Background:Transient osteoporosis (TOP) or transient bone marrow edema syndrome is an enigmatic condition of unknown etiology first described in pregnant women. Though usually self limited, TOP causes pain and debilitation and predisposes the patient to avascular necrosis or fractures. The course can be protracted and patient may suffer relapses. Diagnostic method of choice is magnetic resonance imaging (MRI). Based on small case series and expert opinion, several therapeutic approaches have been proposed to hasten the recovery, including bisphosphonates, calcitonin, teriparatide. However, the literature is scarce and additional experience is needed to promote the understanding of this condition.Objectives:To present our experience with TOP, including patient’s characteristic, approach to diagnosis, prognosis and therapyMethods:It is retrospective, single center study, conducted in Rambam healthcare campus, Haifa, Israel. All the medical files of patients referred to Rheumatology unit between years 2010-2020 were screened for diagnosis of TOP. Search words included: “osteoporosis”, “bone marrow edema”, “transient osteoporosis”. The files were reviewed for patient’s characteristics, modality of diagnosis, duration until full recovery, treatments and relapses.Results:Eight patients with at least one episode of TOP were identified using the search words. Six patients (75%) were female. Three female patients developed TOP during or shortly after pregnancy. Two patients – one male and one non pregnant female suffered from TOP after bariatric surgery. One pregnant woman had a strong family history of TOP. The most frequent involved site in order of frequency were: hip (4/8), ankle (3/8) and knee (2/8). Six patients presented with more than one simultaneous site of TOP (hips, knees and ankles). Blood count, liver and Kidney function tests, markers of bone resorption, rheumatoid factor, Anti cyclic citrullinated peptide, Antinuclear antibodies were negative in all of the patients. C-reactive protein was elevated in 4/8 patients, Erythrocyte sedimentation rate was elevated in 2/8 patients. All patients had vitamin D deficiency. The diagnosis was confirmed by MRI. All the patients were treated with vitamin D and intra-venous Pamidronate, one patient with addition of calcitonin and one patient with addition of intra venous Iloprost. Time to recovery ranged from 1.2 to 6 months. The time to recovery was the same in pregnancy related TOP. Recovery was confirmed with follow-up MRI in all the patients. Relapses occurred in 4/8 patients and only one them had pregnancy related TOP. All the patients were treated by multidisciplinary team, including orthopedic surgeon, physiotherapist and psychologist when needed.Conclusion:Our experience with TOP was enriched in patients presenting with more than one site of disease probably representing referral bias. Pregnancy related TOP was associated with lower risk of relapse. In terms of time to recovery there was no trend between pregnancy related and non related TOP or one site versus several sited TOP. None of the patients developed fracture, advocating in favor of adding bisphosphonates to therapy. Multidisciplinary approach is an essential part of TOP treatment strategy.Disclosure of Interests:Sami Giryes: None declared, Katya Dolnikov: None declared, Alexandra Balbir-Gurman Consultant of: Novartis, Daniela Militianu: None declared, Natalia Puchkov: None declared, Yolanda Braun-Moscovici: None declared
Letter to Editor - A Clinical ‘PIC- Perspectives, issues & Concerns” on Idiopathic Transient Osteoporosis during Pregnancy with alarm bells on its Idiopathic nature - Response
