Category: Calcium/Bone Disorders

Monitor: 34


Saturday, Apr 27
10:30 AM – 11:00 AM

Objective : To highlight the mostly asymptomatic and benign course of diffuse idiopathic skeletal hyperostosis (DISH) when compared to other skeletal disorders such as Paget disease of bone (PDB) or congenital dysplasias like osteopetrosis.

Methods : N/a

Results : N/a

Discussion : 43-year-old Asian woman with history of systemic lupus erythematosus (SLE), lupus nephritis and Hodgkin’s lymphoma (HL) status-post chemotherapy in remission who presents for generalized hyperostosis of the cranium and facial bones that was incidentally discovered on X-ray during evaluation of a maxillary cyst. She is asymptomatic and denies headaches, dizziness, visual/auditory changes, enlarging hands and feet, deepening voice or back pain. She has no history of previous fractures, family history of osteoporosis or delayed healing after dental procedures. Her medications include prednisone, hydroxychloroquine and lisinopril. Physical examination and laboratory workup were unremarkable with calcium, phosphorus, vitamin D and alkaline phosphatase levels within normal limits. Maxillo-facial CT scan showed thickened mastoid, petrous, temporal and sphenoid bones. Dual-energy X-ray absorptiometry (DXA) scan showed Z-score of 3.0 in lumbar spine (L1-L4), 1.8 in right total hip and 1.6 in left total hip, indicating higher-than-average bone density for her age. Ten-year risk for major osteoporotic and hip fracture using the FRAX score was 2.0% and <0.1%, respectively. Based on these findings and absence of symptoms, DISH was diagnosed. Natural history and prognosis of this condition were explained and patient was instructed to return to clinic if she developed bone pain or fractures.

DISH is a non-inflammatory disorder of unknown etiology characterized by calcification and ossification of spinal ligaments and entheses. Extraspinal involvement is common and virtually any osseous or articular site may be affected. Classic symptoms of DISH include musculoskeletal pain and stiffness in affected areas and reduced spinal motion in advanced cases. In the majority of cases, patients are asymptomatic with diagnosis being made on the basis of incidental radiographic findings. DISH can be associated with systemic conditions such as metabolic syndrome and rheumatoid arthritis; nonetheless, association with SLE or HL has not been reported. DISH has a benign course and does not confer a higher risk of cranial complications, fractures or malignancy as seen in PDB or skeletal dysplasias like osteopetrosis.

Conclusion : It is prudent to recognize DISH in asymptomatic patients presenting with incidental findings of hyperostosis on X-ray. This crucial knowledge can assist healthcare providers in differentiating it from other more concerning conditions.


Gonzalo J. Acosta

Resident Physician
Houston Methodist Hospital
Houston, Texas

I am a very motivated Peruvian physician, currently on my 2nd year of Internal Medicine residency at Houston Methodist Hospital and with a great passion/interest/love for Endocrinology.

Ashkan M. Zand

Endocrinology Fellow
Houston Methodist Hospital
La Porte, Texas

Ashkan Michael Zand is currently the chief fellow at the Houston Methodist Endocrinology Fellowship program. As a native Texan, Dr. Zand attended the University of Houston in which he acquired a B.A in Chemistry and B.S. in Biology. Afterwards, Dr. Zand underwent his medical education at the University of Texas Medical Branch at Galveston where he completed his medical degree and Internal Medicine residency.

Ahmad Yehya

Endocrinology Fellow
Houston Methodist Hospital

A graduate of the American University of Beirut, Lebanon, Dr. Yehya completed his Internal Medicine Residency at the University of Kansas Medical Center. Dr. Yehya has a profound interest in metabolism and participated in various weight management programs and clinics throughout his Residency. Dr. Yehya will be working closely with the weight management program at Houston Methodist with special emphasis on weight loss medications, diet adjustment and exercise. Dr. Yehya is also particularly interested in the impact of lifestyle on diabetes. Dr. Yehya has specifically chosen to pursue his Endocrinology Fellowship at Houston Methodist as this will serve as a great template for launching a successful career in Endocrinology and he hopes to be able to develop weight management centers dedicated to focus on lifestyle changes for the community.

Laila Tabatabai

Assistant Professor of Clinical Medicine; Director, Houston Methodist Endocrinology Fellowship
Houston Methodist Hospital

Laila S. Tabatabai, M.D., is the Program Director of the Houston Methodist Endocrinology Fellowship Program. She is also the Director of the Houston Methodist Hospital Fracture Liaison Service (FLS) and Assistant Professor of Clinical Medicine in the Division of Endocrinology. She received her medical degree, with distinction in research, at Albany Medical College in Albany, New York. Her postdoctoral training included an internship and residency in internal medicine at the University of Maryland Medical Center in Baltimore and a fellowship in endocrinology at Johns Hopkins Hospital in Baltimore.

Steven Petak

Division Chief of Endocrinology, Diabetes and Metabolism
Houston Methodist Hospital

He is a past president of the American Association of Clinical Endocrinologists, the American College of Endocrinology, and the International Society for Clinical Densitometry. He is an associate clinical professor at Weill-Cornell Medical College at the Houston Methodist Hospital and is the division head of endocrinology, diabetes and metabolism as well as service chief of endocrinology. He is a bone densitometry and endocrine consultant to NASA at the Johnson Space Center for about 13 years and has been a part of the bone summit planning long duration space missions. He is the secretary of the board of councilors of the Texas Medical Association (2015) and represents the Harris County Medical Society as vice-councilor.

His awards include Master of the American College of Endocrinology, Yank Coble Public Service Award of the American College of Endocrinology, the ISCD Paul Miller Public Service Award, and ISCD Clinician of the Year. He has authored and co-authored articles, editorials and guidelines in endocrinology and reproductive medicine.

He received his MD from the University of Illinois in Chicago and has his JD from the University of Houston (Magna cum Laude). He had his internship, residency, medical chief residency, and fellowship in endocrinology and metabolism at the University of Texas at Houston. He was at the Texas Institute for Reproductive Medicine and Endocrinology in Houston for about 26 years before joining the academic endocrine group at Methodist in May 2013. He is board certified in internal medicine as well as endocrinology and metabolism. His wife is a veterinarian in private practice and he has 2 children, 4 cats and a dog.