Profound and Protracted Hypophosphatemia after A Single Dose of Zoledronic Acid Infusion for Osteoporosis Associated with Normocalcemic Primary Hyperparathyroidism

Chiam, Priscilla Pei Sze; Ch, Manju

doi:10.21767/2471-8041.100059

Cited by 4 publications

(2 citation statements)

References 8 publications

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“…A dangerous reduction in phosphate level following bisphosphonate treatment with an increase in the TRP value would seem to confirm the association. Unlike with typical findings, we noted rare profound hypophosphataemia, seen in just 1% of cases [4]. Given the lack of phosphaturia, glycosuria, and tubular loss of other ions, Fanconi syndrome secondary to bisphosphonate use was not suspected.…”

Section: Discussioncontrasting

confidence: 66%

Life-threatening hypophosphataemia secondary to zoledronic acid implementation in a middle-age patient who presented with advanced osteolysis in the course of multiple myeloma

Radziszewski

Karpiłowska

Podgórska

et al. 2020

Endokrynologia Polska

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A 40-year-old man with a history of chest pain, nausea, and palpitation was admitted to hospital due to hypercalcaemia and renal function exacerbation. On admission the patient's condition revealed signs of dehydration and tachycardia. Moreover, the patient complained of painful ribs. Laboratory tests revealed a high calcium level of 3.69 mmol/L, normal parathormone (PTH) -18.4 pg/mL, and vitamin D deficiency -22.14 ng/mL (Tab. 1). Serum phosphate, magnesium, potassium, and sodium were within the normal range, and there were no acid-base-balance disturbances. Abdominal ultrasound offered no important findings. However, low-dose whole-body computed tomography scanning displayed an advanced diffused osteolysis in numerous bones ( Fig. 1). Additionally, some rib fractures were present. Consecutively, further biochemical analyses found mild normocytic anaemia, an elevated erythrocyte sedimentation rate of 94 mm and lactate dehydrogenase of 325 U/L, monoclonal gammopathy features in protein electrophoresis, and a k/l serum ratio equal to 1696.1.The above led to a suspicion of non-PTH-mediated hypercalcaemia (NPTH-H) in the course of multiple myeloma (MM). Treatment then included intravenous fluids, forced diuresis, and calcitonin and zoledronic acid administered following an improvement of renal function (a glomerular filtration rate of 49 mL/min/1.73 m 2 ). Unexpectedly, a severe (0.2 mmol/L) hypophosphataemia with hypophosphaturia (< 0.1 mmol/L) occurred four days later. Tubular reabsorption of phosphate (TRP) was within the normal range -0.895 (0.85-0.95), while the tubular maximum reabsorption rate of phosphate to glomerular filtration rate (TmP/GFR) decreased significantly to 0.19 mmol/L (1.0-1.35). On the other hand, prior to bisphosphate administration, these parameters were consecutively 0.52 and 0.43 mmol/L, with phosphate concentration 0.82 mmol/L and its excretion in urine at 5.4 mmol/L, together with features of mild acute kidney injury (Tab. 1). The PTH level increased slightly.Despite the patient's relatively stable state, insufficient oral supplementation of phosphate and severity of observed hypophosphataemia accounted for resorting to the application of intravenous phosphate infusion, which was continued for four days. Concomitant treatment i.a. involved alphacalcidol and cholecalciferol.To confirm neoplastic disease, bone marrow biopsy was performed, revealing a level of infiltration of pathological plasma cells equal to 42.7%. DiscussionMultiple myeloma is a neoplastic disease characterised by lytic lesions of bones [1]. The diagnosis is rare in adults under 40 years old (approximately 2%), with average age at diagnosis being 70 years. MM-related hypercalcaemia is caused by osteoclast activation involving a receptor activator of the NF-kB (RANK) system, as accompanied by hydrogen and cytokine release -mainly of interleukin-6, sclerostin, and the glycoprotein Dickkopf-1 (DKK-1) [2]. Zoledronate therefore serves as a standard treatment because it binds to hydroxyapatite complexes at metabolically active

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Section: Discussioncontrasting

confidence: 66%

Life-threatening hypophosphataemia secondary to zoledronic acid implementation in a middle-age patient who presented with advanced osteolysis in the course of multiple myeloma

Radziszewski

Karpiłowska

Podgórska

et al. 2020

Endokrynologia Polska

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“…This adverse event was previously reported following IV zoledronic acid administration for hypercalcemia of malignancy[ 26 ] and osteoporosis. [ 27 ] Another adverse event was the occurrence of atrial fibrillation, which is supported by prior studies that have reported an association between bisphosphonates and atrial fibrillation/flutter. [ 28 ]…”

Section: Discussionmentioning

confidence: 68%

Paget's disease of bone in Tunisia: A study of 69 patients

Maatallah¹,

Rahmouni²,

Miladi

et al. 2020

Indian J Endocr Metab

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Context: Paget's disease of bone is a common bone disease with a striking variation in its incidence and characteristics in different parts of the world. It is uncommonly reported in African patients. Aims: Given the lack of studies describing the characteristics of patients with Paget's disease of bone in North Africa, we aimed to describe demographic, clinical, biochemical, and imaging characteristics, as well as treatment outcomes of Tunisian patients with Paget's disease of bone. Subjects and Methods: This bicentric and retrospective study included patients with Paget's disease of bone. Clinical, laboratory, radiological profile, and response to treatment were analyzed. Results: Sixty-nine patients were identified. The mean age was 64.9 ± 11.6 years and 52.2% were women. One patient reported a positive family history. Seven patients were asymptomatic. Bone pain was the most common presenting symptom. Eight patients had a history of malignancy. In three patients, Paget's disease of bone was diagnosed as part of a metastatic workup. Monostotic disease was found in half of the cases. The most commonly involved sites were pelvis (43.5%), femur (21.7%), and spine (21.7%). The mean serum alkaline phosphatase level at presentation was 591 U/L (68–8380). Two patients received salmon calcitonin (2.8%) and 47 patients (68.1%) received bisphosphonates. After a mean follow-up of 55 months (2–240 months), bone pain improved in 43.1% of patients and the serum alkaline phosphate levels had normalized in 22 of them (43.1%). During follow-up, there was no malignant transformation. Conclusions: In this series of Tunisian patients, Paget's disease of bone had a female predominance and was usually monostotic. The clinical and radiological presentations were similar to the European series.

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Drug-related hypophosphatemia: Descriptive study and case/non-case analysis of the French national pharmacovigilance database

Thillard,

Sade,

Michot

et al. 2024

Therapies

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Profound and Protracted Hypophosphatemia after A Single Dose of Zoledronic Acid Infusion for Osteoporosis Associated with Normocalcemic Primary Hyperparathyroidism

Cited by 4 publications

References 8 publications

Life-threatening hypophosphataemia secondary to zoledronic acid implementation in a middle-age patient who presented with advanced osteolysis in the course of multiple myeloma

Life-threatening hypophosphataemia secondary to zoledronic acid implementation in a middle-age patient who presented with advanced osteolysis in the course of multiple myeloma

Paget's disease of bone in Tunisia: A study of 69 patients

Drug-related hypophosphatemia: Descriptive study and case/non-case analysis of the French national pharmacovigilance database

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