1. What is the most probable diagnosis of Mang Tacio’s condtion?

Osteomalacia means soft bones. Like osteoporosis, osteomalacia weakens the

bones and makes bones more likely to break. However, the process is different
from that in osteoporosis. In osteoporosis, bone is broken down faster than it is
re-formed. In osteomalacia, the two activities are balanced, but the bone that is
formed does not become dense and hard (mineralized). Among older people,
osteomalacia is much less common than osteoporosis.

Osteomalacia is usually caused by vitamin D deficiency or by a digestive tract or

kidney disorder. These disorders can interfere with the body's use of vitamin D.
Rarely, osteomalacia is caused by a low phosphate level.

Osteomalacia causes fatigue and pain in the back, ribs, and hips. Muscles in the
upper arms and thighs become weak. People with osteomalacia may have
trouble getting up from a chair or climbing steps. They may waddle when they
walk. Like osteoporosis, osteomalacia leads to bone fractures.

Doctors diagnose osteomalacia with blood tests, x-rays, and sometimes a biopsy.
Osteomalacia is treated with vitamin D or phosphate supplements depending on
the cause.

2. Based on the data provided by the case, give a basis for such
diagnosis.

- Clinical Manifestations:
- pts generally complain of easy fatigability, malaise, and bone pain;
- pain is diffuse and poorly localized and is accompanied by a general
tenderness of bones;
- frx in an elderly individual that is thought to be the result of osteoporosis may
be first sign of osteomalacia, & these patients must be evaluated carefully;
- all symptomatic elderly patients should be screened for occult disease;
- bizarre complaints may give impression that patient has mental aberration;
- muscular weakness is often seen in severe cases;
- proximal muscle weakness may be evident & pt may haveT-burg gait;

Radiographs:
- Looser's zones:
- osteoid seams are insufficiency types of stress frx which are commonly
seen in patients with osteomalacia;
- they are more common in adults than in children;
- patients may have findings of osteomalacia / renal osteodystrophy such as
decreased mineralization, coarsened texture of the bones, "rugger-jersey"
appearance of spine, and, occasionally, bowed long bones;
- most of these patients have chronic renal disease;
 Laboratory Aspects: Osteomalacia:
- hypocalcemia:
- hypophosphatemia:
- phosphorus level is low or very low depending on type of
osteomalacia, except in renal osteodystrophy;
- renal osteodystrophy;
- phosphorus level is invariably high & calcium level will be quite
low;
- alk phos:
- usually elevated in all forms of osteomalacia (except
hypophosphatasia);

Bone mineralisation requires adequate minerals (calcium, phosphorus and

vitamin D). Inadequate amounts of any one of these will develop into
osteomalacia. Here is a list of the known causes of osteomalacia.

• Lack of vitamin D in diet – info on sources of vitamin d

• Lack of exposure to sunlight, which naturally generates vitamin D in the
body
• Vitamin D absorption problems

Other possible risk factors of osteomalacia

• Hereditary vitamin D metabolism disorders

• Kidney failure
• Mineral deficiency
• Cancer
• Liver disease

Osteomalacia can cause bone pain and muscle weakness, but because the
symptoms are so numerous it is common to be misdiagnosed and confused with
other conditions. Pain is most often felt in the legs, groin, upper thighs, knees
and sometimes in the feet. In some cases pain will be the result of partial
fractures, which are only visible on x-rays. Muscle weakness tends to affect the
thighs and the muscles in the shoulders and main core of the body.

Osteomalacia can be diagnosed by x-ray and with a blood test that will measure
levels of calcium, phosphorus and vitamin D. A blood test can also be measured
for Alkaline phosphatase and parathyroid hormone levels.

Deficiency signs and symptoms

• Vitamins D deficiency is relatively common in the U.S. Studies have

demonstrated that nearly 60% of people over 70 years are vitamin D
 deficient. Furthermore, the average daily intake of vitamin D in the United
States is only 30% of the RDA.
1. Symptoms of vitamin D deficiency include Rickets in children and
osteomalacia in adults resulting from poor ossification of bone
tissue, resulting in weak bones that bend readily.
2. Symptoms in adults include painful softening and bending of bones,
low serum calcium concentrations and tetany. Less severe vitamin
D deficiency can result in hyperparathyroidism and increased bone
turnover leading to bone loss and osteoporosis.
3. A vitamin D deficiency can result from inadequate intake, limited
exposure to sunlight, kidney and/or liver dysfunctions which inhibit
conversion of vitamin D to its metabolically active forms, or fat-
malabsorption syndromes

3. Did the history of gastrointestinal surgery 20 years ago contribute to

the development of Mang Tacio’s condition?

