Cutaneous tuberculosis (TB) is a rare manifestation of extrapulmonary TB, accounting for only 1-1.5% of cases. Among its various forms, cutaneous miliary TB is exceptionally uncommon and often presents with nonspecific clinical features. This makes early diagnosis challenging, especially in individuals who are immunocompromised. We report the case of a 67-year-old woman who presented with a 6-month history of multiple painful, nonhealing ulcers over the mons pubis, perivulvar area and left upper arm. Despite multiple courses of antibiotics, there was no improvement. Clinical examination revealed multiple well-defined ulcers with yellowish discharge. The patient had no history of bacille Calmette-Guérin vaccination. Tissue GeneXpert analysis from the ulcer confirmed Mycobacterium tuberculosis, and chest radiography revealed bilateral pulmonary nodules consistent with miliary TB. Imaging of the spine also showed features of spinal TB. The patient was diagnosed with miliary TB and was initiated on standard antitubercular therapy. Significant clinical improvement was noted within 1 month of treatment. This case highlights the importance of considering cutaneous TB, including its rare miliary form, in the differential diagnosis of chronic nonhealing ulcers, particularly in endemic areas or in patients with systemic symptoms. Early diagnosis and appropriate therapy are crucial for favourable outcomes.

Chromoblastomycosis is a deep fungal infection of the skin and subcutaneous tissue. This case underscores the critical importance of thorough laboratory investigations, particularly histopathology, in chronic dermatological conditions that mimic other granulomatous diseases. Misdiagnosis, such as treating chromoblastomycosis as cutaneous tuberculosis without confirmatory testing, can delay appropriate therapy and prolong morbidity.

Shiitake mushroom-induced flagellate dermatitis is a rare but important condition to consider in patients presenting with pruritic skin lesions following mushroom ingestion, especially in regions where such cases are uncommon. Early recognition and appropriate management with oral and topical steroids are crucial for effective symptom resolution and preventing complications. Clinicians should be aware of the characteristic rash and the temporal relationship between mushroom consumption and rash onset. Educating patients about the risks associated with consuming raw or undercooked shiitake mushrooms is essential to prevent recurrence.

The clinical presentation of primary hyperparathyroidism (PHPT) has evolved over the years from a symptomatic disorder to a predominantly asymptomatic condition. Altered vitamin D metabolism seems to play a role in the presentation of PHPT and may exacerbate the severity of disease. The epidemiology of PHPT differs in the developing versus the developed world, where more severe phenotypes occur in regions where vitamin D deficiency is common. Although it has been validated that patients with PHPT should be vitamin D sufficient, the threshold to supplement in relation to the severity of PHPT and the degree of vitamin D deficiency remains controversial. This review will highlight some of the controversy regarding vitamin D deficiency and the different phenotypes of PHPT.

We report a case of a 93-year-old woman with PHPT secondary to a left inferior parathyroid adenoma. The patient met criteria to be a surgical candidate; however, literature about parathyroidectomy in the elderly was limited and controversial. The patient remained stable through medical management for the next 5 years.

Abstract Pelvic osteomyelitis is an uncommon and challenging condition to treat. Pressure ulcers, spinal injuries, contiguous sources of tracking infections, pelvic surgical procedures, traumatic injuries and open fractures all serve as nidi for developing pelvic osteomyelitis. We present a case of pelvic osteomyelitis suspected to be caused by insufficiency fractures due to osteoporosis in an anorexic adult.51 year old postmenopausal Caucasian female with undiagnosed anorexia presented to the hospital for severe right-sided pelvic pain and nausea. She denied fevers, vomiting, trauma, surgical procedures, history of pelvic infections, abnormal vaginal discharge, travel, prolonged steroid therapy. She disclosed a strict vegetarian diet, excessive daily exercise, low dairy intake and over 100lb intentional weight loss over the past 30 years. She reported normal menses, used oral contraceptives between ages of 25 to 30, and reached menopause at 49 years. For many years, she denied medical care including age-appropriate cancer screenings. She is employed in academia and denies tobacco, alcohol or drug use. On admission, height 153cm and weight 43kg, BMI 16.7kg/m2. Examination was notable for frail body habitus, moderate RLQ and pelvic tenderness, prominent PSIS and SI joints with decreased RLE range of motion. Laboratory results showed calcium 9.5mg/dL (n 8.6–10.4), phosphorus 4.1mg/dL (2.5–4.5), ALP 181IU/L (45–115), PTH 23pg/dL (n 9–76), Vitamin D 35ng/dL (n 25–80), 24-hour urinary calcium 285mg/24h (n 50–400). Abdominopelvic CT scan showed chronic right pubic ramus and bilateral sacral insufficiency fractures confirmed on MRI with septic arthritis of the pubic symphysis, osteomyelitis of pubic bodies and intramuscular abscess extending to the right adductor muscle. Wound culture was positive for Streptococcus viridans and pelvic bone biopsy showed degenerative changes. The patient completed IV Ceftriaxone therapy and underwent DXA scan confirming osteoporosis (T-scores:-3.8 lumbar spine L1-L4, -3.6 left femoral neck, -3.3 right femoral neck). Alendronate 10mg daily and calcium citrate-vitamin D 1000mg-800IU twice daily was prescribed. Diagnostic workup for secondary causes of severe osteoporosis was unremarkable except for hypercalciuria, for which calcium supplement was held with a plan to repeat in the future. Concern for her cachectic appearance and severity of her illness also elicited a dietician referral. Pelvic osteomyelitis and septic arthritis are seldom found without inciting insults. We report an atypical cause of presumed anorexia induced osteoporosis resulting in pelvic osteomyelitis. Untreated osteoporosis may lead to fracture, resulting in inflammation and predisposing patients to infections. Thus, early recognition and evaluation of osteoporosis in patients at high risk for fracture, such as patients with anorexia, is critical for prevention.

