Clinical case series

1. CLINICAL CASE OF A MAN
WITH LOW BACK PAIN
Enida Xhaferi M.D. Resident
Department of Rheumatology
Internal Medicine Clinic
“Mother Theresa Tirana University Hospital
Center

2. CASE PRESANTATION
This is the case of a 49 years old
man, who presented at our clinic one
month ago with a variety of musculo-
skeletal complains.

3. CHIEF COMPLAINS
Chronic pain (lasting more than 6
months) in the lumbar and sacral
regions
Numbness and weakness located at
the postero-lateral thigh, anterior
ankle and rear foot
Muscle weakness and general fatigue
Pain and discomfort in the cervical
area
Frequent headaches
Gastrointestinal disorders
Anorexia

4. PAST ILLNESS HISTORY
Patient relates that low back pain and other
problems started almost two years ago. He
explained his problems 10 months ago
to a physician, who prescribed a combined
therapy comprising glucocorticoids, non
steroidal anti-inflammatory medications and
tranquilizers to dominate the observed
pathologic symptoms. Three months ago he
fell accidentally and one of his lumbar
vertebras got fractured.

5. ADDITIONAL INFORMATION
Patient reports that he drinks regularly and
consumes at least two cups of alcohol per
day. He is not exposed to known toxins
lately, has not received any new
medications and has no drug allergies.

6. PHYSICAL EXAMINATION
Vital Signs and General Examination:
Blood pressure 130/80 mm Hg; heart rate 90
beats/minute; respiratory rate 17 breaths/minute;
T 37.1°C, Hypostenic individual. Patient relates
that he has lost 2 cm of height recently
Mental status: Fully oriented, alert,normal
concentration span, lively and talkative
Respiratory System : Normal vesicular
respiration throughout, free lungs, no wheezing
Cardiovascular System: Patient's heart rate
and rhythm was regular; normal S1 and S2 sounds
with no murmurs, rubs, or gallops
Abdomen: Abdomen was soft, not tender, and
not distended, Blumberg (-)

7. PHYSICAL EXAMINATION
Gastrointestinal System: Normal
bowel sounds, liver is palpated 2 cm under right
costovertebral angle. Patient relates that he
experiences frequently burning pain at the
epigastric region, pyrosis and has other
digestive disorders. He explains that he started
to take NSAI medications 10 months ago.
Genital & Urinar System:
Normal kidneys, Pasternacki (-)

8. PHYSICAL EXAMINATION
Neuro/Muscular examination
Deep aching sclerotomal pain,
worsens while sitting, bending,
while performing Valsava
maneuver and improves while
standing
Paresthesia and weakness of the
posterior thigh and tibialis anterior
Decreased knee jerk reflex
Positive Straight Leg Raising test
Observance of a thoracic kyphosis
Compromised locomotion, painful
spinal bending

9. HOSPITAL COURSE

10. ORDERED EXAMINATIONS
Complete blood cell
counts
Calcium
Alkaline phosphatase
Kidney and liver function
tests
Thyroid hormone levels
Total testosterone
Total glicemia
Abdominal echo
Parathyroid hormone
level to screen for
hyperparathyroidism
24 hour urine
collection to exclude
hypercalciuria
Serum protein
electrophoresis to
exclude multiple
myeloma
Fibrinogen
Pulmonary radiograph

11. LAB TEST RESULTS
Blood Test Results: RBC 4800000/mm³,
Hg 14 g/dl, HCT 42.9 %; MCV 84.3 g/l, MCH 28.2
pg/bl, PLT 235000/mm³, WBC 1000/mm³, LYm
25%, GRA 76%, ES 20 mm.
Biochemical Test Results : Glycemia
78 mg/ dl, Urea 53.7 mg/dl, Creatinin 1.01 mg/dl,
ALP 11.9 U/L, AST 12, Total Bilirubin 0.6 mg/dl, Fib
379 mg/dl, PSA 0.714 ng/Ml,Ionized Ca
1.14mmol/L, Urine Ca 256mol/24h, TSH 0.811
nlU/ml,T3F 3.34 pg/ml, T4F 1.54 pg/ml,
Testosterone 328ng/dl, PTH

12. ELECTROFORESIS OF
PROTEINS
Albumin - 61.7 g/l
Alpha 1 - 2.8 g/l
Alpha 2 – 11.3 g/l
Beta – 10.4 g/l
Gama – 13.8 g/l

13. ABDOMINAL ECHO
Increased liver density, lob dexter
15 cm. Normal gallbladder and
billiary track. No renal stones.
Normal pancreas, mildly increased
prostate.