Usually, the cause of osteomalacia is a deficiency in vitamin D. Vitamin D

insufficiency can cause osteomalacia because vitamin D facilitates the
absorption of calcium and other minerals in your gastrointestinal tract necessary
for bone building. Without vitamin D, calcium and other minerals aren't absorbed
as readily, so they're not available for mineralization in the bone-building process.
This results in "soft" bones — called osteomalacia.

Causes of vitamin D deficiency include:

• Insufficient exposure to sunlight. Sunlight produces vitamin D in your

skin. Osteomalacia can develop in people who spend little time in sunlight,
wear very strong sunscreen, remain covered while outside, or live in areas
where sunlight hours are short or the air is smoggy.
• Insufficient vitamin D intake. A diet low in vitamin D is the most common
cause of osteomalacia worldwide. However, it's a less common cause in
the United States because many foods, such as milk and cereals, are
fortified with vitamin D.
• Certain surgeries. Removing part or all of your stomach (gastrectomy)
can cause osteomalacia because your stomach breaks down foods to
release vitamin D and other minerals, which are absorbed in your
intestines. Surgery to remove or bypass your small intestine also can lead
to osteomalacia.
• Celiac sprue. In this autoimmune disorder, the lining of your small
intestine is damaged by consuming foods containing gluten, a protein
found in wheat, barley and rye. A damaged intestinal lining doesn't absorb
nutrients, such as vitamin D, as well as a healthy one does.
• Chronic pancreatitis. This refers to long-standing inflammation of your
pancreas, an organ that produces digestive enzymes and hormones. If
 your pancreas is inflamed, enzymes responsible for breaking down food
and releasing nutrients don't flow as freely into your intestines.

Osteomalacia can also be caused by disorders that interfere with vitamin D

metabolism. These disorders include kidney failure and primary biliary cirrhosis,
which occurs when your liver's bile-carrying ducts are damaged.

Like calcium, phosphorus is a mineral needed for proper matrix mineralization.

Some conditions that can cause low blood levels of phosphorus
(hypophosphatemia) include:

4. How is Vitamin D metabolized in the body?

• Vitamin D consists of a group of similar molecules called vitamers, which

are involved in calcium homeostasis and in bone metabolism.
• The human body makes vitamin D by the effects of ultraviolet light on the
skin’s cholecalciferol also known as D3. Plants make a slightly different
version of vitamin D called D2; however this form of vitamin D can also be
used by humans.
• Since vitamin D works on specific target tissues, and does not have to be
supplied by the diet, it is by definition a hormone, and not truly a vitamin.
Vitamin D hormone usually functions as a steroid.
• Vitamin D is best absorbed when ingested with lipids. Vitamin D will be
incorporated into micelles and these will be absorbed by the intestine by
passive diffusion. In the intestinal cells, chylomicrons will be formed, and
these will enter the lymphatic system and enter the plasma. Vitamin D will
then be transported to the liver by chylomicron remnants and to specific
target with the help of carrier vitamin D binding protein (DBP) or
transcalciferin.
• D3 will change into its biologically active forms: 25-(OH) D3 and 1, 25-
(OH) 2D3 also known as calcitriol. In the liver vitamin D will undergo
sequential hydrolxylations which will result in 25-hydroxycholecalciferol. In
the kidney, vitamin D will be acted upon by alpha 1 hydroxylase and this
will yield 1, 25 dihydroxyvitamin D3 (or calcitriol).
• Calcitriol is the predominant form of vitamin D found in the circulation. And
the production of calcitriol is regulated by enzymes which lead to a
feedback inhibition mechanism. Efficacy of absorption for vitamin D is 50%
from the diet.

