A 47-year-old woman, without toxic habits, known drug allergies, or relevant medical diseases.
He came to the hospital in January 2010 for presenting pain in the right ankle of one year of evolution, which increased with the load and was accompanied by phlogistic signs.
Bone scintigraphy and MRI showed intense bone edema with severe loss of mineral density, suggestive of osteonecrosis of the talus with associated joint effusion.
Treatment with intravenous pamidronate was started, but the patient presented high fever after the infusion, so its administration was suspended.
Tramadol, diclofenac and rehabilitation treatment were prescribed, without evident pain improvement.
In September 2010, she reported severe pain in the right inguinal region, which increased with walking.
MRI of both hips revealed avascular necrosis of the right femoral head, stage I-II of the FICAT classification.
Treatment was initiated with oral gabapentin (600 mg/8 hours) and was referred to the bone metabolism unit.
The presence of blue sclera stood out in the physical examination in our consultation.
Reinterrupted the patient, she pointed out that her mother had suffered multiple fractures since she was 49 years old, which kept her immobilized.
One brother and two maternal aunts had also suffered early hip fractures.
Densitometry showed severe osteoporosis in the three usual locations (lumbar spine: T-score=-3, Z-score=-1.8, femoral neck: T-score=-3.1, Z-score=-2.0 and T-score=-2.3).
Calciuria was 336 mg/dl, 25(OH) vitamin D levels were 11 ng/ml and intact PTH was 49 pg/ml.
Bone markers were markedly elevated (CTX: 1.036 ng/ml).
Given the clinical findings and family history, the diagnosis of osteogenesis type I was established. Audiometry showed a minimal drop in the acute tones.
Treatment was initiated with calcium (1,000 mg/day), vitamin D (800 IU/day) and risedronate (35 mg/week), in January 2011.
In March that year, risedronate was changed to subcutaneous teriparatide (20 mcg/day) due to digestive intolerance.
In May 2011, a control MRI showed a marked decrease in bone edema and ankle joint effusion as well as spinal cord edema in the right hip.
The patient completed 24 months of teriparatide without complications and progressive clinical improvement.
The markers of formation remained elevated during treatment (aminoterminal propeptide of procol 2013; stage 1 (INP-: 45 ng/ml); clinical procol: >100 ng/ml; radiological treatment with EnOH) was satisfactory.
In the last visit, in January 2015 the patients serum creatinine levels were suppressed (PINP: 5.8 ng/ml; telopeptidase levels are suppressed ng/ml vitamin type 1 -CTX-(OH): 31 D < 30.
Control bone mineral density (BMD) was not significantly reduced compared to baseline (lumbar spine: T-score=-3.1 and Z-score=-1.5; femoral neck: T-score=-3.2) had no fracture.
