A Man With Pain in His Muscles and Bones

Camilo Jimenez, MD, Sai-Ching Jim Yeung, MDSeries Editor: Ashok Balasubramanyam, MD


April 02, 2003

Case Presentation

A 79-year-old white man presented with a 1-year history of severe bone pain. The pain began in his feet and progressed to his ribs, spine, and extremities. The severity of the pain increased progressively, finally becoming constant and poorly controlled with nonsteroidal anti-inflammatory drugs and opioid analgesics. An associated symptom was progressive muscle weakness, first in his lower extremities and then in the upper extremities. Once very active, the patient was wheelchair bound and reported he was unable to get up from a sitting position. He had recently noticed painful deformities in the ribs, decreased height, weight loss, and anorexia.

Medical and surgical histories were unremarkable. The family history also was unremarkable, with no suggestion of a susceptibility to fractures or bone deformities. The patient did not take any medications. He had quit smoking in 1964, and did not consume alcohol. He had worked as a welder in an oil refinery for 25 years.

On physical examination, the patient's blood pressure was 175/73 mm Hg, pulse 76 per minute, and respiratory rate 14 per minute. His weight was 62 kg and height was 1.65 m. He had significant difficulty ambulating. The musculoskeletal evaluation revealed severe tenderness in the rib cage, spine, legs, and feet. He had deformities in the ribs and bowing of the left tibia. Severe cervical kyphosis and muscular wasting were present. The weakness was predominantly in the proximal muscles. Examination of the rest of the systems -- including the neurologic system -- was normal.

A roentgenographic survey of the skeleton showed stress fractures at the bases of the right first metacarpal and left second metacarpal bones, the proximal radial heads, and both tibias. Fractures were also seen in multiple ribs (Figure 1) and the left pubis (Figure 2). There were compression fractures of the upper thoracic and lumbar vertebral bodies, with severe osteopenia (Figure 3). Significant osteomalacia was observed, with extensive demineralization, cortical tunneling, and thinning.

Chest x-ray showing multiple rib fractures. (See arrow.)

Pelvis CT scan showing blastic changes surrounding a fracture of the left inferior pubic ramous. (See arrow.)

X-ray of thoracic spine showing compression of multiple thoracic vertebrae and osteopenia. (See arrow.)

The laboratory data obtained are presented in Table 1 .


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