Refractory diffuse bony pain 20 years after jejunoileal bypass.
Osteomalacia can be a late but unrecognized complication following jejunoileal bypass. We describe a 53-year-old man who underwent jejunoileal bypass for morbid obesity twenty years earlier who suffered from progressive diffuse bony pain refractory to nonsteroidal anti-inflammatory drugs. He was initially diagnosed with a malignancy with bone metastasis. However, pertinent laboratory data were notable for hypocalcemia (7.5 mg/dL, albumin 4.1 mg/dL) with low urinary calcium excretion (14 mg/day), hypophosphatemia (2.0 mg/dL) with low urinary phosphate excretion (53 mg/day), hypomagnesemia (1.5 mg/dL) with low urine magnesium excretion (23 mg/day), low 1, 25 (OH)2 vitamin D3, and elevated serum alkaline phosphatase and intact parathyroid hormone (iPTH). These laboratory findings pointed to a defect in calcium, phosphate, and magnesium handling in the gastrointestinal tract. Bone biopsy of the iliac crest clearly demonstrated typical changes of osteomalacia with excessive osteoid accumulation and reduced mineralization. His clinical symptoms were refractory to oral 1, 25 (OH)2 vitamin D3 and calcium supplementation but significantly improved with the addition of intermittent intravenous active 1, 25 (OH)2 vitamin D3, calcium, phosphate, and magnesium supplementation. Osteomalacia is an easily misdiagnosed late complication of jejunoileal bypass. Early recognition can avoid circuitous diagnosis and inappropriate management.
Sung
Chih-Chien
CC
Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. 1521116@ndmctsgh.edu.tw
Lee
Herng-Sheng
HS
Diang
Liang-Kuang
LK
Lin
Shih-Hua
SH
D001706:Biopsy; D002637:Chest Pain / Q000209:etiology* / Q000473:pathology; D003937:Diagnosis, Differential; D006615:Hip / Q000473:pathology; D006801:Humans; D007085:Ilium / Q000473:pathology; D007581:Jejunoileal Bypass / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D010018:Osteomalacia / Q000175:diagnosis* / Q000209:etiology* / Q000473:pathology; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology* / Q000473:pathology / Q000628:therapy; D011182:Postoperative Care; D011877:Radionuclide Imaging; D020069:Shoulder Pain / Q000209:etiology* / Q000473:pathology; D013669:Technetium Tc 99m Medronate
D013669:Technetium Tc 99m Medronate