Abstract Objective To present a case of using Abaloparatide (PTHrP 1–34 analogue) to promote spinal fusion in a patient with history of cervical instability s/p multiple cervical operations with non-union. Case Presentation 66 year-old female with a history of multiple sclerosis, obesity and hypothyroidism underwent neurosurgical evaluation of neck pain. She was found to have cervical spinal stenosis causing neck pain, radiculopathy, motor deficits and ataxia. Initially underwent anterior cervical discectomy and fusion which temporarily alleviated symptoms before suffering nonunion. Subsequently underwent two additional surgeries which also eventually failed. She presented to our facility for revision corpectomy and spinal fusion. Given her history of nonunion, endocrinology was consulted for evaluation of metabolic bone disease. No known personal or family history of metabolic bones disease. No history of chronic steroid use. Initial endocrine evaluation excluded common pathologies. A decision was made to pursue anabolic osteoporosis therapy to attempt to augment the spinal fusion process. Patient started on Abaloparatide 80mcg daily 2 weeks post procedure with planned 12-week therapy course. Cervical CT at 3 and 6 months showed post-surgical cervicothoracic fusion with no signs of non-union. Discussion Abaloparatide is a 34 amino acid synthetic analogue of parathyroid hormone related peptide (PTHrP) which works by selectively activating PTH1 receptor found on osteoblasts. Currently anabolic therapies are only FDA approved for treatment of osteoporosis but there is reported off label use in cases of spinal fusions, arthroplasty and fracture healing. Studies have shown that presence of PTH and PTHrP are necessary for fracture healing. Animal studies have also shown that intermittent PTH promotes spinal fusion. This case represents a novel use for Abaloparatide to augment spinal fusion in a human clinical model. Conclusion Further studies are warranted to better understand mechanism of action, drug timing and duration for optimal treatment of anabolic therapies in bone fractures and healing. The use of anabolic therapies like Abaloparatide can be considered in patients undergoing spinal fusion surgery at high risk for non-union or undergoing revision for failed fusion.ReferencesO’Loughlin PF, Cunningham ME, Bukata SV et al. Parathyroid Hormone Augments spinal fusion, fusion mass, and fusion mass quality in a rabbit spinal fusion model. Spine 2009 January; 34: 121–130

