Osteomalacia

Osteomalacia is softening of the bones. Osteomalacia is an abnormality of bone metabolism

characterized by an inability of the body to lay down mineral salts upon the bone matrix.

Causes
A lack of the proper amount of calcium leads to weak and soft bones.

Vitamin D is absorbed from food or produced by the skin when exposed to sunlight. Lack of vitamin D
produced by the skin may occur in people who:

 Live in climates with little exposure to sunlight

 Must stay indoors

 Work indoors during the daylight hours

 Wear clothes that cover most of their skin

 Have dark skin pigmentation

 Use very strong sunscreen

You may not get enough vitamin D from your diet if you:

 Are lactose intolerant (have trouble digesting milk products)

 Do not eat or drink milk products (more common in older adults)

 Follow a vegetarian diet

 Are not able to absorb vitamin D well in the intestines, such as after gastric bypass surgery

Mildly affected patients may present with nonspecific bone pain and
tenderness and possibly hypotonia. Severely affected patients may have
difficulty ambulating and may walk with a waddling gait.

Radiologic: diffuse demineralization: osteoporotic-like pattern

 may show a characteristic smudgy "erased" or "fuzzy" type of demineralization 6
 
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Condition
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Osteopenia unaffected unaffected normal unaffected
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

Multiple myeloma (MM) is a plasma cell malignancy in which monoclonal

plasma cells proliferate in bone marrow, resulting in an overabundance of
monoclonal paraprotein (M protein), destruction of bone, and displacement of
other hematopoietic cell lines. Multiple myeloma is the most common primary malignant bone
neoplasm in adults. It arises from red marrow due to monoclonal proliferation of plasma cells and manifests in a
wide range of radiographic abnormalities.

Signs and symptoms

MM can range from asymptomatic to severely symptomatic with complications requiring
emergent treatment. Presenting signs and symptoms of MM include the following:
 Bone pain
 Pathologic fractures
 Spinal cord compression (from pathologic fracture)
 Weakness, malaise
 Bleeding, anemia
 Infection (often pneumococcal)
 Hypercalcemia
 Renal failure
 Neuropathie
Examination for MM may reveal the following:
  HEENT examination: Exudative macular detachment, retinal hemorrhage, or
cotton-wool spots
 Dermatologic evaluation: Pallor from anemia, ecchymoses or purpura from
thrombocytopenia; extramedullary plasmacytomas (most commonly in
aerodigestive tract but also orbital, ear canal, cutaneous, gastric, rectal, prostatic,
retroperitoneal areas)
 Musculoskeletal examination: Bony tenderness or pain without tenderness
 Neurologic assessment: Sensory level change (ie, loss of sensation below a
dermatome corresponding to a spinal cord compression), neuropathy, myopathy,
positive Tinel sign, or positive Phalen sign
 Abdominal examination: Hepatosplenomegaly
 Cardiovascular evaluation: Cardiomegaly

Disseminated multiple myeloma has two common radiological appearances, although it should be noted that
initially, radiographs may be normal, despite the presence of symptoms. The two main diffuse patterns are:

1. numerous, well-circumscribed, lytic bone lesions (more common)

o punched out lucencies
 raindrop skull 7
o endosteal scalloping
2. generalized osteopenia (less common)
o often associated with vertebral compression fractures/vertebra plana

MRI
MRI is generally more sensitive in detecting multiple lesions compared to the standard plain film skeletal
survey. Infiltration and replacement of bone marrow are exquisitely visualized, and newer scanners are able to
perform whole body scans for this purpose, shown to be superior to both CT and skeletal surveys 8.

Most frequently used MR sequences for the evaluation of bone marrow are conventional T1 spin-echo and T2
spin-echo sequences 11.

Signal characteristics include:

 T1
o typically low signal
o high-grade, diffuse involvement may become isointense to adjacent normal marrow
 T2 with fat-suppression
o high signal
o infiltration of the ribs is probably best appreciated on T2 images with fat suppression, appearing bright:
‘white ribs sign’
 T1 C+ (Gd)
o hyperintense
o several enhancement curves may be seen.
 type 4 curve:
  represents a steep wash-in of contrast medium, due to the high vascularization and perfusion
with leakage through the highly permeable capillaries, followed by an early wash-out back into
the intravascular space because of the small interstitial space with closely packed plasma cells 10-
11

 type 3 and type 5 curves may also be seen.

 DWI/ADC
o lesions can appear as areas of increased diffusivity compared to the very low diffusion of normal
background marrow 11
Laboratory findings include:

 reverse albumin/globulin ratio (i.e. low albumin, high globulin)

 monoclonal gammopathy (IgA and/or IgG peak)
 Bence Jones protein (Ig light chain) proteinuria
 hypercalcemia
 decreased or normal ALP unless there is a pathological fracture due to impaired osteoblastic function