Functions:

• Vitamin D plays an important role in calcium and phosphorus homeostasis

by regulating bone resorption, affecting absorption of calcium in the gut,
and by regulating calcium losses in urine.
1. In the kidney vitamin D works with estrogen to regulate renal
tubular reabsorption of calcium and phosphorus.In bones, vitamin D
 works in conjunction with PTH to regulate the release of calcium
and phosphorus from the bones into the bloodstream.
2. Vitamin D also plays a genetic role by regulating the gene coding
for calcium binding protein known as Calbindin.
• Vitamin D’s genetic role has been confirmed in over 50 genes extending
beyond balancing mineral metabolism. New findings have confirmed direct
effects by vitamin D on various nuclear receptors of different cells such as
those of the prostate, liver, thyroid, and brain.
1. Cells of the prostate gland respond to vitamin D levels. These
findings have lead to new potential chemotherapeutic treatments
targeting specific lesions on cancer cells using doses of 1alpha25
(OH) 2D3.
2. Another group of cells directly affected by vitamin D levels appear
to be the T helper cells of the immune system.
3. Polymorphisms in vitamin D receptors in brain cells, (due to low
levels of vitamin D early in life), also appear to be linked to
schizophrenia. This new information has also lead to further
research by the scientific community.

5. What treatment strategies will work best for Mang Tacio?

When osteomalacia arises from a dietary or sunlight deficiency, replenishing low

levels of vitamin D in your body usually cures the condition. Several types of
vitamin D supplements are available, so your doctor will probably recommend a
supplement depending on the dose you need and whether you have any other
health problems. Generally, people with osteomalacia take vitamin D
supplements by mouth for a period of several weeks to several months. Less
commonly, vitamin D is given as an injection or through a vein in your arm.

If your blood levels of calcium or phosphorus are low, you may take supplements
of those minerals as well. In addition, treating any condition affecting vitamin D
metabolism, such as kidney failure or primary biliary cirrhosis, often helps
improve the signs and symptoms of osteomalacia.

After beginning osteomalacia treatment, you may undergo periodic blood tests to
make sure that blood levels of vitamin D and certain minerals are within normal
limits and have X-rays to determine whether your bones are improving. You'll
likely notice that your symptoms lessen within a few weeks. However, your doctor
may suggest that you continue taking vitamin D indefinitely to prevent
osteomalacia from recurring.

Prevention

Osteomalacia caused by inadequate sun exposure or a diet low in vitamin D

often can be prevented. Here are a few suggestions to help reduce your risk of
developing osteomalacia:
 • Spend a few minutes in the sun. Direct sun exposure to your arms and
legs for five to 10 minutes daily is sufficient for proper vitamin D
production. If you live in a cold climate and don't get much sun exposure
during the winter, you can build up vitamin D stores in your skin during the
warmer months.

Using sunscreen regularly helps prevent skin cancer and premature skin
aging, but there's some concern that the frequent application of strong
sunscreen increases your risk of developing osteomalacia. Using
sunscreen won't increase your risk if you follow the American Academy of
Dermatology's guidelines for sunscreen use. If you're going to be in the
sun for more than 20 minutes, the Academy recommends that you
generously apply sunscreen with a sun protection factor (SPF) of at least
15 to all exposed skin surfaces and reapply every two hours or after
swimming or heavy sweating.

• Eat foods high in vitamin D. These include foods that are naturally rich
in vitamin D, including oily fish (salmon, mackerel, sardines) and egg
yolks. If you're a vegetarian, look for foods that are fortified with vitamin D,
such as cereal, bread, milk and yogurt.
• Take supplements, if needed. If you don't get enough vitamins and
minerals in your diet or if you have a medical condition affecting the ability
of your digestive system to absorb nutrients properly, ask your doctor
about taking vitamin D and calcium supplements.

Weight-bearing exercise, such as walking, helps strengthen bones, but if you

have slight fractures in your bones due to osteomalacia, avoid strenuous
exercise until your bones heal.

• Dietary Sources :
The only frequently consumed dietary source of vitamin D is milk fortified
with D2, as well as dried whole milk. Cereals, infant formulas, including
soy, are usually also fortified with vitamin D. Cod liver oil and fatty fish oils
are also excellent sources of vitamin D.