Bisphosphonates are the most commonly prescribed treatments for osteoporosis in both postmenopausal women and men. They inhibit bone resorption by osteoclasts and indirectly reduce bone formation coupled to resorption without direct effects on bone formation by osteoblasts. Several of the nitrogen-containing bisphosphonates (N-BP) have been shown to reduce the risk of fractures of the spine, proximal femur and non-vertebral fractures in prospective placebo-controlled studies up to 4 years long. While fracture risk reduction implies improved bone strength and bone strength cannot be measured in individual patients, current models indicate that decreased bone resorption results in both improved bone microarchitecture and greater bone mass, and that both effects contribute to bone strength. All bisphosphonates share the "bisphosphonate" P-C-P structure responsible for their affinity for hydroxyapatite on bone surfaces, while the chemistry of the moiety linked to the central carbon results in their inhibition of osteoclast-mediated bone resorption. The pharmacokinetic profiles of all N-BPs are similar and differ substantially from most other drugs. Oral bioavailability is <1% and they must be administered fasting or via intravenous (IV) infusion. BPs in blood distribute quickly to bone surfaces or are eliminated in urine. The half-life of BPs on bone surfaces is 3–5 weeks, where they inhibit osteoclasts that form resorption lacunae on BP-coated surface. Their long bone-surface half-life allows weekly, monthly and even yearly treatment regimens. BPs are not metabolized and may be incorporated into new bone, where they are not pharmacologically active unless a subsequent round of bone remodeling results in their resorption. When BP treatment is stopped, bone resorption increases in two phases. The first phase occurs over weeks to months as the concentration on the surface of bone decreases. If enough BP has been incorporated into new bone formed during prior treatment, that bisphosphonate may be released and again inhibit bone resorption. The second phase of post-treatment resorption increase occurs gradually as BP within bone decreases (estimated half-life with bone is approximately 5 years). Upper gastrointestinal symptoms are the only common side effects of oral bisphosphonates and may require use of an intravenous formulation. Less common side effects include musculoskeletal pain that begins several months after the start of treatment and resolves when treatment is interrupted. Two rare potential side effects (osteonecrosis of the jaw and atypical femoral fractures) limit broader patient acceptance and lead to the use of a "drug holiday" after 3–5 years of treatment to reduce side effect risk. Controlled clinical trials are required to determine the persistence of both fracture risk reduction and risk of adverse events (including atypical femoral fractures) after long-term (3–5 years) treatment with bisphosphonates is either discontinued, continued at the same dose or continued at a lower dose, to develop an evidence-based approach to the use of drug holidays.

The incidence and prevalence of diabetes continues to increase, and proper understanding of the adverse effects on bone metabolism is important. This review attempts to discuss the pathophysiology of the effects of diabetes and diabetic medications on bone metabolism and bone health. In addition, this review will address the mechanisms resulting in increased fracture risk and delayed bone healing to better treat and manage diabetic patients in the orthopedic clinical setting.

Objective: The concomitant presence of three histopathologically different lesions in the pituitary gland is a rare occurrence. We present a case of a woman with a large pituitary mass composed of a growth hormone–producing microadenoma, lymphocytic hypophysitis, and a Rathke cleft cyst.Methods: The clinical presentation, laboratory data, imaging studies, and pathology report of the patient's hospital course are described.Results: A 35-year-old woman presented with complaints of fever, persistent headaches, and amenorrhea for 1 year. The patient noted snoring, increase in shoe size, and bilateral hand edema for 3 months. Evaluation revealed a suprasellar mass measuring 2.1 × 1.7 × 2.7 cm with an upward mass effect on the optic chiasm. The physical exam revealed frontal bossing, wide-spaced teeth, prognathism, and sausage digits. Hormonal evaluation was consistent with acromegaly. She underwent a transsphenoidal resection of the lesion, and pathology revealed a growth hormone–producing microadenoma, lymphocytic hypophysitis, and a Rathke cleft cyst.Conclusion: Reports have identified the co-existence of ruptured Rathke cleft cysts with lymphocytic hypophysitis, the presence of Rathke cleft cyst with growth hormone–producing pituitary adenomas, and lymphocytic hypophysitis with growth hormone–producing adenomas. However, we are not aware of any reports of the presence of these three lesions in a single pituitary.Abbreviations: IGF-1 = insulin-like growth factor 1; MRI = magnetic resonance imaging

The precursor of the active form of vitamin D, 25-hydroxyvitamin D (25(OH) D), is recognized as the optimal indicator of vitamin D status. Vitamin D3 undergoes conversion through a multitude of enzymatic reactions described within the paper, and vitamin D levels are dependent on many factors including the vitamin D binding protein (DBP). The free hormone hypothesis postulates that protein-bound hormones are not biologically available and that unbound hormones are biologically active. The majority of circulating 25(OH) D and 1,25-dihydroxyvitamin D is tightly bound to DBP and albumin, with less than 1% circulating in an unbound form. As a result, factors affecting DBP alter the interpretation of 25(OH) D levels. The aim of this review is to assess the current methodology used to measure total and free 25(OH) D, and DBP. Additionally, we analyze the effects of other endocrine hormones and disease processes on DBP levels and subsequently, the interpretation of 25(OH)D levels.