Abstract
The aim of this study was to analyse the clinical manifestations and the most frequent causes of osteomalacia (OM) in a group of 28 patients diagnosed with this disorder during a 20-year period. OM was diagnosed by bone biopsy and/or by Bingham and Fitzpatrick criteria (two of the following: low calcium, low phosphate, elevated total alkaline phosphatase [total AP] or suggestive radiographs). Of these patients, 13 had vitamin D deficiency OM (VD-OM), 14 hypophosphatemic OM (HypoP-OM) and one had OM-associated hypophosphatasia. Deficient sun exposure and celiac disease were the most frequent etiologies of VD-OM, whereas most HypoP-OM were hereditary forms. The main clinical symptoms were polyarthralgias (89%), frequently associated with fractures (75%). Fifty seven percent had densitometric criteria of osteoporosis. Patients with VD-OM showed significantly higher total AP and PTH serum values, but lower vitamin D, serum calcium, calciuria and bone mass than patients with HypoP-OM. Conversely, HypoP-OM patients had significantly lower serum phosphate and higher phosphaturia than patients with VD-OM. Briefly, high total AP, low serum calcium and low serum phosphate were observed in 85%, 65% and 15%, respectively, of patients with VD-OM, being observed in 64%, 14% and 100%, respectively, of HypoP-OM patients. Nearly 50% of these latter showed increased FGF23 levels. In conclusion, in this study, the frequencies of HypoP-OM and VD-OM were similar. The most frequent laboratory abnormalities were increased total AP and decreased serum phosphate. A urinary calcium loss of less than 50 mg/dl was highly discriminatory for VD-OM and a serum phosphate less than 2.3 mg/dl was also high discriminatory for HypoP-OM. Low densitometric values and fractures were frequent among these patients.
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Reginato AJ, Falasca GF, Pappu R, McKnight B, Agha A (1999) Musculoskeletal manifestations of osteomalacia: report of 26 cases and literature review. Semin Arthritis Rheum 28:287–304
Reginato AJ, Coquia JA (2003) Musculoskeletal manifestations of osteomalacia and rickets. Best Pract Res Clin Rheumatol 17:1063–1080
Fukumoto S, Yamashita T (2007) FGF23 is a hormone-regulating phosphate metabolism—unique biological characteristics of FGF23. Bone 40:1190–1195
Jonsson KB, Zahradnik R, Larsson T, White KE, Sugimoto T, Imanishi Y, Koshiyama H, Ljunggren O, Oba K, Yang IM, Miyauchi A, Econs MJ, Lavigne J, Jüppner H (2003) Fibroblast growth factor 23 in oncogenic osteomalacia and X-linked hypophosphatemia. N Engl J Med 348:1656–1663
Bingham CT, Fitzpatrick LA (1993) Noninvasive testing in the diagnosis of osteomalacia. Am J Med 95:519–523
Imel EA, Peacock M, Pitukcheewanont P, Heller HJ, Ward LM, Shulman D, Kassem M, Rackoff P, Zimering M, Dalkin A, Drobny E, Colussi G, Shaker JL, Hoogendoorn EH, Hui SL, Econs MJ (2006) Sensitivity of fibroblast growth factor 23 measurements in tumor-induced osteomalacia. J Clin Endocrinol Metab 9:2055–2061
Walton RJ, Bijvoet OL (1975) Nomogram for derivation of renal threshold phosphate concentration. Lancet 2:309–310
Holick MF (2007) Vitamin D deficiency. N Engl J Med 357:266–281
Stechschulte SA, Kirsner RS, Federman DG (2009) Vitamin D: bone and beyond, rationale and recommendations for supplementation. Am J Med 122:793–802
(1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organization technical report series 843:1–129
Peris P (2003) Stress fractures. Best Pract Res Clin Rheumatol 17:1043–1061
Finch PJ, Ang L, Eastwood JB, Maxwell JD (1992) Clinical and histological spectrum of osteomalacia among Asians in south London. Q J Med 83:439–448
Erkal MZ, Wilde J, Bilgin Y, Akinci A, Demir E, Bödeker RH, Mann M, Bretzel RG, Stracke H, Holick MF (2006) High prevalence of vitamin D deficiency, secondary hyperparathyroidism and generalized bone pain in Turkish immigrants in Germany: identification of risk factors. Osteoporos Int 17:1133–1140
Fogelman Y, Rakover Y, Luboshitzky R (1995) High prevalence of vitamin D deficiency among Ethiopian women immigrants to Israel: exacerbation during pregnancy and lactation. Isr J Med Sci 3:221–224
Black AJ, Topping J, Durham B, Farquharson RG, Fraser WD (2000) A detailed assessment of alterations in bone turnover, calcium homeostasis, and bone density in normal pregnancy. J Bone Miner Res 15:557–563
