Bone pain and extremely low bone mineral density due to severe vitamin D deficiency in celiac disease

Abstract

Case report: A 29-year-old wheelchair-bound woman was presented to us by the gastroenterologist with suspected osteomalacia. She had lived in the Netherlands all her life and was born of Moroccan parents. Her medical history revealed iron deficiency, growth retardation, and celiac disease, for which she was put on a gluten-free diet. She had progressive bone pain since 2 years, difficulty with walking, and about 15 kg weight loss. She had a short stature, scoliosis, and pronounced kyphosis of the spine and poor condition of her teeth. Laboratory results showed hypocalcemia, an immeasurable serum 25-hydroxyvitamin D level, and elevated parathyroid hormone and alkaline phosphatase levels. Spinal radiographs showed unsharp, low contrast vertebrae. Bone mineral density measurement at the lumbar spine and hip showed a T-score of -6.0 and -6.5, respectively. A bone scintigraphy showed multiple hotspots in ribs, sternum, mandible, and long bones. A duodenal biopsy revealed villous atrophy (Marsh 3C) and positive antibodies against endomysium, transglutaminase, and gliadin, compatible with active celiac disease. A bone biopsy showed severe osteomalacia but normal bone volume. She was treated with calcium intravenously and later orally. Furthermore, she was treated with high oral doses of vitamin D and a gluten-free diet. After a few weeks of treatment, her bone pain decreased, and her muscle strength improved.

Discussion: In this article, the pathophysiology and occurrence of osteomalacia as a complication of celiac disease are discussed. Low bone mineral density can point to osteomalacia as well as osteoporosis.

Fig. 1

Radiographs, lateral view, of the lower thoracic (a) and lumbar vertebrae (b). Thoracic vertebrae are blurred and lumbar vertebrae show codfish appearance

Fig. 2

Bone scintigraphy; Whole body, anterior view (a) and detail of the ribs, lateral view (b). Hot spots may indicate pseudofractures or fissures

Fig. 3

Crista biopsy; Goldner stain, magnification 5 × 10 (a), Goldner stain, magnification 10 × 10 (b), and Tartrate-resistant acidic phosphatase stain, magnification 10 × 10 (c). Mineralized bone is green and osteoid tissue, red. Osteoid seems very thick, and osteoid volume is 75%. Bone resorption by multinucleated osteoclasts is increased (arrows)