This document discusses four cases of unusual osteoporosis: 1) A 73-year-old man with vertebral fractures caused by hyperthyroidism due to amiodarone use. 2) A 51-year-old cyclist with recurrent fractures possibly due to low bone mineral density from cycling. 3) A 68-year-old man with low testosterone and back pain diagnosed with hypogonadism-induced osteoporosis. 4) A 45-year-old runner with vertebral fractures found to have an adrenal carcinoma causing Cushing's syndrome.

1. UNUSUAL OSTEOPOROSIS

2. Case 1

3. ∗ 73 year old man presented with recent onset
of back pain and weight loss.
∗ X-rays showed multiple vertebral fractures.
∗ PMH AF controlled with amiodarone.
∗ Non smoker, little alcohol.
∗ Differential diagnosis?
Case 1

4. ∗ FBP
∗ Admission profile, bone profile, PSA
∗ ESR / CRP
∗ PPE, Bence Jones
∗ Testosterone
∗ TFTs, 24hr urinary cortisol
∗ Coeliac screen
Case 1 Investigations

9. ∗ T4 96.9 pmol/L
∗ TSH < 0.02 mu/L
∗ Hyperthyroidism secondary to
amiodarone
Case 1 Diagnosis

10. ∗ Increased frequency of bone remodelling
∗ Shortened cycle with bone formation
shortened more than resorption
∗ Leads to loss of bone with each cycle
∗ relative increased Ca -- decreased PTH--
decreased 1-25 Vit D -- decreased Ca
absorption and increased Ca excretion
Hyperthroidism and Bone

11. ∗ Increased fracture rate
X 3 to 4 increased rate & only in part related
through BMD.
Hyperthyroidism and Fracture

12. ∗ BMD increases on average 4% in first year.
∗ BMD returns to normal range within 3-5 yrs.
∗ But there remains an increased fracture rate
for up to 5 years.
∗ Therefore in severe osteoporosis use
antiresorptive therapy for 3-5 years.
Correction of Hyperthyroidism
Bone response

15. Case 2

16. ∗ 51 year old man # elbow after fall off bicycle,
March 2017
∗ Keen club cyclist
∗ Previous #s in falls off bike
∗ Hip 2007
∗ Pubic ramus 2013
Case 2

19. ∗ FBP
∗ Admission profile, bone profile, PSA
∗ ESR / CRP
∗ PPE, Bence Jones
∗ Testosterone
∗ TFTs, 24hr urinary cortisol and calcium
∗ Coeliac screen
∗ All normal
Case 2 Investigations

21. ∗ Sherk et al. (2014)14 cycling (F)>1 year of competition history26–41Longitudinal (1 year) BMD of the hip decreases 1–2% after a
year of training and competition.
∗ Gómez-Bruton et al. (2013) 20 cycling19 control (M)10 h/wk16.4
Cross-sectional Lower BMD of young cyclists in some places.
∗ Guillaume et al.(2012)29 cycling (M)25,000–30,000 km/year26–5 Descriptive ND between groups on calcium and vitamin D
intake
∗ Nichols et al.(2011)19 cycling
18 control (M)11.1 h/wk
4.5 h/wk50–57Longitudinal (7 years) Cycling has not demonstrated positive effects on BMD. High rate of
osteopenia/osteoporosis in cyclists (84.2% and 89.5% after seven years)
∗ Abe et al.(2014) 14 cycling (masters)13 moderately active youngsters (M)17 years of training 20–71 Cross-sectional BMD lower
in femoral neck of cyclists versus control. ND in BMD of lumbar spine.
∗ Olmedillas et al. (2011)21 cycling
23 control (M)10 h/wk 4 h/wk15–21 Cross-sectional Lower BMD of the hip, leg and pelvis of cyclists versus control
∗ Campion et al. (2010)30 cycling
30 control (M)22–25 h/wk
<1 h/wk29 ± 3 28 ± 4 Cross-sectional Professional cycling affected negatively BMD (femoral neck: −18%)
∗ Penteado et al.(2010)31 cycling
28 control 21 h/wk20–30 Cross-sectional ND in BMD versus control
∗ Barry et al.(2008)14 cycling (M)>450 h/y27–44 Two groups: low and high doses of calcium supplementation during one year
Both groups decreased BMD of the hip and sub-regions, regardless of calcium intake
∗ Rector et al.(2008) 27 cycling 18 marathon (M)≥6 h/wk≥6 h/wk20–59 Cross-sectional 63% of cyclists had lumbar spine
osteopenia and were 7-fold times more likely to have osteopenia
Cycling and BMD

