Page 22 - Delaware Medical Journal - November/December 2020

TABLE 1
LABORATORY INVESTIGATION
LABORATORY VALUE
INSTITUTIONAL REFERENCE RANGE
25-OH Vitamin D
12 ng/ml
>29 ng/ml
Calcium
8.5 mg/dl
8.4–10.5 mg/dl
Serum Iron
22 mcg/dl
40–150 mcg/dl
Ferritin
8 ng/dl
13–150 ng/dl
Hgb
11.9
11.7 15.7 g/dl
Hct
38.80%
35–47 %
PTH
83 pg/ml
8–24 pg/ml
the duration of her pain and lack
of improvement with conservative measures, an MRI was performed to further evaluate the potential source of her pain. Results of the MRI showed a nondisplaced fracture along the medial cortex of the left femoral neck, in addition to a nondisplaced fracture of the right hemisacrum (Figures 2 and 3).
Due to the patient’s pain, along
with the duration of and concern
for completion with displacement of the femoral neck fracture, surgical intervention was recommended. Non- operative treatment was indicated for the sacral fracture, which once again did not appear to be causing her any problems based on history and physical exam. She was made non-weight- bearing on her left side and admitted
to the hospital for surgical intervention for her femoral neck fracture,
along with further workup of any underlying medical issues that could be contributing to decreased bone strength. Laboratory evaluation was performed upon admission (Table 1).
The rest of the patient’s laboratory evaluation was unremarkable, including normal coagulation studies,
normal basic metabolic panel, and normal renal function. She was diagnosed with severe vitamin D and iron deficiency without anemia. It was also felt at that time that her hyperparathyroidism was secondary to the vitamin D deficiency. Given the aforementioned diagnosis, she underwent rule-out testing for celiac disease as a possible cause of her nutritional malabsorption (Table 2).
The elevated anti-tissue transglutaminase antibody greater than 10 U/mL provided a presumed diagnosis of celiac disease as the cause of her malabsorption. Of note, the patient reported no prior history
of abdominal issues, cramping, food intolerances, diarrhea, or constipation.
On the second day of her hospital admission, she underwent percutaneous pinning of the left femoral neck using three 6.5mm, partially threaded canullated screws (Figure 4). The surgery was completed without complication and the patient was transitioned to the orthopedic
ward, where she had an uneventful postoperative course. She was made limited weight-bearing to the left
lower extremity, with the use of
crutches, and ambulated well on the morning of postoperative day #1. She was started on oral calcium, iron, and vitamin D supplementation. The patient was ultimately discharged from the hospital on the afternoon
of postop day #1. Her pain was well controlled with minimal narcotic use. She participated in outpatient physical therapy for the purpose of improving strength and range of motion. She
had no complications in the initial postoperative period.
After discharge from the hospital, the patient was seen by her primary care provider and set up for DEXA scanning, which showed overall low-normal bone mineral density for her age (R hip Z score 0.7, Lumbar Z score 0.8). However, she was diagnosed with osteomalacia given her multiple nontraumatic fractures and nutritional deficiencies. She
was seen by endocrinology in the outpatient setting for evaluation
of osteomalcia and presumed secondary hyperparathyroidism. Her daily calcium and vitamin D were switched to weekly ergocalciferol,
and oral iron supplementation. Her hyperparathyroidism was ultimately determined to be secondary to vitamin
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Del Med J | November/December 2020 | Vol. 92 | No. 6