Cough-Induced Rib Fractures in a Frequent Tea Drinker

Bruce M. Rothschild, MD


August 11, 2020


The anterior-posterior height differential noted on personal examination of the lateral chest x-ray (Figure 1) identified the presence of compression fractures.

Figure 1.

The loss of anterior vertebral height explained her height loss. Height loss does not occur with Scheuermann disease. Her history of rib fractures upon minimal exertion and height loss support a diagnosis of osteoporosis.

Her 10-year history of repeated fractures with minimal trauma and normal erythrocyte sedimentation rate made metastatic disease and tuberculosis unlikely. Her normal calcium-to-albumin ratio made hyperparathyroidism unlikely. A review of her dental films revealed persistence of the lamina dura (Figure 2), which further ruled out hyperparathyroidism.

Figure 2.

Her bone density studies were canceled because examination of the chest x-ray revealed the nature of the problem: osteoporotic compression fractures that had been overlooked in a radiology report.

Multiple factors predisposed this woman to osteoporosis. She is nulligravid (risk factor) and had lost estrogen bone protection (postmenopausal). Consistent ingestion of certain medications, including proton pump inhibitors (eg, omeprazole), reduces bone density.[1] Although the patient drew attention to her excess caffeine (theobromine) ingestion, it was probably not a factor in this case.[2] Ingestion of aluminum hydroxide and magnesium hydroxide, rather than calcium carbonate, lessened her calcium intake. The latter is a significant concern. Her history of asthma suggests a possible exposure to corticosteroids, which is also a known cause of bone loss.


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