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An Old Lady with an Unstable Knee

Mrs E.B. Presenting complaint:74 year old ladyReferred to Rheumatology clinic with an unstable kneeFirst seen November 2004. Mrs E.B. History of presenting illness:Had a fall 4 months prior - slipped overFell onto right kneePain at time of injury, but settled without specific treatmentKnee feeling unstable and had given way on 2 occasions causing further fallsAs a result, had not left the house for over 3 months.

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An Old Lady with an Unstable Knee

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    1. An Old Lady with an Unstable Knee� Grand Rounds April 21 2005 Dr Jane Clayton Rheumatology Fellow Royal Newcastle Hospital

    2. Mrs E.B Presenting complaint: 74 year old lady Referred to Rheumatology clinic with an unstable knee First seen November 2004

    3. Mrs E.B History of presenting illness: Had a fall 4 months prior - slipped over Fell onto right knee Pain at time of injury, but settled without specific treatment Knee feeling unstable and had given way on 2 occasions causing further falls As a result, had not left the house for over 3 months

    4. Mrs E.B Past Medical History: Orbital BCC removed 10 years previously No cardiovascular, respiratory, gastrointestinal, endocrine or neurological complaints Usually very well

    5. Mrs E.B Social History: Lives with husband in house in Valentine 5 adult children Lifelong non smoker Drinks 10-20g alcohol per week Active in the community - sings in concerts for nursing home residents Mobilising with stick since fall

    6. Mrs E.B Medications: Aspirin 150mg / day Garlic tablet daily Omega 3 fatty acid tablet daily Vitamin B and E daily Glucosamine daily (since fall) No known allergies

    7. Mrs E.B Examination: Pale BMI 22 Cardiovascular and respiratory examination unremarkable Palpable liver edge, otherwise gastrointestinal examination normal

    8. Mrs E.B Examination: Right knee Obvious deformity of patella Active ROM - 30 degree loss of extension Passive ROM - normal No pain or effusion

    9. X ray R knee Report Bones demineralised Patella - superior migration Inferior pole - avulsed Minor degenerative disease

    10. Mrs E.B Progress: Referred to Orthopaedic surgeon Physiotherapy arranged for appropriate mobility aid and falls prevention Occupational therapy review for home modifications Risedronate 35mg / week prescribed BMD and blood tests arranged

    11. DEXA Scan

    12. DEXA Scan

    13. DEXA Scan

    14. Mrs E.B - pathology EUC Na 144 K 4.1 Cl 108 bicarb 26 urea 3.3 Creat 49 LFT ALT 42 AST 41, otherwise LFT normal CMP Corr Ca 2.14 (2.18 - 2.49) PO4 1.17 (0.88 - 1.46) FBC Hb 96, MCV 71.8, MCH 22.1 WCC 6.1 Plt 283

    15. Mrs E.B - pathology Fe studies Ferrit 4.7 (30-260) Iron 2 (10-27) TIBC 80 (48-68) T/ferrin sat 3 (15-50)

    16. Mrs E.B - pathology Urine Calcium mmol/L 1.31 Creat 5.3 Ca:Creat 0.25 (<0.4)

    17. Mrs E.B - pathology Hormones PTH pg/ml 191 (8-73) PTH pmol/ml 20 (0.8-8)

    18. Mrs E.B - pathology Hormones 25-OH vit D 6 (33-107)

    19. Mrs E.B Further Blood tests EPG - normal

    20. Mrs E.B

    21. Mrs E.B Transglutaminase IgA 29 (<20) Gliadin IgA 127 (<34) Gliadin IgG 95 (<42)

    22. Mrs E.B Further progress: Underwent surgery to R knee 25/1/05 Open reduction internal fixation Patellar fragments debrided and sutured together No post op complications Discharged in Zimmer splint

    23. Mrs E.B Further progress - surgery to knee

    24. Mrs E.B Further progress: Home modifications completed Awaiting endoscopy, small bowel biopsy Commenced on Caltrate 600mg /day, Vit D 50 000 units / week, FGF daily PTH 4 months later 49, Vit D increased to 26 and calcium 2.34

    25. Coeliac Disease First described in 1888 by Samuel Gee �On the Coeliac Affection�, although similar descriptions date back to 2 AD Occurs primarily in caucasians of North European ancestry Prevalence previously documented at between 1:4000 - 1:8000, but now felt to approach 1% of the population with serological testing

    26. Coeliac Disease Triggered by gliadin - protein component of gluten Found in wheat, barley and rye (?oats) Characterised by an inflammatory response in the small intestine Histologically, villous atrophy, crypt hyperplasia and a lymphocytic infiltration Severity of the coeliac intestinal lesion does not necessarily correlate with clinical symptoms

