Osteomalacia: The Daily PANCE Blueprint
A 55-year-old woman presents with diffuse bone pain and muscle weakness. She has a history of malabsorption syndrome and limited sun exposure. You suspect osteomalacia. Which of the following is the next best step to confirm your suspicion?
A. Serum calcium level
B. Dietary vitamin D2 level
C. 25-hydroxyvitamin D level
D. 1,25-hydroxyvitamin D level
E. Bone biopsy
Answer and topic summary
The answer is C. 25-hydroxyvitamin D level
In a patient with suspected osteomalacia, particularly with a history suggestive of vitamin D deficiency (such as low dairy intake and limited sun exposure), measuring the 25-hydroxyvitamin D level is crucial. Vitamin D deficiency commonly presents with symptoms like lower back pain, proximal muscle weakness, muscle aches, and bone pain. A serum 25-hydroxyvitamin D level of less than 20 ng/mL is indicative of deficiency. The treatment involves repleting vitamin D stores to decrease the risk of fractures and falls.
Incorrect Answers:
A. Serum calcium level – While hypocalcemia may be present in osteomalacia, it is not specific and can be seen in various other conditions.
B. Dietary vitamin D2 level – Dietary vitamin D2 and D3 levels change on a daily basis and are, therefore, not the best representation of the patient’s vitamin D stores.
D. 1,25-hydroxyvitamin D level – This is the active form of vitamin D, and its level can be normal or even elevated in osteomalacia due to secondary hyperparathyroidism.
E. Bone biopsy – While definitive, a bone biopsy is an invasive procedure and not typically the first step in the diagnostic process for osteomalacia.
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