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MEDICAL IMAGES| Volume 85, ISSUE 9, e65, September 2010

Bone Tenderness

      A 46-year-old woman who was taking antipsychotic drugs for schizophrenia presented to our hospital because of worsening generalized body pain that had persisted for 1 year. Physical examination revealed bone tenderness over her entire body, especially over her upper arms, ribs, and pelvis. Initially, the only apparent laboratory abnormality was a serum alkaline phosphatase level of 830 IU/L. Bone radiography showed bone thinning; multiple symmetrical “hot spots” were detected on bone scintigraphy with technetium Tc 99m hydroxymethylene diphosphonate. We suspected multiple metastatic bone cancers but found no lesion.
      A few weeks later, the patient's bone pain had resolved completely with no treatment. On follow-up, the patient acknowledged that she had recently begun taking calcium and vitamin D supplements on the basis of a friend's recommendation. Additionally, the patient was a strict vegan. The differential diagnosis was osteomalacia. Her intact parathyroid hormone level was 98 pg/mL. The antipsychotic drugs that the patient was taking might have induced CYP3A4 and reduced 1,25 dihydroxyvitamin D values.
      • Holick MF
      Vitamin D deficiency.
      Her vegan diet probably accelerated vitamin D deficiency.


        • Holick MF
        Vitamin D deficiency.
        N Engl J Med. 2007; 357: 266-281