laboratory findings, which depend on the cause and radiological findings.
In osteoporosis, bone mass decreases, but the ratio of bone mineral/bone matrix is normal, while in osteomalacia, the ratio of bone mineral/bone matrix is low. Bone Biopsy preceded by a Dexa scan may be, will give us more information and guide our treatment on whether to give antiresorptive treatment in addition to vitamin D supplementation.
Serum calcium, phosphorus and 25 OH vitamin D should be ordered for this case. X-ray and DEXA scanning for osteoporosis may be needed as well.
D- Would you recommend any further investigations and why?
E- Discuss the rationale of bone biopsy in this case.
persistent symptoms without improvement with high risk for fractures
features between osteomalacia and osteoporosis.
in osteomalacia :
hypophosphatemia, hypocalcemia, low levels of vit D, and increased parathyroid hormone (PTH) and alkaline phosphatase levels.
in osteoporosis:
normal PO4, Ca, Alk. phosphatase, PTH, and LOW vitamin D.
Thanks Dr.Ashraf! Agree that 25(OH)D levels may be low in patients with osteoporosis and a subset of these patients may also have secondary elevations of PTH.
D- Would you recommend any further investigations and why?
Pth level to exclude parathyroid dysfunction serum mg and dexa scan
E- Discuss the rationale of bone biopsy in this case.the bone biobsy will be tha last option for diagnosis of patient if other paremter not clue to diagnosis also if persistence of symptoms after correction of ca po4 and vit d
F- Compare the key features between osteomalacia and osteoporosis.
Osteomalacia is demineralization of the bone due to lack of ca, phosphate, and vitamin D. The ratio of bone mineral to the bone matrix is low.
Osteoporosis is a condition in which bone is weak and brittle, decreased bone mass, but the ratio of bone mineral to the bone matrix is normal.
Calcium level osteoporosis; Normal
.osteomalacia; low or normal.
Phosphate level osteoporosis; Normal.
Osteomalacia; Low or normal.
PTH osteoporosis; Normal.
Osteomalacia; High or normal.
. ALPosteoporosis; Normal.
Osteomalacia; High
Although bone biopsy is the most accurate way to diagnose osteomalacia. However, it is infrequently performed clinically because it is invasive and because the diagnosis can usually be made from a combination of clinical (eg, bone pain and tenderness, fractures, and/or muscle weakness); laboratory findings, which depend on the cause and radiological findings.
THIS CASE WAS DISCUSSED BEFORE IN THE LAST WEEK
D- Would you recommend any further investigations and why?
FURTHER LAB TESTING PTH , MG , ISOTOP SESTAMIBI SCAN and bone biopsy
E- Discuss the rationale of bone biopsy in this case.
persistent symptoms without improvement in patient with high risk for fractures
F- Compare the key features between osteomalacia and osteoporosis.
osteoporosis — bone mass decreases, but the ratio of bone mineral to bone matrix is normal.
osteomalacia — the ratio of bone mineral to bone matrix is low.
Osteomalacia is characterized by low vitamin D, low serum calcium, phosphorus, and high PTH and serum alkaline phosphatase. however, 25(OH)D levels may be low in patients with osteoporosis and a subset of these patients may also have secondary elevations of PTH.
D- Would you recommend any further investigations and why? PTH , MG and bone biopsy
E- Discuss the rationale of bone biopsy in this case. persistent symptoms without improvement in patient with hiph risk for repeated fractures .
F- Compare the key features between osteomalacia and osteoporosis. osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal.
osteomalacia, the ratio of bone mineral to bone matrix is low.
Serum calcium, phosphorus and 25 OH vitamin D should be ordered for this case. X-ray and DEXA scanning for osteoporosis may be needed as well.
Would you recommend any further investigations and why? Yes, we need to check for PTH level,Mg ., check urine Ca and Phophore level.
Discuss the rationale of bone biopsy in this case.
A bone biopsy will help us here, confirming the diagnosis of osteomalacia, as this patient still has bone pain despite being on treatment for the last 3 months.
Bone biopsy, osteomalacia will appear mainly with low mineralization of trabecular bone
indistinct tetracycline labels occur from impaired mineralization.
Compare the key features between osteomalacia and osteoporosis.
In osteomalacia, the bone mineralization ifs affected by low CA and Phophors deposition in the bone. In osteoporosis, the main issue is the bone matrix and the relation between osteoblast and osteoclast activity.
For that, in osteomalacia, there is a low or average ca level along with high ALP, while in osteoporosis, we may not have low ca or phosphor but will have fragility fracture with normal bone biomarkers.
Thank you for your comprehensive answer! DEXA scanning for osteoporosis may be needed.
D- Would you recommend any further investigations and why?
E- Discuss the rationale of bone biopsy in this case.The patient is still symptomatic(persistent bone pain ) despite the correction of Ca, PO4, and Vitamin D.
Bone biopsy remains the diagnostic gold standard for osteomalacia.
It is characterized histologically by broad seams of uncalcified bone matrix in sections of trabecular bone.
Bone biopsy rarely used to diagnose and manage patients with osteoporosis
F- Compare the key features between osteomalacia and osteoporosis.
Great! Thank you!
PTH : it is expected to be high secondary to vitamin d deficiency
serum mg
DEXA scan to exclude associated osteoporosis
bone biopsy:
Bone histomorphometry plays a crucial role in arriving at precise diagnosis and help in therapeutic approach
Osteoporosis results from a combination of low peak bone mass, increased bone resorption, and impaired bone formation. Osteomalacia is due to impaired mineralization, usually because of severe vitamin D deficiency or abnormal vitamin D metabolism .
In osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal.
In osteomalacia, the ratio of bone mineral to bone matrix is low.
Thanks Alaa! Moreover, 25(OH)D levels may be low in patients with osteoporosis and a subset of these patients may also have secondary elevations of PTH.
Would you recommend any further investigations and why?
Discuss the rationale of bone biopsy in this case.
Compare the key features between osteomalacia and osteoporosis.
2. Pathophysiology
3. Radiograph
4. Calcium level
5. Phosphate level
6. PTH
7. ALP
Great! Moreover, 25(OH)D levels may be low in patients with osteoporosis and a subset of these patients may also have secondary elevations of PTH.
D- Would you recommend any further investigations and why?
E- Discuss the rationale of bone biopsy in this case.
the further investigation follow up lab ca . ph. pth alk
added bone imaging x-ray and dexa scan
but gold standard to confirm diagnosis is bone biopsy which
describe histomorphometric character of osteomalacia
# trabeculae covered with long , wide osteoid seam due to lack of mineralization
on biopsy with tetracycline labelling smudged, indistinct tetracycline labels occur from the impaired mineralization
F- Compare the key features between osteomalacia and osteoporosis.
osteomalacia is defined as >>lack of available calcium or phosphorus or both for mineralization of newly formed osteoid
etiological calcification
1-) Deficiency causes
#vit.d deficiency
# calcium , phosphorus defiecincy
#chelator diet
2-) Absorptive causes
#gastric abnormality # billary disease # entric absorpitive defect
3-)Renal causes
# proximal tubular lesions # proximal and distal tubular lesion # renal tubular acidosis
4-) Renal Oteodystrophy ( ROD)
osteoporosis
defect in bone matrix any factors affect on osteoblastic activity or differentiation , or proliferation
Although bone biopsy is the most accurate way to diagnose osteomalacia, it is infrequently performed clinically because it is invasive and because the diagnosis can usually be made from a combination of clinical (eg, bone pain and tenderness, fractures, and/or muscle weakness); laboratory findings, which depend on the cause and radiological findings.
D- Would you recommend any further investigations and why?
E- Discuss the rationale of bone biopsy in this case.
F- Compare the key features between osteomalacia and osteoporosis.
Great! Osteomalacia is characterised by osteoid accumulation with a thickening of osteoid seams associated with a decreased mineralization rate and an elongation of the mineralization lag time. A decreased mineralization rate alone is not specific to osteomalacia, it may be a sign of osteoblast activity diminution with a reduced matrix apposition.
D- Would you recommend any further investigations and why?
Bone biopsy because it gives detailed information on the structure and composition of the bone meanwhile it can guide the medication plan as well.
E- Discuss the rationale of bone biopsy in this case.
despite medications patient’s symptoms persisted, bone biopsy can provide valuable insights into the endocrine role of bone and the relationship between osteoporosis and other bone diseases.
F- Compare the key features between osteomalacia and osteoporosis.
Osteomalacia is unmineralization of the bone due to lack of ca, phosphate, and vitamin D. The ratio of bone mineral to the bone matrix is low.
Osteoporosis is a condition in which bone is weak and brittle, it’s usually due to hormonal imbalance leading decreased bone mass, but the ratio of bone mineral to the bone matrix is normal.
Although bone biopsy is the most accurate way to diagnose osteomalacia, it is infrequently performed clinically because it is invasive and because the diagnosis can usually be made from a combination of clinical (eg, bone pain and tenderness, fractures, and/or muscle weakness); laboratory findings, which depend on the cause and radiological findings
D- if no surgical problems are present and lab values improved with persistant symptoms , bone biopsy should be considered in this condition together with Mg levels and PTH
E- bone biopsy should be considered in this patient due to persistance of symptoms inspite of surgical correction and improved lab results with good diet and pharmacotherapy
F- in osteoporosis there is decreased bone mass but the ratio of bone mineral to bone matrix is normal while this ratio is low in osteomalacia
Bone biopsy is infrequently performed in such a case because it is invasive and because the diagnosis can usually be made from a combination of clinical (eg, bone pain and tenderness, fractures, and/or muscle weakness); laboratory findings, which depend on the cause and radiological findings
D- Would you recommend any further investigations and why?
repeat the lab done before
Calcium, Phosphate, Alkaline phosphatase, 25-hydroxyvitamin D (25[OH]D)
Parathyroid hormone (PTH)
Electrolytes, Mg, blood urea nitrogen (BUN), and creatinine
protein electrophoresis, ESR
serum fibroblast growth factor (FGF) 23
Bone biopsy
DD: Osteoporosis, osteomalacia, other causes of hypophosphatemia(PRTA, tumor-induced osteomalacia.
E- Discuss the rationale of bone biopsy in this case.
The patient is still symptomatic despite the correction of Ca, PO4, and Vitamin D.
and if the PTH and alkaline phosphatase are within the normal range, the patient will need a bone biopsy to detect the cause of his symptoms. especially if a new treatment will be initiated.
F- Compare the key features between osteomalacia and osteoporosis.
The lab findings in osteomalacia are hypophosphatemia, hypocalcemia, low levels of 25-hydroxyvitamin D (25[OH]D), and increased parathyroid hormone (PTH) and alkaline phosphatase levels.
the lab findings in osteoporosis: normal PO4, Ca, Alk. phosphatase, PTH, and 1,25-dihydroxy vitamin D; low or normal 25-hydroxy vitamin D.
Basically, in osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal. However, in osteomalacia, there is a a state of impaired mineralization secondary to severe vitamin D deficiency, hypophosphatemia or profound hypocalcemia.