Vol 39 # 2 June 2007 - Kma.org.kw

June 2007KUWAIT MEDICAL JOURNAL 155Table 1b: biochemical values post-treatment with high dose of vitD.Patient Calcium Phosphate Alkaline Urinary PTH25 (OH)DNo. (mmol/l) (mmol/l) phospha- Calcium phosphate (pmol/l) leveltase(mmol/l) (mmol/24hr) (nmol/l)1 2.51 1.32 273 7.1 2.68 4.7 1022 2.29 1.71 126 0.9 4.7 1.2 1203 2.36 1.22 72 3.49 10.1 5.9 784 2.34 1.57 144 6.2 9.4 4.4 1125 2.17 1.01 224 2.33 8.43 10.1 1556 2.18 0.92 119 3.32 12.3 5.5 2227 2.32 1.67 34 1.04 21.4 2.8 808 2.04 1.32 85 4.12 4.5 16.3 969 2.4 1.39 469 3.66 16.3 19.1 10910 2.6 1.22 122 2.46 7.92 17.4 6511 2.26 1.77 272 2.8 9.4 6.1 19412 2.4 1.44 360 2.61 8.8 12.6 9013 2.35 1.34 215 1.99 1.01 4.61 5014 2.4 1.47 68 3.21 5.96 2.33 14115 2.32 1.35 166 1.86 6.73 5.5 —-16 2.31 1.19 93 1.02 8.7 4.93 7817 2.09 1.12 219 1.82 0.27 6.22 8918 2.34 1.35 122 2.0 5.4 3.8 —-19 2.3 1.41 96 0.98 4.2 2.15 3920 2.61 2.44 112 3.21 4.47 5.2 12021 2.4 1.33 147 — — —- 7522 2.2 1.04 401 2.31 6.11 7.01 8123 2.19 1.02 213 1.97 9.01 5.7 6524 2.41 1.23 89 3.12 .95 4.3 91— = data not availablehr (normal = 13-42), serum PTH = 38.68 ± 23.43,10.85 ± 4.49 pmol/l (normal = 0.7-5.6), 25(OH)D =8.10 ± 8.05 nmol/l (normal = 23-113) and skeletal X-ray showed pseudofractures (looser’s zones, whichare nearly pathognomonic features of rickets andosteomalacia) in some of our patient andpathological fracture in one patient. Bonedensitometry scan showed osteopenia andosteoporosis in most patients and the mean T-Scorewas - 2.086 ± 0.91. All symptoms and signsimproved dramatically during treatment with highdose of vitamin D and calcium. Health educationthat helped in greater exposure to sunlight (at least10 minutes daily) and an increase in theconsumption of dairy products to obtain approximately1 g of calcium daily had an important role inthe management. There were no re p o r t e dsymptoms or biochemical finding of hyperc a l c e m i a .DISCUSSIONIn our study, we found that patients in a sunnyclimate like Kuwait may still present withosteomalacia due to vitamin D deficiency as a resultof insufficient sunlight exposure and inadequatedairy product intake. Almost all our patient (96%)consumed less than 1,000 mg of calcium per week,while the daily requirement is about 1,200 mg. Alsosome of our patients were from the lowsocioeconomic status and lived in houses wherelittle if any sunlight was allowed to enter. Theywere also ignorant about the value of vitamin Dand calcium for the process of bone mineralization.They were eating very minimal amounts of calciumcontaining products (because they did not like milkand/or diary products) and they were wearingtraditional or religious clothing that covered all thebody except the eyes (long dress hejab, niquab,abaya, gloves and socks). This resulted ininadequate exposure to sunlight re q u i red forvitamin D synthesis. These overclothing styleamong women as young as eight years old maylead to vitamin D deficiency. This also explains whyall our patients were female since this clothinghabit is exclusive to women. This is in agreementwith a previous study which concluded thatvitamin D deficiency in the Middle East was due toclothing habits [5] . It is also known from previousstudies that UV radiation passes through glass andmost plastics [ 1 ] but not through clothing andsunscreen [6,7] .The prevalence of osteomalacia due to vitaminD deficiency is unknown in Kuwait and anepidemiological study is required.Almost all of our patients presented with typicalnon-specific symptoms of osteomalacia such aslethargy, proximal muscle weakness, and diffusebone pain. We noticed that proximal muscleweakness is so prominent among our patients thatit can be used as a good indicator of improvementfollowed by other symptoms like diffuse bone painand the feeling of lethargy. On presentation onepatient had symptoms of hypocalcemia (numbnessand tingling sensation around the mouth andc o r rected serum calcium found to be low (1.8mmol/l) and another had a pathological fracturedue to severe osteoporosis which is a knowncomplication of severe osteomalacia.The clinical diagnosis of osteomalacia is basedon the findings of low levels of 25(OH)D, serumcalcium, serum phosphate, urinary calcium andphosphate and increased levels of alkalinephosphatase, PTH. These abnormal biochemicalfindings result from vitamin D deficiency whichresults in decreased intestinal absorption of calciumand phosphate that consequently lead to secondaryh y p e r p a r a t h y roidism. The cornerstone in thediagnosis of osteomalacia is the demonstration of areduction in the mineral apposition rate,mineralization surface, and bone formation rate,which can be measured after the administration ofdouble tetracycline labels before the bone biopsy.The diagnosis of osteomalacia in our patients wasobvious from the clinical presentation, biochemicalfinding and radiological images. Therefore, therewas no need for an invasive pro c e d u re liketranscortical bone biopsy to establish the diagnosis.