Multiple ipsilateral femoral stress fractures in a patient taking denosumab for osteoporosis-a case report.

This is the first report describing three ipsilateral femoral stress fractures in a patient taking denosumab. INTRODUCTION: Multiple reports of atypical femur fractures (AFF) in patients receiving denosumab have emerged recently. Denosumab is an anti-resorptive agent approved for treatment of osteoporosis. It is a human monoclonal antibody which blocks osteoclast activation, maturation, and function. METHODS: This is a case report of a 74-year-old female patient who sustained three stress fractures of her left femur. RESULTS: The patient healed her fractures after intramedullary nailing of the femur and was able to return to her activities. CONCLUSIONS: High index of suspicion is needed in any patient with osteoporosis on denosumab complaining of thigh or groin pain. Careful examination and radiographic studies of both femurs are warranted if AFF is discovered.

Spontaneous infectious discitis in adults.

PURPOSE: In adults, discitis most frequently follows spinal surgery. We report 16 adult patients with spontaneously occurring infectious discitis and compare them with an additional 52 patients abstracted from the literature. Infecting organisms, predisposing factors, imaging modalities, and response to therapy are described. PATIENTS AND METHODS: The medical records of adult patients treated for infectious discitis of a community hospital during the past 10 years were reviewed. Postoperative spine patients and patients with primary osteomyelitis were excluded. Sixteen patients were identified with spontaneous primary infection of the disc space. The particulars of comorbid conditions, infection organisms, site of culture, and response to antibiotic therapy were noted and compared to 52 additional cases of spontaneous discitis reported in the literature since 1980. RESULTS: A wide variety of infecting organisms was identified as causing spontaneous discitis, in contrast to previous reports of both postoperative discitis and spontaneous discitis. Nine of 10 patients with positive disc cultures had negative blood cultures. Appropriate antibiotics were curative in all patients but 1, regardless of the duration of symptoms. Nuclear imaging, computed tomography, and magnetic resonance imaging were all useful, although the last appears to be the most sensitive and specific imaging modality for detecting discitis. CONCLUSIONS: Spontaneous infectious discitis is an uncommon cause of low back pain in adults. Nevertheless, it should be considered in any patient with acute or subacute pain. Elevated acute-phase reactants with appropriate imaging modality suggest the diagnosis. given the wide variety of infecting organisms identified, culture of blood and/or disc for the specific causative organism is critical to successful treatment outcome.

Henoch-Schönlein purpura: a diagnosis not to be forgotten.

Henoch-Schönlein purpura (HSP) is a systemic, generalized vasculitis of unknown etiology thought to be related to an IgA-mediated autoimmune phenomenon. Diagnosis is based on a constellation of physical findings that include the characteristic nonthrombocytopenic petechial or purpuric rash, migratory polyarthralgias, abdominal pain, and renal complications. We report the case of a 19-year-old man with a diagnosis of HSP who had severe abdominal pain and endoscopic documentation of duodenal involvement. Though not clear at presentation, the diagnosis became obvious when the characteristic rash emerged.

Antiphospholipid syndrome: the reality and implications.

A case is made for the existence of a primary antiphospholipid antibody syndrome. This clinical entity can be characterized as including an elevation in titers of antibodies to negatively charged phospholipids, hypercoagulation, thrombocytopenia, and recurrent fetal loss. With further elucidation, the systemic pathologic roles of antiphospholipid antibodies should emerge.

Postpartum hemolytic uremic syndrome associated with antiphospholipid antibodies. A case report and review of the literature.

Postpartum hemolytic uremic syndrome (HUS) is described in a woman with a history of spontaneous abortions and both circulating lupus anticoagulant and anticardiolipin antibody (ACA). After termination of her pregnancy because of severe preeclampsia, ACA blood levels increased simultaneously with the onset of a microangiopathic process associated with severe hypertension and renal failure. Plasma exchange resulted in a rapid decline in ACA levels and immediate improvement in her clinical condition. This case strongly suggests an important causal relationship between ACA and postpartum HUS. The possible mechanisms of ACA-related postpartum HUS and the potential role of plasmapheresis in its treatment are reviewed and discussed.