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Clinical presentation and etiology of osteomalacia/rickets in adolescents

Article  in  Saudi journal of kidney diseases and transplantation: an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia · September 2013
DOI: 10.4103/1319-2442.118087 · Source: PubMed

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Saudi J Kidney Dis Transpl 2013;24(5):938-941

© 2013 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Original Article

Clinical Presentation and Etiology of Osteomalacia/Rickets in Adolescents

Mohammad A. Hazzazi1,2, Ibrahim Alzeer1,2, Waleed Tamimi1,2, Mohsen Al Atawi2,
Ibrahim Al Alwan1,2
1
King Saud bin Abdulaziz University for Health Sciences, 2King Abdulaziz Medical City,
Riyadh, Saudi Arabia

ABSTRACT. This study was conducted to determine the causes and clinical presentations of
osteomalacia/rickets in adolescents seen at the King Abdulaziz Medical City (KAMC), Riyadh.
Because osteomalacia and rickets constitute the same entity, the term osteomalacia will be used
for future discussion. A retrospective file review was performed on all adolescents (10–16 years)
with osteomalacia, defined as alkaline phosphatase levels ≥ 500 IU/L, seen at the KAMC, Riyadh,
from 2000 to 2006. We recorded the signs and symptoms, dietary history and amount of sun
exposure at presentation. A total of 135 patients were found to fit the inclusion criteria for the
study. Of them, 57 had nutritional causes, with a mean age of 13.2 years, and included 32 females.
At diagnosis, 22 patients were found to have bone pain, 10 had bone deformities, eight had
pathological fractures and 17 were asymptomatic. Secondary causes for osteomalacia were found
in 59 cases who had liver and renal disease and in 19 other patients who were on medications such
as anticonvulsants and steroids, which are known to cause osteomalacia. Our study indicates that
osteomalacia is a significant health burden that deserves special attention. Bone pain is the most
common presenting symptom at diagnosis. Because of the high risk of osteomalacia associated
with the use of anticonvulsants and steroids, it is advised that all patients on these drugs should be
routinely screened for secondary osteomalacia.

