Clinical Case 5.7

A 78-year-old widow presented to the Rheumatology clinic with a several year history of deformity and discomfort in the lower right leg (Box 5.37). Her serum Ca²⁺ was 2.76 mmol/l (NR 2.2–2.6 mmol/l) with a P_i of 1.03 mmol/l (NR 0.8–1.4 mmol/l) and an alkaline phosphatase of 335 IU/l (NR 30–100 IU/l). She was treated with an oral bisphosphonate. Nine years later she tripped on a pavement fracturing her right tibia (Box 5.37). At that time the serum Ca²⁺ was 2.57 mmol/l with a P_i of 1.00 mmol/l and an alkaline phosphatase of 684 IU/l. She was treated with a plaster of Paris cast and the fracture healed over the subsequent 6 months. Seventeen years after presentation, she complained of deteriorating hearing and was referred to the audiology department. At the age of 95 years her serum Ca²⁺ was 2.42 mmol/l with a P_i of 0.92 mmol/l and an alkaline phosphatase of 513 IU/l.