The prevalence and severity of osteoporosis in patients with type 1 diabetes (T1DM) is increased compared to non-diabetic patients, attributed mainly to insulin deficiency and its positive effects on osteoblast proliferation. The association of T1DM with other autoimmune malabsorptive conditions, such as coeliac disease, predisposing to osteoporosis is not uncommon. However, the co-existence of pancreatic exocrinopathy and T1DM leading to osteoporosis is exceptionally rare. Here we present a case of a 29-year-old female with a 10-year history of suboptimally controlled T1DM presenting with significant weight loss and osteofragility fractures who was found to have chronic malabsorption, prolonged vitamin D deficiency and probable osteoporosis/osteomalacia due to severe pancreatic exocrinopathy.
The patient initially presented with an atraumatic left tibial fracture. The patient had suboptimally controlled T1DM with an elevated HbA1c (10.1-14.7%), proliferative retinopathy, polyneuropathy, nephropathy and autonomic neuropathy. Physical examination revealed reduced muscle strength and body composition confirmed very low skeletal muscle mass (19.2kg) but an elevated fat mass (25.5kg). She had a 4-year history of amenorrhea due to weight-related hypothalamic hypogonadism (low FSH <0.1mu/L and estradiol <70pmol/L). Spinal x-rays demonstrated osteofragility fractures. DXA confirmed a low peak bone mass/osteoporosis with significantly reduced total hip BMD of 0.60g/cm² (t-score of -3.4). Malabsorption was documented with low serum 25-vitamin D (50nmol/L), ferritin (8μmol/L), vitamin B12 (12pmol/L) and faecal elastase (42mcg/G). Coeliac serology was negative.
Therapy was initiated with oral cholecalciferol 5000IU daily, calcium citrate 500mg TDS and Creon pancreatic enzyme capsules 75,000IU TDS. Intensive diabetic management was achieved using a Medtronic-770G Smartguard insulin pump and dietary adjustments. The benefits of parenteral bisphosphonates were considered.
This case highlights the complex nature of osteofragility fractures in a young individual with T1DM and highlights the need for a comprehensive investigation of potential contributing factors. A multifactorial approach to management is vital to ensure overall long-term well-being.