Introduction deformities and delayed developmental mile-

Rickets is a disorder of defective minerali-
zation of cartilage in the epiphyseal growth
plates of children, leading to widening of the
ends of long bones, growth retardation, skeletal
Correspondence to:
Dr. Mohammad Hazzazi,
King Saud bin Abdulaziz University for
Health Sciences, PO Box 22490, MC 3130,
Riyadh, Saudi Arabia
E-mail: dr.alhazzazi@gmail.com
stones.1,2 By contrast, osteomalacia, seen pri-
marily in adults, is a metabolic disorder caused
by the deficiency of vitamin D or its meta-
bolites, which leads to failure of mature bone
to mineralize, leading to reduced bone den-
sity.3 Because ostomalacia and rickets cons-
titute the same entity, the term osteomalacia
will be used for future discussion. Osteoma-
lacia can manifest as bone pain, tenderness
and/or muscle weakness.3 Fractures of the ribs,
vertebrae and long bones, as well as waddling
gait, were reported in some studies; however,
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Clinical presentation and etiology of osteomalacia/rickets
skeletal deformities are infrequent in adults.3,4
Reasons for vitamin D deficiency include in-
adequate dietary intake of calcium and vitamin
D, malabsorption, inadequate exposure to sun-
light, renal and liver disease and medications.5
The diagnosis of osteomalacia can be deter-
mined by several methods; however, in 1982,
Hedley Peach and his group concluded that
plasma alkaline phosphatase activity is the best
single routine biochemical screening test for
osteomalacia.6,7
In developing countries, osteomalacia is still
seen in older children and adolescents with
increasing frequency.8 In Saudi Arabia, despite
the prevailing economic affluence and adequate
sunlight all year round, vitamin D deficiency is
fairly common in infants, children and adole-
scents as well as in pregnant and lactating wo-
men.8-11 Although there is an awareness of the
high prevalence of vitamin D deficiency in
Saudi Arabia, a review of the literature revealed
a lack of data on the most common presentations.
The aim of this study was to identify the
possible etiologies of osteomalacia in adoles-
cents seen at the King Abdulaziz Medical City
(KAMC), Riyadh, and to discern any predomi-
nantly shared presentation at diagnosis.
Methods
This is a retrospective study conducted at the
KAMC, Riyadh. The records of all adolescents
(age: 10–16 years), seen between 2000 and
2006, with osteomalacia (defined by alkaline
phosphatase equal to, or more than 500 IU/L)
were reviewed.
A total of 8494 patients were tested and 135
had alkaline phosphatase levels of over 500
IU/L. The initial sample size was 135 patients.
The patients were divided into two groups
according to etiology. Group A included pa-
tients with either liver or renal disease or both,
or those who were found to be on medications
that might cause secondary osteomalacia. Group
B included patients who had no obvious secon-
dary etiology and, thus, were assumed to have
nutritional osteomalacia.
A detailed review and data extraction was
performed on the medical records of each case
939
of nutritional osteomalacia (Group B). Ana-
lysis included age, sex, presenting symptoms
and signs, presence or absence of fractures and
bone deformities (confirmed by bone X-ray or
presence of symptoms), diet history, sun expo-
sure (assessed by duration and frequency of
direct sun exposure) or chronic illness as well
as medication history (steroids, anti-convul-
sants, calcium supplements and phosphates).
Statistical analysis was performed using Sta-
tistical Package for Social Sciences (SPSS)
version 16.
Results
In Group A, there were 59 patients (43%)
who had secondary osteomalacia due to liver
or renal disease or both and 19 patients (14%)
who were on medications known to cause os-
teomalacia. Table 1 shows a list of these medi-
cations and their frequencies. Despite having
abnormal alkaline phosphatase levels, these
patients were not given vitamin D or calcium.
Group B, classified as nutritional osteoma-
lacia, consisted of 57 patients aged between 10
and 16 years, with a mean age of 13.2 years ±
1.5 years, and included 32 females (56%).
Bone pain was the most common presenta-
tion seen in 22 patients (38.2%) and the least
common clinical presentation was pathological
fractures, seen in eight patients (14%). Table 2
summarizes the common presentations and their
frequencies.
Table 1. List of medications associated with
osteomalacia and their frequencies.
Type of medication N (%)
Anticonvulsants 11 (58)
Chemotherapy 4 (21)
Steroids 3 (16)
Anticonvulsants + steroids 1 (5)
Total cases 19 (100)
Table 2. Common clinical presentations among
patients with nutritional osteomalacia.
N (%)
Bone pain 22 (38.5)
Asymptomatic 17 (30)
Bone deformities 10 (17.5)
Pathological fractures 8 (14)
Total cases 57 (100)
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940
Fifteen patients had a documented dietary
history of an unbalanced diet with increased
consumption of fast food and soft drinks. One
patient had good sun exposure (three to five
times per week) and three patients had rare sun
exposure (<2 times per week) documented in
their medical records.
Discussion
Our study revealed that in adolescents with
osteomalacia secondary to nutritional etiology,
38% had non-specific symptoms and 30%
were asymptomatic. These patients are more
likely to be under-diagnosed.
Rickets and osteomalacia have been identi-
fied as persistent global health concerns.6 In
the USA, Weisberg et al reviewed the cases
reported between 1980 and 2003 and con-
cluded that osteomalacia and rickets are still
prevalent in the US.12 In a study from the UK
conducted in 2002, Shaw reported that vitamin
D deficiency in Asian families is a continuing
problem.13 Although the aforementioned stu-
dies are from countries that are prone to have a
high prevalence of rickets and osteomalacia
due to their limited sun exposure, there are
many reports from countries with adequate or
high sun exposure, like Saudi Arabia14 and
Australia.15 These studies show that rickets and
osteomalacia are still a major health burden.
In Saudi Arabia, inadequate vitamin D levels
were detected in a population-based study, and
it was shown that vitamin D deficiency osteo-
malacia/rickets is common.16,17 Siddiqui com-
mented that Saudi females tend to have less
sun exposure due to socio-cultural reasons and
lack of an awareness of the importance of sun
exposure for bone health as well as cosmetic
reasons or because it is thought to be harm-
ful.18 O’Hare and Mishal noted that in many
countries, Asian females have low levels of
vitamin D, increasing their risk of developing
osteomalacia.19,20
Unlike Siddiqui and O’Hare and Mishal, we
found no significant difference between females
(56%) and males (44%) in the prevalence of
osteomalacia in our study. A possible explana-
tion for these differences may be due to the
Hazzazi MA, Alzeer I, Tamimi W, et al
site, i.e. school or hospital based, and the re-
gional area of the study.
Karrar (1998) found that most cases of osteo-
malacia were asymptomatic and, if present, the
symptoms were non-specific. He attributed the
high prevalence of vitamin D deficiency to a
lack of both dietary intake and sun exposure.21
Al Jurayyan et al reported that the majority of
patients in their study presented with non-
specific symptoms such as bone pain, which
caused difficulty in making a clinical diagnosis
in the less-severe cases.10 Similar findings
were reported by Siddiqui, indicating that most
patients presented with non-specific symptoms
or were asymptomatic. Similarly, most of our
patients presented with non-specific symptoms
like bone pain or were asymptomatic.
Siddiqui noted that girls who had severe
vitamin D deficiency were rarely exposed to
the sun, came from lower income families and
that their vitamin D deficiency may be related
to living in smaller, crowded houses with li-
mited internal sunlight.18
Sedrani reported that while Saudi Arabia has
an abundance of sunlight, exposure is gene-
rally limited due to the high daytime tempe-
ratures, which reduce the tendency of people
to go out.8,17,22 Fida agreed with Sedrani that
even though Saudi Arabia enjoys year-round
sunlight, it is common for children in Central
and Western Saudi Arabia to have vitamin D
deficiency.23,24
In our study, it was noted that in patients who
developed secondary osteomalacia due to ste-
roids or anticonvulsants, the diagnosis was
often missed and the patients were not given
vitamin D or calcium supplements.
Our retrospective study was limited by using
medical records as the only source of data and
the fact that these records were limited to
patients seen at the KAMC only. Thus, these
results may not be representing the Saudi
adolescents as a whole. We recommend that a
more detailed and comprehensive study be
considered to confirm our findings in the assess-
ment of the dietary intake of vitamin D and sun
exposure in relation to the onset of osteomalacia.
Our study suggests that nutritional osteoma-
lacia is a health problem seen in adolescents in
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Clinical presentation and etiology of osteomalacia/rickets
Saudi Arabia, even though there is economic
affluence and abundant sunlight. Patients with
low dietary intake of vitamin D or those with
limited sun exposure may be at a risk of deve-
loping osteomalacia. Patients who are on either
steroids or anticonvulsants are similarly at a
risk of developing secondary osteomalacia.
Special attention should be given to preven-
tive measures through education and appro-
priate dietary supplements of vitamin D and
minerals. Outdoor activities with direct or indi-
rect exposure of sunlight are to be encouraged
and supervised. We advise that all patients on
either anticonvulsants or steroids be screened
periodically for osteomalacia and, if they are at
a high risk, should be started on vitamin D and
calcium supplements as prophylaxis.
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