Rickets osteomalacia
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RICKETS/OSTEOMALACIA. The case of Sunset Sky. Sunset Sky Davis. 7 month old female Pomeranian Hx: Hypocalcemia, hyperphosphatemia Accession 86423 MRN 136554. Radiographic signs. Flared metaphyses Widened, lucent physes “Cupping” of physes. Diagnostic Testing.

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Rickets osteomalacia

RICKETS/OSTEOMALACIA

The case of Sunset Sky


Sunset sky davis
Sunset Sky Davis

7 month old female Pomeranian

Hx: Hypocalcemia, hyperphosphatemia

Accession 86423

MRN 136554


Radiographic signs
Radiographic signs

  • Flared metaphyses

  • Widened, lucent physes

  • “Cupping” of physes


Diagnostic testing
Diagnostic Testing

  • Increased PTH 90.7 (3-17)

  • Low ionized Calcium 0.94 (1.25-1.45)

  • Low vitamin D 43 (60-215)

  • These findings are consistent with nutritional sec. hyperPTH with decreased vitamin D intake/GI absorption. Strange, since other pups in household are unaffected.


Metabolic Bone Disease

Osteolysis

(i.e.—hyperparathyroid states)

Defective Bone Formation

  • Nutritional sec.

  • Renal sec.

  • Primary

Defective osteoid production (aka Osteoporosis)

Inadequate mineralization of osteoid (RICKETS)

  • HAC

  • Osteogenesis imperfecta

  • Renal sec.

  • Decr. Ca or P

  • VITAMIN D DEF.

  • Hepatic

  • anticonvulsant


Osteolysis
Osteolysis

  • Nutritional—too much P or too little Ca causes PTH secretionbone resorption

  • Renal secondary—inadequate P excretionhypocalcemiaPTH secretionbone resorption

  • Hypercalcemia of malignancy (PTHrp)

  • Primary hyperPTH


Causes of osteoporosis decreased osteoid production
Causes of Osteoporosis (decreased osteoid production)

  • Hyperadrenocorticism

  • Osteogenesis imperfecta

  • Other causes of decreased collagen or matrix production


Causes of inadequate min
Causes of Inadequate Min.

  • USUALLY HYPOVITAMINOSIS D

    --inadequate intake

    --disorders of vitamin D metabolism

    --renal failure (decreased synth. Of 1,

    25-(OH)2-vitD—the most active)

  • Decreased Calcium or phosphorus intake (e.g.—inappropriate feeding of renal diets)


Dietary related skeletal changes in a shetland sheepdog puppy
Dietary-Related Skeletal Changes in a Shetland Sheepdog Puppy

  • 10 wk old Sheltie

  • Suspected renal failure (azotemia, isosthenuria)

  • Placed on a commercial renal failure diet (low phosphorus/low protein/adequate vit D)

  • Presented with carpal varus and failure to grow

  • Radiographs—consistent with rickets

J Am Anim Hosp Assoc 2006; 42:57-64


Bottom line nutritional rickets
Bottom line: Nutritional Rickets Puppy

  • Note: serum PTH was LOW due to low phosphorus intake (in nutritional sec. hyperPTH, the PTH goes UP in response to decreased Ca)

  • Hypophosphatemia/Normocalcemia

  • Treatment: commercial puppy food


Interesting points
Interesting points Puppy

  • In this case, PTH was low because of decreased P, rather than decreased Ca.

  • Both nutritional sec. hyperPTH and vitamin D deficient rickets can present with HIGH PTH levels.

  • So, diagnosis can be complex—must carefully analyze diet

  • Ca:P is ideally 1:1, no higher than 1:2


Vitamin d dependent rickets type ii in a cat
Vitamin D-Dependent Rickets Type II in a Cat Puppy

  • 4 month old male DSH

  • Presented for inappetence and decreased mobility

  • Radiographic signs of rickets

  • Fed adult food/chicken/white fish

  • Changed to a commercial kitten food

  • Signs continued to progress (devel. rachitic rosary)

Journalof Small Animal Practice (2005); 46:440-444


Unable to utilize vitamin d appropriately
Unable to utilize vitamin D appropriately Puppy

  • PTH concentrations were HIGH

  • Calcium levels were slightly LOW

  • Phosphorus levels were normal

  • At 20 mos, plasma 1,25-(OH)2-vitD concentrations were VERY HIGH


How to test vit d receptors
How to test vit D receptors?? Puppy

  • Skin biopsy

  • Obtain fibroblast cultures

  • Test for ability of radiolabelled 1,25-(OH)2-vit D to bind to nuclear extracts

  • This cat showed complete lack of binding


Dietary Vitamin D Intake Puppy

Liver converts to 25-OH-vit D

Kidney—proximal tubules convert to 1,25-(OH)2-vit D, the most active form

1, 25-(OH)2-vit D tells GI to absorb more Calcium


Over 30 diseases can decrease vitamin d absorption metabolism or actions
Over 30 diseases can decrease vitamin D absorption, metabolism, or actions!

Dietary

Renal failure

Liver disease

Pancreas/small intestinal dz

Hypoparathyroidism


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