Undiagnosed Osteoporotic Vertebral Fractures in an Octogenarian During the Coronavirus Disease Pandemic.

Osteoporotic vertebral fractures are frequently misdiagnosed or under-recognized in the older population, leading to disease progression and reduced quality of life. This case of an 87-year-old woman with acute back pain highlights the importance of early diagnosis and management of fragility fractures. During the coronavirus disease (COVID-19) pandemic, patients with a history of well-managed osteoporosis experienced worsening symptoms of vertebral collapse due to activity limitations and prolonged immobilization. The initial diagnosis of spinal stenosis delayed appropriate treatment for four months. Serial magnetic resonance imaging revealed compression fractures at L1 and L3, and a dual-energy x-ray absorptiometry scan showed osteoporosis with a T-score of -3.2. Pharmacological therapy, including bisphosphonates, was initiated. A comprehensive rehabilitation program with a multidisciplinary approach, with bracing, and lifestyle changes helped stabilize the spine, reduce pain, and maximized function. Her condition improved with close monitoring and guidance during home exercises. This case exemplifies the necessity of a precise and timely diagnosis of osteoporotic vertebral fractures to initiate management and mitigate disease progression.

Superior mesenteric vein thrombosis and osteoporotic vertebral fractures.

Superior mesenteric vein (SMV) thrombosis is relatively rare disease with unspecific symptoms. Thrombus formation within the SMV eventually leads to congestive intestinal necrosis. In most cases, the lack of specific symptoms makes early diagnosis difficult. Therefore, it is important to suspect the disease and actively investigate it, given a causative factor. Here, we report a case of SMV thrombosis with a novel predisposing factor, compression of SMV by deformed spine, found on contrast medium-enhanced computed tomography. Treatment with intravenous heparin followed by oral anticoagulants resulted in favorable outcome. This is the first picture showing the novel mechanism of SMV thrombus formation relating to spinal deformity. Treating osteoporosis before spinal deformity could prevent SMV thrombosis with such a mechanism.

The osteo-metabolic phenotype of COVID-19: an update.

CONTEXT: In the multifaceted COVID-19 clinical scenario characterized by a multi-system disorder with negative implications not only on respiratory function but also on cardiac, hematological, neurological and endocrine-metabolic systems, a distinctive osteo-metabolic phenotype with an independent influence on disease severity and recovery of patients affected was early reported. AIM: To summarize and update the main evidences regarding the distinct components of this phenotype in acute and Long COVID-19, reinforcing its clinical relevance and discussing the main pathophysiological and clinical-therapeutic implications of the most recent reported findings. RESULTS: This emerging phenotype is characterized by a widespread acute hypocalcemia and hypovitaminosis D with an impaired compensatory parathyroid hormone response, and a high prevalence of skeletal complications such as vertebral fractures. The clinical relevance of this osteo-metabolic phenotype on acute COVID-19 is well characterized, and novel seminal evidences are progressively highlighting its importance also in predicting patient's long-term outcomes and Long COVID-19 occurrence. CONCLUSIONS: These findings reinforced the central role of a multidisciplinary team, including endocrinologists, in evaluating these patients for a proactive search of each aspect of the osteo-metabolic phenotype components since they may represent suitable therapeutic targets to prevent SARS-CoV-2 infection, poor COVID-19 outcomes, Long COVID-19 occurrence and even possibly better responses to COVID-19 vaccination.

Vertebral fractures at hospitalization predict impaired respiratory function during follow-up of COVID-19 survivors.

PURPOSE: Morphometric vertebral fractures (VFs) have been recently reported as an important component of the endocrine phenotype of COVID-19 and emerging data show negative respiratory sequelae at long-term follow-up in COVID-19 survivors. The aim of this study was to evaluate the impact of VFs on respiratory function in COVID-19 survivors. METHODS: We included patients referred to our Hospital Emergency Department and re-evaluated during follow-up. VFs were detected on lateral chest X-rays on admission using a qualitative and semiquantitative assessment and pulmonary function tests were obtained by Jaeger-MasterScreen-Analyzer Unit 6 months after discharge. RESULTS: Fifty patients were included. Median age was 66 years and 66% were males. No respiratory function data were available at COVID-19 diagnosis. VFs were detected in 16 (32%) patients. No differences between fractured and non-fractured patients regarding age and sex were observed. Although no difference was observed between VF and non-VF patient groups in the severity of pneumonia as assessed by Radiological-Assessment-of-Lung-Edema score at admission, (5 vs. 6, p = 0.69), patients with VFs were characterized as compared to those without VFs by lower Forced Vital Capacity (FVC, 2.9 vs. 3.6 L, p = 0.006; 85% vs. 110% of predicted, respectively, p = 0.001), Forced Expiratory Volume 1st s (FEV1, 2.2 vs. 2.8 L, p = 0.005; 92% vs. 110% of predicted, respectively, p = 0.001) and Diffusing Capacity of the Lungs for Carbon Monoxide (DLCO 5.83 vs. 6.98 mmol/min/kPa, p = 0.036, 59% vs. 86.3% of predicted, respectively, p = 0.043) at 6-month follow up. CONCLUSIONS: VFs, expression of the endocrine phenotype of the disease, appear to influence medium-term impaired respiratory function of COVID-19 survivors which may significantly influence their recovery. Therefore, our findings suggest that a VFs assessment at baseline may help in identifying patients needing a more intensive respiratory follow-up and patients showing persistent respiratory impairment without evidence of pulmonary disease may benefit from VFs assessment to preventing the vicious circle of further fractures and respiratory deterioration.

