Session: SAT 199-223-Disorders of Bone & Calcium Homeostasis: Case Reports
Poster Board SAT-220
Clinical case: A 44-year old woman was admitted due to multiple joint pains. She was diagnosed with Juvenile Idiopathic Arthritis (JIA) at the age of two, was prescribed Prednisone 5mg daily with improvement of symptoms, however was lost to follow-up but continued taking Prednisone 5-10mg daily for 42 years. On admission, she had cushingoid facies, hypertrichosis, buffalo hump, central obesity, stunted growth (height of 123cm, compatible with a 7 year-old), fusiform deformities of fingers, a swollen and tender right knee, and tenderness on both shoulder joints, right elbow and hips.
Xrays showed rheumatoid arthritis of the shoulders, hands and knees; cervical spondylosis and disc disease, C2-C3 and C3-C4; osteoporosis of the lumbosacral spine with compression deformity of most of the thoracic vertebrae; and avascular necrosis of both hips. BMD of the hips and lower spine showed severe or established osteoporosis (Z score of -3.5), moderate wedge deformity of T11. She was shifted to hydrocortisone for two days prior to plasma cortisol determination, which were elevated: 8am – 1,320nmol/L, 9am – 936nmol/L (n AM values: 138-690nmol/L), 11pm – 527nmol/L (n PM values: half of AM). ACTH (4.708pg/mL), IFG-I (149ng/mL), GH (2.783ng/mL), iPTH (44.934pg/mL), Phosphorus (3.82mg/dL), RF (11.7IU/mL), ESR (13mm/hr) and anti-CCP (1U/mL) were normal. Hypocalcemia (8.38mg/dL, n 8.6-10.2mg/dL), Vitamin D deficiency (15.9ng/mL, n ≥30ng/mL), and elevated CRP-LX (23.73mg/L, n <5mg/L) were noted. To rule out any genetic factor that may have contributed to her stunted growth, karyotyping was requested which was normal. She was discharged on Alendronate+Cholecalciferol 70mg/5600IU/tab one tablet once a week, Calcium carbonate 600mg/cap one capsule OD, Vitamin D3 2000IU/cap one capsule BID, and Prednisone 5mg/tab one tablet OD. Plans for this patient are to slowly taper her off from steroids and discontinue, if her ACTH stimulation test is normal, and start her on Methotrexate for her JIA.
Conclusion: Prolonged steroid use, even in small doses, can cause stunted growth due to premature closure of the epiphyses, severe osteoporosis and avascular necrosis.
Nothing to Disclose: ASU, TDC
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