Category: Calcium/Bone Disorders
Objective : To describe a case of spontaneous rib fractures in a 35 year-old man with a history of cocaine and heroin addiction.
Methods : N/A
A 35 year-old man with a two-year history of daily heroin, cocaine, and roxicodone abuse presented with severe cough and was treated for chlamydia pneumonia and cocaine induced lung injury. Initial imaging demonstrated a right fifth rib fracture and degenerative changes of osseous and cartilaginous structures of anterior chest wall and spine. Twelve days later, imaging revealed new fractures of the right fourth and sixth ribs.
Laboratory workup for osteoporosis (OP), defined as low bone density for the age, was unremarkable, including vitamin D, 25 hydroxy-calciferol: 24.2ng/mL [n: 20-50 ng/mL], calcium: 8.3 [n: 8.6-10.3 mg/dL], parathyroid hormone: 16.2pg/mL [n: 14-72 ng/mL], thyroid stimulating hormone: 2.65 mlu/L [n: 0.36-5.8 mlu/L], estradiol, 17 beta: 70 pg/mL [n: <40 pg/mL] and testosterone, free: 13 pg/mL [n: 8.7-25.1pg/mL].
The patient did not fall or have trauma during or prior to hospitalization. While the patient was initially healthy, he lost 30lbs (13% of his total body weight) in two years when he was abusing drugs and had decreased caloric intake. On admission, his albumin was 3.3gm/dL and body mass index was 25.7. He had no history of alcoholism, eating disorders, or chronic use of OP-inducing medications.
The patient’s history and laboratory analysis were non diagnostic for known secondary causes of OP. Our patient’s fractures can be explained by an association of OP with cocaine and heroin abuse. Prolonged heroin addiction is associated with accelerated bone turnover and lower than normal bone mineral density (BMD) at an early age. This has been explained by opioids’ inhibition of osteoblast function and osteocalcin synthesis. Seifert et al. have shown that exposure to cocaine is associated with lower bone density than that of a control group in rats.
Our patient likely developed rib fractures secondary to drug abuse rather than calorie restriction and weight loss. The effect of the latter is not significant enough to cause OP and fracture as that of drug abuse over a short period of time. Studies of pre-, peri-, and post-menopausal women and/ or men who had weight loss or calorie restricted diets showed a loss of total BMD ranging from 0-2.5%. In comparison, a study investigating young heroin-dependent patients found that 16% had z-scores in the osteoporotic range.
Prolonged cocaine and heroin abuse may be associated with OP in young adults, resulting in spontaneous fractures. These patients would benefit from routine screening for OP, and if identified, to be offered treatment.
Internal Medicine Resident
NYU Winthrop Hospital
Mineola, New York
Dr. Groysman is an internal medicine resident at NYU Winthrop Hospital
NYU Winthrop Hospital, New York
Dr. Neril is an Endocrinology Fellow at NYU Winthrop Hospital