P-17 THE HIDDEN CULPRIT: CELIAC DISEASE IN A POSTPARTUM OSTEOPOROSIS PATIENT
Authors: Saydam Simge , Eralp Deniz , Sayim Kubra , Ciftci Sema , Çakır Ilkay , Bozkur Evin , Mert Meral 
Published: January 2025

Abstract

Introduction
Pregnancy and lactation-associated osteoporosis is a rare type of osteoporosis that is often accompanied by vertebral fractures. It is considered to be a result of pregnancy-related factors, as well as due to underlying secondary causes. Here we present a case of severe hypocalcemia following parenteral zoledronic acid administration for postpartum osteoporosis, in which further evaluation for secondary causes had not been made and underlying Celiac disease was missed.

Clinical Case
A 34-year-old female patient had applied to an out-patient clinic with widespread bone pain at third month postpartum. She was diagnosed as postpartum osteoporosis based on examination with the dual X-ray absorptiometry (DXA) scan. Lumbar spine L1-L4 bone mineral density (BMD) and Z-score was found 0.614 g/cm²; and -3.9 respectively. No data was present regarding a fracture. She was referred to our clinic with severe muscle cramps and numbness following administration of Zolendronic acid 5 mg intravenously. The patient denied any chronic diseases, but she noted that she had undergone an intestinal operation due to ileus when she was 22 years old. She had a history of four pregnancies and had breastfed each of her children for at least a year. Family history was insignificant. On physical examination, symptoms of proximal myopathy, Chvostek and Trousseau signs were evident. Laboratory investigation revealed severe hypocalcemia; results of laboratory were as follows: Corrected-Ca: 5.5 mg/dL, P: 1.8 mg/dL, 25-Hydroxyvitamin D: 6.4 g/L, Parathormone (PTH): 1044 pg/mL, and Alkaline phosphatase (ALP): 269 U/L. In addition to parenteral and oral calcium, calcitriol and cholecalciferol treatments were started subsequently. Upon further evaluation for the secondary causes of osteoporosis, Celiac antibodies tested positive, additionally the appearance of the upper gastrointestinal system endoscopy and the biopsy of the second part of the duodenum were found to be compatible with Celiac disease. Thus, the patient's follow-up continued with calcium and vitamin D replacements, as well as dietary adjustments for celiac disease. The patient has been followed up in our clinic for approximately two years, a significant increase in bone density and improvement in biochemical values were detected with the current diet and replacements.
DXA scans:
2022:
Femoral neck BMD 0.694 g/cm², Z-score -1.5;
Lumbar spine L1-L4 BMD: 0.614 g/cm², Z-score: -3.9
2024:
Femoral neck BMD 1.080 g/cm², Z-score +1.2
Lumbar spine L1-L4 BMD 1.246 g/cm², Z-score: +0.8

Conclusion
In patients presenting with postpartum osteoporosis, secondary causes should be investigated and treatment should be determined according to diagnosis. Bisphosphonate treatment in postpartum osteoporosis can be applied only to a group of individually selected patients and adequate calcium and vitamin D supplementation should be given prior to treatment.Table 1:Laboratory FindingsLaboratory findings during the two-year follow-up of the patient