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Osteomalacia and Osteoporosis: Evaluation of a Diagnostic Index

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Osteomalacia and Osteoporosis: Evaluation of a Diagnostic Index J Clin Pathol: first published as 10.1136/jcp.36.3.245 on 1 March 1983. Downloaded from J Clin Pathol 1983;36:245-252 Osteomalacia and osteoporosis: evaluation of a diagnostic index MJ McKENNA,* R FREANEY, OM CASEY, RP TOWERS, FP MULDOWNEY From the Department ofMetabolism and Renal Disease and Department ofPathology, St Vincent's Hospital, Dublin 4, and, Department ofMedicine, University College Dublin SUMMARY Data from a retrospective study in 41 patients is used to suggest an index of bone disease. This is designed as a means of collating available results, clarifying the significance of each in diagnosing either osteomalacia or osteoporosis, and reducing the significance of a single abnormal finding-for example, a raised alkaline phosphatase activity or low serum 25 hydroxy vitamin D, when the overall index score is low. Index scores above 35% would be diagnostic of osteomalacia; scores below 15% if associated with collapsed vertebrae suggest osteoporosis. Scores between 15% and 35% would indicate the need for a bone biopsy to discriminate between osteoporosis and osteomalacia. Osteoporosis and osteomalacia are common forms of alternative non-invasive procedures could be shown metabolic bone disease. They share certain features to yield results upon which diagnosis could be firmly in common-namely, bone pain, decreased bone made. In this communication we hope to demon- copyright. radio-density, and bone fractures. I Differential diag- strate the capacity of the index to separate those with nosis is often difficult without recourse to bone biopsy. Histological demonstration of excess osteoid with a mineralisation defect is diagnostic of osteo- Table 1 Osteomalacialosteoporosis discriminant index malacia.2 The finding of normal bone composition Parameter Score Patient Risk (and decreased bone volume, where measured). score ratio contributes to a of which is a http://jcp.bmj.com/ diagnosis osteoporosis, Clinicalfeatures diagnosis made by the exclusion of other forms of Limbpain 1 2-1 metabolic bone disease.' Proximal myopathy 1 1-8 Chemistry Morgan4 suggested that osteomalacia could be Calcium-phosphate product diagnosed on the basis of biochemical and 1-62-2-4f (mmol/l) 1 1-21-1-61 2 3 5 radiological abnormalities and clinical features and <1.21 3 felt that bone biopsy was rarely necessary. In a Alkaline phosphatase retrospective study of 41 subjects we are examining (score only if LFTs normal) on September 30, 2021 by guest. Protected 75-100 lU/1 1 this question, and for that reason we have designed 101-201 2 4.8 and applied an index of metabolic bone disease 201-300 3 >300 4 (Table 1) as a means of collating and evaluating data 25 (OH) vitamin D from investigative procedures in such patients. The 5-12-5 nmol/ 1 <5 2 3*0 diagnostic procedures are each assigned a numerical Radiology value or score and the resultant score sheet is the Pseudofractures 1 1-5 index and is to indices used in the analagous diagnosis Total score of thyroid disorders5 or in the assessment of disease status in cystic fibrosis.6 % index score = total score obtained x ioo. The reduction of the need for an invasive test such .total possible score *Possible score = maximum value for tests scored. as a bone biopsy is desirable and would be possible if Interpretation ofindex score >35% = osteomalacia 15-35% = bone biopsy indicated *Research Fellow to Our Lady's Manor, Dalkey, Dublin. no osteomalacia <15% = osteoporosis if colUapsed vertebrae Accepted for publication 30 September 1982 Ipresent 245 J Clin Pathol: first published as 10.1136/jcp.36.3.245 on 1 March 1983. Downloaded from 246 McKenna, Freaney, Casey, Towers, Muldowney osteomalacia from those with osteoporosis, to Material and methods demonstrate when a biopsy is indicated, and in addition to evaluate the eapacity of any single PATIENTS STUDIED parameter to forecast the final diagnosis. Such an The data were obtained from 41 subjects previously approach would be particularly helpful in the assess- diagnosed as having metabolic bone disease. All ment of elderly subjects since osteoporosis and subjects studied had normal renal function, and none osteomalacia are common disorders in the elderly, had radiological evidence of Paget's disease. They and invasive procedures are undesirable. were divided into two groups. Tables 2 and 3 show The osteoid volume measured in the bone biopsy clinical, biochemical, histological