22. ∗ Is low BMD in cyclists associated with higher
fracture rate?
∗ Why low BMD?
∗ Effect of Skeletal loading on osteocyte
∗ Lazy Bones may be right !
∗ Advise weight bearing exercise
Cycling and Fracture

23. Case 3

24. ∗ 68 year old man presented with tiredness
after small CVA.
∗ PMH of AF.
∗ Lower thoracic back pain
Case 3

28. ∗ FBP
∗ Admission profile, bone profile, PSA
∗ ESR / CRP
∗ PPE, Bence Jones
∗ Testosterone
∗ TFTs, 24hr urinary cortisol and calcium
∗ Coeliac screen
∗ Testosterone 2.8 (6.7-25.7)
Case 3 Investigations

29. ∗ Very aware of postmenopausal bone loss. but
hypogonadism in men?
∗ Studies suggest up to 50% of osteoporosis in men is
secondary.
∗ Alcohol probably accounts for half of this and
hypogonadism ? a quarter.
Hypogonadism and Osteoporosis

30. ∗ Testosterone(T) has direct effect on bone cells
through androgen receptor.
∗ T has indirect effect through peripheral
conversion of T to oestrogen via aromatase in fat
tissue.
∗ Stronger correlation between oestrogen and
BMD and fractures than T in men.
∗ Low T could be linked to increased fracture rate
through reduced muscle strength and falls
Testosterone and bone

31. ∗ Treat hypogonadism in men when it is
symptomatic.
∗ Treat osteoporosis with bisphosphonates
(Denosumab) as per guidelines.
∗ Treat osteoporosis with testosterone
replacement when there is no alternative
therapy available.
Treatment

32. ∗ Aromatase inhibitors
∗ Treat when T score is less than -2.0
∗ Androgen deprivation therapy
∗ Treat with bisphosphonates ( oral, iv)
∗ Denosumab licensed USA
Iatrogenic

33. Case 4

34. ∗ 45 year old man presented with acute mid
thoracic back pain.
∗ Keen runner up to marathon level.
∗ Fatigue recently, not running and weight gain.
∗ No past medical history.
∗ X-rays showed 3 thoracic vertebral fractures
Case 4

35. ∗ FBP
∗ Admission profile, bone profile, PSA
∗ ESR / CRP
∗ PPE, Bence Jones
∗ Testosterone
∗ TFTs, 24hr urinary cortisol and calcium
∗ Coeliac screen
∗ Urine Cortisol 4020 (<210) and subsequent CT
showed adrenal carcinoma
Case 4 Investigations

40. ∗ Endogenous is very rare compared with
exogenous corticosteroids.
∗ Complex effect on bone metabolism.
∗ Direct bone cell effects with initial rapid
increase in bone resorption followed by long
term decrease in bone formation.
∗ Indirect effects through Vit D and calcium,
growth hormones, IGF and hypogonadism.
Glucocorticoid Induced Osteoporosis
(GIO)

41. ∗ Standard relationship between BMD and
fracture risk does not apply.
∗ In GIO apply higher threshold for treatment
( T score -1.5).
∗ Bone microstructure is important.
∗ Trabecular bone is affected most.
∗ Vertebral fractures are often asymptomatic.
GIO and Fracture

42. ∗ Lifestyle, weight bearing exercise.
∗ Calcium (1000mg) and Vit D (800iu).
∗ Depending on fracture risk
∗ Bisphosphonates oral (IV)
∗ Denosumab if C/I to bisphosphonates.
∗ New ACR guidelines
∗ Pred dose 2.5mg for > 3 months or 5 gm total
∗ Based on fracture risk and age < or > 40yrs.
Management of GIO