Vertebral fractures and mortality risk in hospitalised patients during the COVID-19 pandemic emergency.

BACKGROUND AND OBJECTIVE: Bone fragility has been linked to COVID-19 severity. The objective of this study was to evaluate whether a diagnosis of vertebral fracture (VF) increased mortality risk in COVID-19 patients and whether this effect was greater than in those without COVID-19. METHODS: We assessed VFs by computed tomography (CT) in a cohort of 501 patients consecutively admitted to the emergency department (ED) for clinical suspicion of SARS-CoV-2 infection during the first wave of pandemic emergency. Of those, 239 had a confirmed diagnosis of COVID-19. RESULTS: VF prevalence was similar between COVID-19 and non-COVID-19 groups (22.2 vs. 19%; p = 0.458). Death rates were similar between COVID-19 and non-COVID-19 groups at both 30 (15.8 vs. 12.2%; p = 0.234) and 120 days (21.8 vs. 17.6%; p = 0.236). The mortality risk was higher in COVID-19 patients either with one or multiple fractures compared to those without VFs, at 30 and 120 days, but statistical significance was reached only in those with multiple VFs (30-day HR 3.03, 95% CI 1.36-6.75; 120-day HR 2.91, 95% CI 1.43-5.91). In the non-COVID-19 group, the 30-day mortality risk was significantly higher in patients either with one (HR 7.46, 95% CI 3.12-17.8) or multiple fractures (HR 6.2, 95% CI 2.75-13.98) compared to those without VFs. A similar effect was observed at 120 days. After adjustment for age, sex and bone density, mortality risk remained associated with VFs in the non-COVID-19 group only. CONCLUSIONS: VFs were not independently associated with short-term mortality in patients with COVID-19, but they strongly increased mortality risk in those without COVID-19.

Should denosumab treatment for osteoporosis be continued indefinitely?

Denosumab was approved for the treatment of postmenopausal osteoporosis in 2010, based on the FREEDOM study, which indicated a benefit in terms of increased bone mineral density and reduced risk of major osteoporotic fracture. In the initial clinical studies it was noted that discontinuation of denosumab can lead to a rebound of bone turnover markers and loss of accrued bone mineral density. An increased risk of fractures (multiple vertebral fractures in particular) associated with discontinuation was noted after approval and marketing of denosumab. For many patients experiencing gain in bone mineral density and fracture prevention while taking denosumab, there is no reason to stop therapy. However, discontinuation of denosumab may happen due to non-adherence; potential lack of efficacy in an individual; where reimbursement for therapy is limited to those with bone mineral density in the osteoporosis range, when assessment reveals this has been exceeded; or patient or physician concern regarding side effects. This review paper aims to discuss these concerns and to summarize the data available to date regarding sequential osteoporosis therapy following denosumab cessation to reduce the risk of multiple vertebral fracture.

Hypovitaminosis D and the endocrine phenotype of COVID-19.

BACKGROUND: Vitamin D and its deficiency have recently been suspected to be involved in increased susceptibility and negative outcomes of COVID-19. This assumption was based on the well known immunomodulatory actions of vitamin D and on the consistent finding of low levels of 25 hydroxyvitamin D (25OHD) in hospitalized patients with COVID-19. Moreover, several studies reported a correlation between 25OHD levels and different clinical outcomes of the disease. AIM: Aim of the current review was to approach the topic of vitamin D and COVID-19 from a different perspective summarizing the data which led to the evidence of the existence of an endocrine phenotype of COVID-19. CONCLUSIONS: This review analyzed in the light of the current knowledge the possibility that several endocrine manifestations of COVID-19 could be holistically interpreted in the context of an inadequate vitamin D status.

Radiological Thoracic Vertebral Fractures are Highly Prevalent in COVID-19 and Predict Disease Outcomes.

CONTEXT AND OBJECTIVE: COVID-19 has become the most relevant medical issue globally. Despite several studies that have investigated clinical characteristics of COVID-19 patients, no data have been reported on the prevalence of vertebral fractures (VFs). Since VFs may influence cardiorespiratory function and disease outcomes, the aim of this study was to assess VFs prevalence and clinical impact in COVID-19. DESIGN AND PATIENTS: This was a retrospective cohort study performed at San Raffaele Hospital, a tertiary health care hospital in Italy. We included COVID-19 patients for whom lateral chest x-rays at emergency department were available. VFs were detected using a semiquantitative evaluation of vertebral shape on chest x-rays. RESULTS: A total of 114 patients were included in this study and thoracic VFs were detected in 41 patients (36%). Patients with VFs were older and more frequently affected by hypertension and coronary artery disease (P < 0.001, P = 0.007, P = 0.034; respectively). Thirty-six (88%) patients in VFs+ group compared to 54 (74%) in VFs- group were hospitalized (P = 0.08). Patients with VFs more frequently required noninvasive mechanical ventilation compared with those without VFs (P = 0.02). Mortality was 22% in VFs+ group and 10% in VFs- group (P = 0.07). In particular, mortality was higher in patients with severe VFs compared with those with moderate and mild VFs (P = 0.04). CONCLUSIONS: VFs may integrate the cardiorespiratory risk of COVID-19 patients, being a useful and easy to measure clinical marker of fragility and poor prognosis. We suggest that morphometric thoracic vertebral evaluation should be performed in all suspected COVID-19 patients undergoing chest x-rays.