Resident Physician Jefferson Health - New Jersey Stratford, New Jersey, United States
Case Diagnosis: Glucocorticoid-Induced Osteoporosis
Case Description: A 36-year-old male presented for evaluation of lower back pain with associated urinary incontinence, clonus, unsteady gait, and bilateral lower extremity weakness. When questioned, the patient admitted to chronic steroid abuse following a workplace accident three years prior. He utilized both telemedicine and an online pharmacy to obtain up to 50 mg of PO prednisone per day and multiple supplemental methylprednisolone dose packs.
An MRI of the thoracic spine revealed compression fractures of T6, T7, and T10 and hip X-rays revealed concurrent avascular necrosis of the bilateral femoral heads. Neurosurgery and orthopedic surgery were both consulted but offered no acute intervention on his admission. The patient was ultimately stabilized for discharge to acute rehab with a TLSO brace and an extended steroid taper.
Discussions: In individuals under 50-years-old, glucocorticoid-induced-osteoporosis (GIOP) is the most common iatrogenic cause of secondary osteoporosis.1 Pathological fractures in GIOP typically occur in the vertebral column, hip, or wrist, thereby leading to a variety of presentations which may be confounded by distracting injuries. The patient’s alarm symptoms also provided potential diagnostic distraction, as the resultant cauda equina syndrome was the patient’s principal problem, but not his only hospital problem on admission.
As the prevalence of prescription steroids expands over time, the prevention and management of any resulting GIOP is crucial throughout medical practice. Diligent risk assessments and monitoring of all patients prescribed extended steroid courses should be reiterated and include discussions of “online shopping” and/or telehealth utilization for excessive prescriptions.
Conclusions: GIOP and pathological fractures are critical components in the differential diagnosis of patients with longstanding steroid use and alarm symptoms.This case draws attention to both the possibility for steroid abuse through online pharmacies and unregulated telemedicine, as well as the need for a thorough evaluation and strategic treatment design in the setting of GIOP.