features, and samples is the parameter against which the index is diagnoses. No patient had primary hyperpara- assessed. However once a bone biopsy has been thyroidism or hyperthyroidism. performed (as in this retrospective study) additional Group I consisted of 26 subjects (20 women, 6 men: or alternative information such as the number of mean age 52 yr, range 17 to 74 yr) with osteomalacia lamellae, the bone ash content, and the pathologist's diagnosed on the basis ofosteoid volume greater than subjective evaluation may also be obtained. In this 2-4% on quantitative bone histology, as defined communication the relative diagnostic importance of in methods section (normal range ±2 SD = 0-2-4%). these investigations compared to the osteoid volume Group 2 consisted of 15 subjects (11 women, 4 men: is noted. mean age 57 yr, range 29 to 69 yr) with osteoporosis Table 2 Biochemical and histologicalfindings in osteomalacia (group 1) and osteoporosis (group 2) Subjects Osteoid Serum Alkaline 25 (OH) vit D Ash content Maximum Pathologist's volume (%) calcium-phosphate phosphatase (nmolll) (%) number of report of product (mmolll) (JUI!) lamellae biopsy Group I MB 7-6 1-76 474 38 63 5 Mild copyright. MC 35.5 2-27 149 <5 31 7 Severe JC 25-7 1-86 190 <5 - 8 Severe JC 41-6 1-05 428 <5 - 10 Severe MC 7-3 1-76 43 <5 55 6 Mild BD 2-8 2-37 119 <5 55 3 Mild ED 23-1 1-81 167 <5 - 8 Severe AD 22-9 2-03 434 9 44 9 Severe MD 3.1 3-16 - <5 26 3 Mild RF 20-4 1-78 156 <5 47 9 Severe BH 4.7 0-86 236 <5 45 4 Moderate http://jcp.bmj.com/ AH 19-4 1-20 190 6 30 7 Moderate Mi 3-8 1-36 - <5 47 4 Mild EK 30-3 3-25 86 9 54 10 Severe JMcC 11-5 2-54 59 19 57 8 Moderate MMcG 27-2 1-54 340 <5 46 10 Severe IM 48-4 1-07 - 7 40 16 Severe JM 4-8 2-42 142 - 43 5 Mild AN 21-6 1-82 422 - 32 6 Severe MN 19-2 1-16 215 <5 50 9 Severe MP 21-4 1-25 158 <5 42 9 Severe ER 6-1 1-56 110 - 47 3 Mild on September 30, 2021 by guest. Protected HS 27-4 1-48 255 <5 47 9 Severe ES 3-3 2-38 142 - 54 6 Mild KS 13-5 1-15 283 - 50 6 Moderate BW 8-9 2-28 103 - 50 6 Mloderate Group 2 MB 1-4 2-48 65 34 57 3 Normal EC 1-2 2-51 51 22 54 4 Mild NC 1-9 2-83 46 23 46 2 Normal PC 0-7 3-21 45 - 46 4 Normal MD 1-2 2-71 35 50 43 3 Normal JF 0-3 1-92 76 45 47 0 Normal EH 2-1 2-64 57 19 62 4 Normal MK 0-1 2-71 163 - 60 1 Mild CK 1-5 2-03 79 - 28 3 Normal JL 0-4 3-08 57 97 53 2 Normal EMcG 0-7 3-64 48 62 59 3 Mild EM 0-7 2-94 96 28 - 2 Normal CM 1-5 2.92 46 34 46 3 Normal TN 1-4 1-77 60 34 44 4 Mild EO'T 0-4 2-63 123 30 50 3 Normal J Clin Pathol: first published as 10.1136/jcp.36.3.245 on 1 March 1983. Downloaded from Osteomalacia and osteoporosis: evaluation of a diagnostic index 247 diagnosed on the basis of radiological changes (ie presence of liver disease, as in those cases the collapsed vertebrae) with normal bone histology. maximum number of points would be reduced also. In this retrospective study the tests were weighted in INDEX an effort to produce a system, that would give the The proposed index (Table 1) includes clinical best separation between patients with osteomalacia features, serum chemistry (calcium-phosphate pro- and osteoporosis. The weighting was supported by duct, alkaline phosphatase, and serum 25 (OH) the risk ratios (for detecting osteomalacia-Table 1). vitamin D), and radiological findings. The osteoid A risk ratio greater than one indicates that the volume measured in the bone biopsy samples is not probability of having disease is increased if a test scored in the index, as this is the parameter used in result is positive. The assigned scores for all the the classification of patients as osteomalacic and parameters parallel the risk ratios for detecting osteoporotic. Table 1 lists the scores awarded on the osteomalacia. basis of the results obtained. The total number of points for the maximum number of abnormalities is LABORATORY METHODS 12. The points are expressed as a percentage of the Serum calcium, inorganic phosphorus, alkaline phos- total. This compensates in cases where investigations phatase and 25 (OH) vitamin D were measured as were not carried out or where results were ex- previously described.7 Serum calcium correction for cluded-that is, raised alkaline phosphatase in the albumin was not routinely performed, using any of Table 3 Clinical and radiologicalfindings, index score and diagnosis in osteomalacia (group 1) and osteoporosis (group 2) Subjects Bonepain Proximal myopathy Pseudofractures Index score (%) Predisposing condition Group 1 MB Limb No No 50 Idiopathic Fanconi syndrome MC Both Yes No 58 Renal tubular acidosis copyright.
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