A Case with Multiple Punched-out Lesions in the Skull and Generalized Fractures Associated with Steroid-induced Osteoporosis
A 56-year-old Korean male was referred to our hematology department for the evaluation of multiple myeloma. He had an extensive history of repeated and multiple vertebral fractures. Three years ago, the patient experienced pain in his lower back and on his bilateral hip pain without any particular injury history and was treated with analgesics. Six months ago, the symptoms progressed and became intolerable in spite of analgesia. Magnetic resonance imaging (MRI) confirmed compression fractures at 9th and 12th thoracic vertebrae and a percutaneous vertebroplasty was performed to help relieve the pain. A month ago, radiographs showed new compression fractures at 8th and 9th thoracic vertebrae and the percutaneous vertebroplasty was performed again (). Unfortunately, ten days ago, back pain redeveloped and lower extremity weakness occurred. MRI showed spinal cord compression as well as mass effect at 8th and 9th thoracic vertebrae. Also, compression fractures at 10th thoracic vertebra were newly observed. According to the patient's medical history, he was diagnosed with hypertension 3 years ago and he has been taking medications occasionally. He tended to drink alcohol of 160 g per week for about 20 years and had a habit of smoking about 20 pack-year. Although, the patient had stable vital signs, his physical examination had shown that he had chronic ill-looking appearance and a Cushingoid appearance with moon face, easy bruising, thin skin and atrophy of upper leg muscles. Manual muscle testing of lower extremity showed weakness of grade 3-3+ out of 5.\nOur laboratory work-up including complete blood cell count, liver and renal function test, serum electrolytes and blood glucose did not show any abnormal results except the neutrophilia and elevation of erythrocyte sedimentation rate (ESR) (hemoglobin: 14.5 g/dL, thrombocyte: 192,000/mm3, white blood cell: 6,9701/mm3 [neutrophil; 80%], ESR: 32 mm/h [reference value: 0-15], blood urea nitrogen: 11 mg/dL, creatinine: 0.63 mg/dL, total protein: 6.5 g/dL, albumin: 3.8 g/dL, calcium: 8.9 mg/dL [reference value: 8.0-10.0], phosphate: 2.9 mg/dL [reference value: 2.6-4.5], intactparathyroid hormone: 27.23 pg/mL [reference value: 13.0-54.0]). Simple radiography revealed calcified granuloma on the right upper lung, multiple punched-out lesions in the skull, healed fracture of the left febula, multiple rib fractures, kyphosis of the thoracic vertebrae and lesions of bone cement injections at 8th, 9th, and 12th thoracic vertebrae (). Computed tomography (CT) and MRI of the spine showed multiple compression fractures and spondylitis with left paraspinal and anterior subligamentous abscesses (). In the evaluation of the multiple myeloma, serum and urine protein electrophoresis were normal and bone marrow biopsy revealed only granuloma consistent with mycobacterial infection. Tumor markers (alpha-fetoprotein [AFP], prostate-specific antigen [PSA], cancer antigen [CA]125, CA19-9, carcinoembryonic antigen [CEA]) were normal. On the CT of chest and abdomen, there were small nodules and branching linear structure, suggesting pulmonary tuberculosis, on the both sides of upper lung, calcified granuloma on the right apex, and multiple osteolytic lesions with vertebral collapse. In bone biopsy, necrotic bone fragment and hemorrhage was seen and tuberculosis (TB)-polymerase chain reaction (PCR) was positive.\nThe patient was referred to the endocrinology because there was no evidence of multiple vertebral compression fractures cause by multiple myeloma and malignancy and he had a Cushingoid appearance. We found that he had past medical history included psoriasis managed by intramuscular self-injection of triamcinolone since 5 years ago; 6 cc of triamcinolone injected 5 times in the first year and then 3 cc of triamcinolone was injected twice per month for the following 4 years. Values of 30 and 60 minutes post-250 µg-injection adrenocorticotropic hormone were 0.94 µg/dL and 4.42 µg/dL, respectively, indicating adrenal insufficiency. A dual-energy X-ray absorptiometry (DXA) revealed osteoporosis (L2-L4 T-scores = -4.7, femur neck T-score = -3.8) (). In bone turnover maker, bone-specific alkaline phosphatase (ALP) was raised (36.00 µg/L, reference value: 6.00-30.00) and osteocalcin was decreased (8.79 ng/mL reference value: 13.0-28.0). 25(OH) vitamin D3 measured by enzyme-linked immunosorbent assay (ELISA) was 5.4 ng/mL, indicating vitamin D deficiency.\nThe patient was received non-steroid anti-inflammatory analgesic drugs (NSAIDs) in order to relieve pain and 7.5 mg of prednisolone orally to manage adrenal insufficiency. For the treatment of osteoporosis, vitamin D3 (1,000 IU daily), elementary calcium (500 mg daily) and risedronate (35 mg weakly) were given. Also, he was treated with antituberculosis medication. Unfortunately, six days after his discharge from the hospital, and on his way back home from the first out-patient visit, he had fallen down on his right side and had the proximal humerus fracture. Then, he received conservative treatment (). Two months after the medical treatment, osteocalcin decreased (5.27 ng/mL) and serum C-terminal telopeptide (CTx) was lower than the normal value (0.375, reference value < 0.7 ng/mL) and 25(OH) vitamin D3 increased 14.3 ng/mL.