Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 55-year-old man is reevaluated during a follow-up examination for a wrist fracture and anemia. The patient is otherwise asymptomatic. He was treated in the emergency department 2 weeks ago after he slipped in his driveway and sustained a right wrist fracture; mild iron deficiency anemia was detected at that time. He had normal results of a routine screening colonoscopy 5 years ago. Since his emergency department evaluation, 3 stool samples have been negative for occult blood. He takes no medication.

On physical examination, vital signs are normal; BMI is 19. Other than a cast on his right wrist, all other findings are normal.

Hemoglobin level is 11.9 g/dL (119 g/L), and 25-hydroxyvitamin D level is 17 ng/mL (42 nmol/L). Results of a comprehensive metabolic profile and urinalysis are normal.

A dual-energy x-ray absorptiometry (DEXA) scan shows T-scores of −1.6 in the lumbar spine, −2.2 in the femoral neck, and −1.9 in the total hip.

Which of the following is the most appropriate next step in management?

A: Begin alendronate
B: Begin teriparatide
C: Repeat DEXA scan in 1 year
D: Screen for celiac disease

MKSAP Answer and Critique

The correct answer is D: Screen for celiac disease.

The most appropriate next step in management is to screen this 55-year-old man for celiac disease as part of the evaluation for secondary causes of his low bone mass and fracture. This patient has a history of fragility fracture (fracture sustained in a fall from a standing height), and his bone density results show osteopenia. In an otherwise healthy 55-year-old man, these findings raise concern for a secondary cause of his low bone mass and fragility fracture. Half of the men with osteoporosis will have an identifiable cause. Therefore, screening guided by history and physical examination findings may include testing for hypogonadism, vitamin D deficiency, primary hyperparathyroidism, calcium malabsorption, and multiple myeloma. Measurement of 24-hour urine calcium excretion while the patient consumes 1000 mg/d of calcium also may be useful. Low values for urine calcium may indicate calcium malabsorption, which can be seen in celiac disease. In light of this patient’s low BMI, fragility fracture, and history of iron deficiency anemia, celiac disease is a concern, even if gastrointestinal symptoms are absent.

Initiation of alendronate or teriparatide can be considered after the evaluation for secondary causes is completed. These agents will be more effective once the secondary cause of low bone mass has been corrected.

Repeating the bone density test in 1 year without any intervention now would allow time for additional bone loss to occur and thus would not be the best management.

Key Point

• Low urine calcium excretion in a patient with a fragility fracture may indicate calcium malabsorption.

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