title: [Severe vitamin D deficiency osteomalacia by coincidence of multiple risk factors].
abstract: METHODS
  An 82-year-old woman was admitted with bilateral clavicular fractures after falling out of bed. She complained of pain in all her bones. She reported having undergone a partial gastrectomy (Billroth II) 40 years ago with subsequent milk intolerance and a dislike of direct sun light.
  
  
  METHODS
  Scintigraphy revealed multiple areas of abnormal uptake. Conventional radiography showed in both ulnae transverse zones of increased density with a central translucent band. Laboratory tests demonstrated the constellation of increased bone turnover in secondary hyperparathyroidism with hypocalcaemia (1.49 mmol/l) and hypophyosphataemia (0.62 mmol/l). The 25-hydroxyvitamin D-level was too low to be measured. Ileal crest biopsy indicated osteomalacia.
  
  
  METHODS
  Serum levels of calcium, alkaline phosphatase and vitamin D became normal after 7 weeks of daily administration of 10,000 IU vitamin D and 1000 mg calcium. The severe pains had subsided after two weeks and no longer required analgesics.
  
  
  CONCLUSIONS
  Multiple areas of increased uptake on skeletal scintigraphy, combined with diffuse bone pain and increased alkaline phosphatase, were at first misinterpreted as extensive skeletal metastases. But the history, at first seemingly of little significance, contained three long-term risk factors for the development of vitamin D and calcium deficiency and thus of osteomalacia, namely partial gastrectomy, milk intolerance and inadequate exposure to sun light. Early recognition of risk factors for bone changes will rapidly lead to the correct diagnosis and immediate treatment of the treatable underlying disease.
authors.affiliation: Klinik für Innere Medizin, Klinikum Neustadt.
authors.forename: B
authors.initials: B
authors.lastname: Bätge
authors.forename: J
authors.initials: J
authors.lastname: Struck
authors.forename: H H
authors.initials: HH
authors.lastname: Klein
authors.forename: J
authors.initials: J
authors.lastname: Brinckmann
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002968:Clavicle / Q000293:injuries; D003937:Diagnosis, Differential; D005260:Female; D005598:Fractures, Spontaneous / Q000175:diagnosis; D006801:Humans; D016269:Milk Hypersensitivity / Q000175:diagnosis; D010018:Osteomalacia / Q000175:diagnosis*; D011178:Postgastrectomy Syndromes / Q000175:diagnosis*; D011183:Postoperative Complications / Q000175:diagnosis*; D012307:Risk Factors; D014808:Vitamin D Deficiency / Q000175:diagnosis*