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Letter to the Editor
Osteomalacia and Vitamin D Deficiency in the Elderly
Maria do Carmo Sitta
Corresponding author
m.sitta@globo.com

Tel.: 55 113069-7813
, Stella V.A. Cassis, Nidia C Horie, Rosa M.A. Moyses, Vanda Jorgetti, Luíz Eugênio Garcez-Leme
Geriatrics – Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo/SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Osteomalacia is one of the most common osteometabolic diseases among the elderly and may be associated with osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> It is typically caused by lack of vitamin D and is characterized by mineralization deficiency of the osteoid matrix in the cortical and trabecular bone&#44; resulting in accumulation of osteoid tissue&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> Vitamin D deficiency is a pathogenic factor of osteoporosis that can be modified&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#44; <a class="elsevierStyleCrossRef" href="#bib9">9</a> The elderly are at particularly high risk for developing osteomalacia&#44; which is frequently misdiagnosed&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#44; <a class="elsevierStyleCrossRef" href="#bib3">3</a></p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">SAMPLE AND METHODS</span><p id="para20" class="elsevierStylePara elsevierViewall">We report the case of a 62-year-old woman who had experienced body pains and weakness for two years&#46; She had suffered from multiple fractures of the ribs and the left clavicle without trauma for two months before she was admitted to the hospital&#46; Comorbidities included hypertension&#44; diabetes mellitus&#44; hypothyroidism&#44; depression and neurological sequelae with left hemiparesis&#46; The patient was using levothyroxine&#44; omeprazole&#44; metformin&#44; glymepiride&#44; milnacipran&#44; mirtazapine and atenolol&#46; Radiography showed fractures of nine costal arches and of the left clavicle&#46; Bone scintigraphy revealed multiple osteogenic reaction areas&#44; with predominance in the axial skeleton &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46; Bone densitometry showed osteoporosis with a lumbar spine &#40;L1&#8211;L4&#41; T score of &#8722;3&#46;1 and a femur &#40;neck&#41; T score of &#8722;2&#46;8&#46; The laboratory test results showed alkaline phosphatase &#40;AP&#41; 491 U&#47;L &#40;RR-ref range &#60; 104 U&#47;L&#41;&#59; parathyroid hormone &#40;PTH&#41; 146 pg&#47;ml &#40;RR 7&#8211;62 pg&#47;ml&#41;&#59; total serum calcium 8&#46;5 mg&#47;dl &#40;RR 8&#46;6&#8211;10&#46;2 mg&#47;dl&#41;&#59; ionized calcium 4&#46;7 mg&#47;dl &#40;RR 4&#46;6&#8211;5&#46;3 mg&#47;dl&#41;&#59; serum phosphorus 3&#46;6 mg&#47;dl &#40;RR 2&#46;7&#8211;4&#46;5 mg&#47;dl&#41;&#59; urinary calcium 42&#46;3 mg&#47;24h &#40;RR 100&#8211;320 mg&#47;24h&#41;&#59; and urinary phosphate 397&#46;4 mg&#47;24 h &#40;RR 400&#8211;1300 mg&#47;24h&#41;&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para30" class="elsevierStylePara elsevierViewall">These findings led us to hypothesize that the patient had osteomalacia&#46; It was decided to perform a trans-iliac bone biopsy&#46; The patient was pre-labeled with oral tetracycline &#40;20 mg&#47;kg&#47;day for 3 days&#41; administered over two separate intervals 10 days apart&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">The biopsy revealed diminished trabecular volume &#40;13&#46;3&#37;&#41;&#44; increased osteoid surface &#40;82&#37;&#41; and volume &#40;43&#37;&#41;&#44; and confluent tetracycline labeling &#40;<a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a>&#41;&#59; thus&#44; the hypothesis was confirmed&#46; Serum 25-OH-vitamin D levels were determined to be 11 ng&#47;ml &#40;RR &#62; 40 ng&#47;ml&#41;&#46; The patient was prescribed calcitriol at 0&#46;75 mg&#47;day and 2 g of calcium carbonate to normalize PTH and alkaline phosphatase &#40;AP&#41; levels&#46; Body pains and weakness were eventually reduced&#46; Over a follow-up period of three years&#44; the patient did not have any new fractures&#46; Her bone mineral density improved by 38&#37; in the lumbar spine &#40;L1-L4 T-score &#8722;0&#46;56&#41; and 67&#46;3&#37; in the femur &#40;neck T-score &#8722;1&#46;21&#41;&#46; Laboratory test levels had normalized to alkaline phosphatase &#40;AP&#41; 81 U&#47;L &#40;RR-ref range &#60; 104 U&#47;L&#41;&#59; parathormone &#40;PTH&#41; 53 pg&#47;ml &#40;RR 7&#8211;62 pg&#47;ml&#41;&#59; total serum calcium 9&#46;4 mg&#47;dl &#40;RR 8&#46;6&#8211;10&#46;2 mg&#47;dl&#41;&#59; ionized calcium 4&#46;9 mg&#47;dl &#40;RR 4&#46;6&#8211;5&#46;3 mg&#47;dl&#41;&#59; serum phosphorus 4&#46;4 mg&#47;dl &#40;RR 2&#46;7&#8211;4&#46;5 mg&#47;dl&#41;&#59; urinary calcium 151 mg&#47;24 h &#40;RR 100&#8211;320 mg&#47;24 h&#41; and serum 25-OH-vitamin D 42 ng&#47;ml &#40;RR &#62; 40 ng&#47;ml&#41;&#46; At present&#44; the patient is using colecalciferol at 1000UI a day with good results&#46;</p><elsevierMultimedia ident="fig2"></elsevierMultimedia></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para50" class="elsevierStylePara elsevierViewall">Vitamin D plays a role in bone mineralization and in the regulation of circulating calcium&#46; Deficiency of this vitamin results in increased parathyroid hormone &#40;PTH&#41; synthesis and secretion&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a> This secondary hyperparathyroidism increases bone turnover&#44; resulting in increased risk of fracture&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> Osteomalacia develops when this process is intense and chronic and was histologically apparent in 13 to 33&#37; of patients with osteoporotic femoral neck fractures&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#44; <a class="elsevierStyleCrossRef" href="#bib5">5</a></p><p id="para60" class="elsevierStylePara elsevierViewall">Vitamin D deficiency has been implicated in osteoporotic pathophysiology of the elderly and can cause muscle weakness as well as predisposition to falls and fractures&#46; Osteomalacia may be associated with fractures due to minimal stress trauma and should be suspected when laboratory exams show increased levels of alkaline phosphatase &#40;AP&#41; with normal or decreased serum calcium and phosphorus&#44; increased PTH &#40;secondary hyperparathyroidism&#41;&#44; and absence of lithic lesions and neoplasic bone disease&#46; In most cases&#44; osteomalacia can be diagnosed by assaying for 25-OH-vitamin D&#44;<a class="elsevierStyleCrossRef" href="#bib8">8</a> which can be useful for early detection of the deficiency&#46; Vitamin D3&#44; or cholecalciferol&#44; is synthesized in the skin by ultraviolet radiation from the sun&#46; In order to become active&#44; it must furthermore undergo two hydroxylations in the liver and kidneys&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a> Low intake&#44; poor absorption&#44; and insufficient exposure to the sun can all result in Vitamin D deficiency&#46; In some cases&#44; the defect occurs in the receptor&#44; and the diagnosis can only be confirmed through bone biopsy&#44; which also allows for differentiation between osteomalacia and osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a></p><p id="para70" class="elsevierStylePara elsevierViewall">Cancer and prolonged use of anticonvulsants such phenytoin can also cause osteomalacia&#46; The main differential diagnosis is osteoporosis&#44; which shows normal results on biochemical tests for calcium&#44; phosphorus&#44; AP and PTH&#46; Vitamin D deficits among the elderly have been reported in several countries&#44;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#44;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#44;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#44;<a class="elsevierStyleCrossRef" href="#bib8">8</a> even in Brazil&#44; despite its tropical location&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a> Vitamin D deficiency has been implicated in various pathological conditions including osteoporosis&#44; muscle weakness and predisposition to falls and fractures&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#44;<a class="elsevierStyleCrossRef" href="#bib7">7</a>&#44;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#44;<a class="elsevierStyleCrossRef" href="#bib11">11</a> Epidemiological studies suggest that adequate serum concentrations of Vitamin D are related to reduced risk of autoimmune diseases&#44; falls&#44;<a class="elsevierStyleCrossRef" href="#bib9">9</a> and prostate&#44; colon&#44; breast and ovarian cancer&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#44;<a class="elsevierStyleCrossRef" href="#bib9">9</a></p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION</span><p id="para80" class="elsevierStylePara elsevierViewall">Vitamin D deficit may cause osteomalacia&#44; which should be included in the differential diagnosis for fractures caused by minimal trauma&#46; It is suggested that Vitamin D assays should be included in routine assessments of the elderly and that Vitamin D supplementation should be considered even in tropical countries&#46;</p></span></span>"
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Article information
ISSN: 18075932
Original language: English
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es en pt

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