A 26-Year-Old Woman Who Uses a Walking Cane Because of Pain

Ricardo Correa, MD; Gauri Behari, MD

Disclosures

September 13, 2019

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 26-year-old woman with a medical history of calcium pyrophosphate deposition disease presents with severe knee pain. She now requires a cane for walking, owing to hip and knee pain. She also has abnormal dentition with tooth loss that required dental implants a few years ago. For 2 years, she has had a nonhealing small avulsion fracture in her right first metatarsal, which is confirmed by radiography.

Physical Examination and Workup

Upon physical examination, the patient is alert, awake, and oriented. Dental implants in the frontal area are noted. Cardiopulmonary examination reveals regular rate and rhythm, with no murmurs. Her lungs are clear to auscultation. Her abdomen is soft, nondistended, and nontender, with normal bowel sounds.

She has no joint swelling but has decreased range of motion of her shoulders, hip, and bilateral knees owing to pain. Her left tibia is tender to palpation.

Laboratory findings reveal the following:

  • Calcium level: 9.2 mg/dL

  • Phosphorus level: 3.7 mg/dL

  • Albumin level: 4 g/dL

  • Vitamin D level: 52 ng/mL

  • Vitamin B6 level: 175 ng/mL

  • Alkaline phosphatase (ALP) level: 12 U/L

The remainder of her laboratory findings, including complete blood cell count, renal function, and liver function test results, are normal.

Imaging studies include the following:

Figure 1.

Figure 2.

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