McKenna MJ, Freaney R, Casey OM, Towers RP, Muldowney FP (1983) Osteomalacia and osteoporosis: evaluation of a diagnostic index. J Clin Pathol 36:245–252
Johnson MW, Ellis HJ, Asante MA, Ciclitira PJ (2008) Celiac disease in the elderly. Nat Clin Pract Gastroenterol Hepatol 5:697–706
Vilppula A, Kaukinen K, Luostarinen L, Krekelä I, Patrikainen H, Valve R, Mäki M, Collin P (2009) Increasing prevalence and high incidence of celiac disease in elderly people: a population-based study. BMC Gastroenterol 9:49
Bikle DD (2007) Vitamin D insufficiency/deficiency in gastrointestinal disorders. J Bone Miner Res 22(Suppl 2):V50–V54
McMahon MM, Sarr MG, Clark MM, Gall MM, Knoetgen J III, Service FJ, Laskowski ER, Hurley DL (2006) Clinical management after bariatric surgery: value of a multidisciplinary approach. Mayo Clin Proc 81(10 Suppl):S34–S45
Malinowski SS (2006) Nutritional and metabolic complications of bariatric surgery. Am J Med Sci 331:219–225
Gasteyger C, Suter M, Gaillard RC, Giusti V (2008) Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation. Am J Clin Nutr 87:1128–1133
Compher CW, Badellino KO, Boullata JI (2008) Vitamin D and the bariatric surgical patient: a review. Obes Surg 18:220–224
Flechner SM, Kobashigawa J, Klintmalm G (2008) Calcineurin inhibitor-sparing regimens in solid organ transplantation: focus on improving renal function and nephrotoxicity. Clin Transplant 22:1–15
McLin VA, Girardin E, Lecoultre C, Mentha G, Belli DC (2005) Glomerular and tubular function following orthotopic liver transplantation in children. Pediatr Transplant 9:512–519
Endo I, Fukumoto S, Ozono K, Namba N, Tanaka H, Inoue D, Minagawa M, Sugimoto T, Yamauchi M, Michigami T, Matsumoto T (2008) Clinical usefulness of measurement of fibroblast growth factor 23 (FGF23) in hypophosphatemic patients: proposal of diagnostic criteria using FGF23 measurement. Bone 42:1235–1239
Heijboer AC, Levitus M, Vervloet MG, Lips P, ter Wee PM, Dijstelbloem HM, Blankenstein MA (2009) Determination of fibroblast growth factor 23. Ann Clin Biochem 46:338–340
Ito N, Fukumoto S, Takeuchi Y, Yasuda T, Hasegawa Y, Takemoto F, Tajima T, Dobashi K, Yamazaki Y, Yamashita T, Fujita T (2005) Comparison of two assays for fibroblast growth factor (FGF)-23. J Bone Miner Metab 23:435–440
Lorenz-Depiereux B, Benet-Pages A, Eckstein G, Tenenbaum-Rakover Y, Wagenstaller J, Tiosano D, Gershoni-Baruch R, Albers N, Lichtner P, Schnabel D, Hochberg Z, Strom TM (2006) Hereditary hypophosphatemic rickets with hypercalciuria is caused by mutations in the sodium-phosphate cotransporter gene SLC34A3. Am J Hum Genet 78:193–201
Burnstein MI, Lawson JP, Kottamasu SR, Ellis BI, Micho J (1989) The enthesopathic changes of hypophosphatemic osteomalacia in adults: radiologic findings. AJR Am J Roentgenol 153:785–790
Liang G, Katz LD, Insogna KL, Carpenter TO, Macica CM (2009) Survey of the enthesopathy of X-linked hypophosphatemia and its characterization in Hyp mice. Calcif Tissue Int 85:235–246
Ros I, Alvarez L, Guanabens N, Peris P, Monegal A, Vázquez I, Cerdá D, Ballesta AM, Muñoz-Gómez J (2005) Hypophosphatemic osteomalacia: a report of five cases and evaluation of bone markers. J Bone Miner Metab 23:266–269
Mornet E (2008) Hypophosphatasia. Best Pract Res Clin Rheumatol 22:113–127
Chuck AJ, Pattrick MG, Hamilton E, Wilson R, Doherty M (1989) Crystal deposition in hypophosphatasia: a reappraisal. Ann Rheum Dis 48:571–576
Bhambri R, Naik V, Malhotra N, Taneja S, Rastogi S, Ravishanker U, Mithal A (2006) Changes in bone mineral density following treatment of osteomalacia. J Clin Densitom 9:120–127
El-Desouki MI, Othman SM, Fouda MA (2004) Bone mineral density and bone scintigraphy in adult Saudi female patients with osteomalacia. Saudi Med J 25:355–358
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We thank Xavier Filella and Carme Mallofré for their contribution in the biochemical and histologic evaluation of cases.
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* Gifre and Peris contributed equally to this work.
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Gifre, L., Peris, P., Monegal, A. et al. Osteomalacia revisited. Clin Rheumatol 30, 639–645 (2011). https://doi.org/10.1007/s10067-010-1587-z
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DOI: https://doi.org/10.1007/s10067-010-1587-z