    27. Coeliac Disease 75% concordance in monozygotic twins HLA DQ2 present in 95% of coeliac pts, HLA DQ8 in the remainder DQ2 and DQ8 molecules confer susceptibilty by presenting specific gluten peptides to intestinal T cells Associated with autoantibodies against gliadin and endomysial tissue - in 1997 tissue transgluaminase enzyme (TTG) found to be the autoantigen for endomysial antibody

    28. Coeliac disease

    29. Coeliac disease

    30. Coeliac disease

    31. Coeliac disease

    32. Coeliac Disease Diagnosis: �Coeliac disease is present if histologic changes are found on intestinal biopsy whilst the patient consumes a diet containing gluten and unequivocal improvement occurs while he or she consumes a gluten free diet�. Alaedini and Green (2005)

    33. Coeliac Disease Clinical presentation varies greatly, asymptomatic to severe malnutrition Common presentation Abdominal pain Increased frequency of bowel motions Weight loss Anaemia Weakness

    34. Coeliac Disease Atypical - GI symptoms absent or mild Short stature Infertility Neurological - ataxia, depression, anxiety, epilepsy, headaches Arthritis - 26% in one series of 200 coeliac patients Metabolic bone disease - common and can occur with no GI symptoms

    35. Why does coeliac disease cause osteoporosis? Malabsorption of calcium and vitamin D from GI tract leads to secondary hyperparathyroidism Excess parathyroid hormone associated with bone loss Evidence to suggest that appendicular skeletal bone loss may be greater than axial skeleton

    36. Why does coeliac disease cause osteoporosis? Selby et al (1999), J Bone Min Res 35 biopsy proven coeliac patients on GFD Mean age 50.6 None were vitD deficient - 9 pts supplemented mean level 52.7 nmol/L Mean corrected calcium was 2.21 Evidence of secondary hyperparathyroidism in 28% patients

    37. Why does coeliac disease cause osteoporosis? Selby et al (1999), J Bone Mineral Res Significant negative relationship between forearm BMD and serum PTH (r=-0.48, p=0.009) Negative relationship between BMD at forearm and Vit D concentration - weak negative relationship in lumbar spine Forearm Z score -1.40 (p<0.0001) Postulated that increased endogenous faecal calcium loss is major stimulus to 2o PTH

    38. Do coeliac patients have an increased fracture risk? West et al (2003), Gut Case control study 4732 patients with coeliac disease and 23,620 age matched controls Calculated hazard ratios for any fracture, radius or ulna fracture or hip fracture

    39. Do coeliac patients have an increased fracture risk? West et al (2003), Gut Mean age at diagnosis was 44 years Rate of any fracture 137.9/10,000 in coeliac population, 105.9/10,000 in control Therefore, 30% increase in fractures Hazard ratio for hip 1.90 Hazard ratio for radius or ulna 1.77 Overall risk 3.19 fractures per 100 person years

    40. Does a gluten free diet increase BMD? Kemppainen et al (1999), Bone 26 patients with newly diagnosed coeliac disease (biopsy proven) Followed for 5 years after commencing GFD BMD increased 2% at lumbar spine, femoral neck 1% trochanter 6% and 3% at Wards triangle All increases occurred during first year of diet Did not measure appendicular skeleton

    41. Does a gluten free diet increase BMD? Mora et al (1999), Am J Gastroenterology 30 coeliac patients, mean age at diagnosis 11.4 years old On gluten free diet for a mean of 10.7 years 240 controls Measured lumbar spine and whole body BMD BMD of coeliac patients did not differ from controls

    42. Should osteoporotic patients be screened for coeliac Dx? Stenson et al (2005), Arch Int Med 266 patients with osteoporosis compared with 574 without - mean age 60 Serological screening with TTG and endomysial antibody - biopsied if positive Prevalence of coeliac disease 3.4% in osteoporosis group, compared with 0.2% in non osteoporosis group

    43. Should osteoporotic patients be screened for coeliac Dx? Stenson et al (2005), Arch Int Med Also found that anti TTG levels correlated with T score at hip, femoral neck and lumbar spine 8 patients with coeliac disease maintained a GFD for 1 year - T scores sig improved Authors recommended screening - $US 1500 to identify a coeliac patient

    44. Should osteoporotic patients be screened for coeliac Dx? Buchman (2005) Arch Int Med Cost of screening US population $2 billion Cost to prevent a single fracture $43,000 Similar figures to detect a breast cancer by mammography

    45. Conclusions Coeliac disease may present atypically May present later in life Mechanism of osteoporosis is secondary hyperparathyroidism Fracture risk is increased in coeliac patients Gluten free diet does increase bone mass Screening has been recommended in a recent study

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