Nishil Patel, DO
Resident
Mount Sinai
New York, New York, United States
Amie Kim, MD
Physician
Mount Sinai
New York, New York, United States
65y.o. female with PMH of Hypothyroidism, Multinodular Goiter, and Eczema was evaluated for low back pain after fall. Pain was described as achy. Worsened with prolonged sitting and standing. Improved with Tylenol and movement. Patient did report a history of Rheumatoid Arthritis but was not on any biologics/DMARDS. X-ray demonstrated bones were diffusely osteopenic and chronic anterior wedging of T11 with exaggeration of the kyphosis. Referred to Endocrine for evaluation of bone demineralization in setting of incidental finding of compression fracture. Parathyroid hormone (PTH) was screened found to be elevated; started on cholecalciferol 2000U daily and calcium supplements with repeat PTH normalized after one month.
Discussions:
Hyperparathyroidism (hyperPTH) is a relatively common endocrine disorder that is seen three times more in women than men leading to secondary bone manifestations such as back pain, bone pain, or articular changes. Bone mineral density (BMD) is a clinical marker that is inversely correlated to levels of PTH. Higher levels of PTH have been linked to decreased BMD which leads to increased risk of fractures to the appendicular skeleton and less commonly the axial skeleton. Idiopathic osteoporosis is a common cause of compression fractures with hyperparathyroidism being an etiology. PTH is not routinely screened unless there are calcium/phosphate abnormalities or suspicion of osteoporosis. Per Khosla et al., there is an approximately 3x risk in patients with hyperPTH. Approximately 25% of women over age of 50 will have a compression fracture vs. 40% of women above 80. Furthermore, atraumatic compression fractures in these patients are rarer.
Conclusions:
The patient’s incidental finding of thoracic compression fracture was likely a result of osteoporosis secondary to new onset hyperPTH which was a delayed but good catch due to screening of PTH. Further investigation is needed for early screening of PTH to prevent potential disease progression.