14. Results of Gastrointestinal
examination
Based on patient complains a gastrointestinal
endoscopic examination was ordered and it
showed the presence of irritated hyperemic
gastric and duodenal mucosa without lesions.
Recommended treatment for the diagnosed
gastroduodenitis
Ranitidini 150 mg
2x1 tab per os
-Citogeli 1 pack
In the evening
-Maloxi 500 mg
3x1 tab

15. X-RAYS
Osteopenia, approximaly 20-40% of Bone
Mass lost
Compressive fracture at the L2 vertebrae
Vertebral compression L2-L4-L5
Intervertebral disk space narrowing L4–L5
Spondilolistesis Grade I, L4-L5

16. BONE FORMATION
OVERVIEW
Bone formation is a sophisticated multidimensional process
involving synchronized physiologic interactions among cell types,
systemic regulators of calcium metabolism that influence
osteoblasts and osteoclasts through specific membrane receptors,
matrix bound proteins and a large number of other
macromolecules.
Mineralization or binding of mineral compounds (mainly
hydroxyapatite crystals) to the hole zones between collagen fibrils
is the successful culmination of all these inter-relationships,
presenting a final marvelous step in the process of creating a
unique and exceptional tissue capable of fulfilling both mechanical
and metabolic responsibilities.
Scientific information from reference 1

17. WHO OSTEOPOROSIS
DEFINITION AND DIAGNOSTIC
CRITERIA
A systemic skeletal disease characterized
by low bone mass and microarchitectural
deterioration of bone tissue leading to
enhanced bone fragility and a consequent
increase in fracture risk.
Osteoporosis T-score <-2.5 Standart Deviation
Established osteoporosis T-score < -2.5 SD
and the presence of one or more fractures.

18. MALE OSTEOPOROSIS RISK
FACTORS
PRIMIARY OSTEOPOROSIS
Ageing and genetic factors
SECONDARY OSTEOPOROSIS
Use of 5 mg or more of glucocorticoids for more than 6
months *
Hiperparatiroidism
Hyperthiroidism or Hypothiroidism
Hypogonadism
Excessive alcohol and tobacco consumption
Anti convulsive therapy
Immobilization
Neoplastic disorders producing osteoclast activating factors
Others
Information from references [1],[2],[3],[4]

19. OSTEOPOROSIS
TREATMENT OBJECTIVES
Limit corticosteroid therapy, alcohol
consumption and cigarette smoking
Provide calcium and vitamin D
supplements
Exercise program to improve muscle
tone
Modification of risk factors
Application of fall prevention strategies

20. PRESCRIBED THERAPY
Calcium 1000 - 1500 mg, per day
Vitamin D 400 - 800 U per day
Alendronate (Fosamax) 70 mg, 1 tab
per week
Non steroidal anti-inflammatory drugs
i/m or per rectum
Tranquillizers

21. FINAL RECCOMANDATIONS
Taking into account compression deformities
observed in the acquired radiological images
and their potential detrimental impact on
intervertebral disk stability,together with the
clinical signs related by the patient, a
preliminary diagnosis of Lumbar Disc
Herniation at the L4-L5 level was also
established and the patient was referred
imediately to a neurologist, who would
perform further clinical and instrumental
examinations (MRI,CT).

22. REFERENCES
Kelley Textbook of Rheumatology
WHO
American family physician journal
British rheumatology journal

23. THANK YOU FOR
YOUR ATTENTION!
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