A 67-year-old woman comes to the emergency department due to sudden-onset, severe low back pain that began when she was lifting her grandson. The pain does not radiate to the lower extremities; she has had no weakness or sensory loss in her legs or urinary incontinence. The patient has had back pain in the past but not of this severity. She has a history of hypertension, hyperlipidemia, and hypothyroidism, for which she takes lisinopril, atorvastatin, and levothyroxine. The patient was also found to have low bone mineral density during a screening test 2 years ago. She has been feeling more tired lately and has not been able to exercise as recommended but does take daily calcium and vitamin D supplements and weekly alendronate as prescribed. She also has not consumed dairy products regularly as in the past due to her poor appetite; she has lost about 4.5 kg (10 lb) over the past several months. The patient is a lifelong nonsmoker and drinks alcohol occasionally. Blood pressure is 148/86 mm Hg and pulse is 96/min. BMI is 21 kg/m². Physical examination shows tenderness to percussion over the lower thoracic spine. Bilateral lower extremity muscle strength, sensation, and deep tendon reflexes are normal. Laboratory results are as follows: Spine radiography shows a T12 vertebral compression fracture. In addition to analgesics, which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_bf64_fe49_8f63_cf11b0d06295_MD0005_00 This patient has an acute fragility fracture despite appropriate treatment for osteoporosis that includes a bisphosphonate (alendronate) and calcium and vitamin D supplementation. When a patient does not respond to treatment as expected or has rapidly progressive osteoporosis, secondary causes should be sought. This patient also has clinical findings that raise suspicion for multiple myeloma, including weight loss, anemia, hypercalcemia, and an increased serum protein concentration (with a low-normal albumin concentration). In addition to the classic punched-out skeletal lesions, multiple myeloma can present as rapidly-progressive generalized bone loss (due to increased levels of osteoclast-activating factor secreted by the neoplastic cells) resembling primary osteoporosis and leading to fragility fractures. In light of this, serum and urine protein electrophoresis are warranted to screen for multiple myeloma. (Choice A) Teriparatide is a recombinant peptide identical to the N-terminal portion of parathyroid hormone. It is used as a second-line agent in patients who have failed bisphosphonate therapy. However, it can raise serum calcium concentrations and would be contraindicated in this patient with hypercalcemia. (Choice B) Switching from an oral to an intravenous bisphosphonate preparation (eg, ibandronate) would be appropriate if failure is due to impaired medication absorption. This could be considered if no secondary cause of osteoporosis is found. (Choice C) Imaging for localization of a parathyroid adenoma is performed only after the biochemical diagnosis of primary hyperparathyroidism is confirmed. This patient's parathyroid hormone assay is not complete, and her other clinical findings (as noted above) suggest multiple myeloma. (Choice E) Celiac disease causes malabsorption, which can lead to vitamin D and calcium deficiency as well as impaired response to bisphosphonate therapy. However, these patients would have low or low-normal serum calcium rather than hypercalcemia, as in this patient. Educational objective: When a patient does not respond to therapy for osteoporosis or has rapidly progressive osteoporosis, secondary causes should be sought. Skeletal manifestations of multiple myeloma can include rapidly progressive generalized bone loss and punched-out lytic lesions. References: Coexistent osteoporosis and multiple myeloma: when to investigate further in osteoporosis. (http://www.ncbi.nlm.nih.gov/pubmed/26452412) Secondary osteoporosis and metabolic bone disease in patients 50 years and older with osteoporosis or with a recent clinical fracture: a clinical perspective. (http://www.ncbi.nlm.nih.gov/pubmed/24841229)

A 67-Year-Old Woman Comes to the Emergency Department Due to Sudden-Onset