PMC3235277_01
Radiographs, lateral view, of the lower thoracic (a) and lumbar vertebrae (b). Thoracic vertebrae are blurred and lumbar vertebrae show codfish appearance
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Fig1
The lumbar vertebrae had a biconcave codfish appearance (Fig. 1a, b) Bone mineral density measurement (Hologic) showed extremely low absolute values and T-scores (Table 1).
Bone scintigraphy; Whole body, anterior view (a) and detail of the ribs, lateral view (b). Hot spots may indicate pseudofractures or fissures
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Fig2
There were also multiple symmetric focal lesions with enhanced uptake in the ribs, compatible with rib fractures or fissures (Fig. 2a, b).
Crista biopsy; Goldner stain, magnification 5 x 10 (a), Goldner stain, magnification 10 x 10 (b), and Tartrate-resistant acidic phosphatase stain, magnification 10 x 10 (c). Mineralized bone is green and osteoid tissue, red. Osteoid seems very thick, and osteoid volume is 75%. Bone resorption by multinucleated osteoclasts is increased (arrows)
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Fig3
To confirm the clinical diagnosis of osteomalacia in this patient with severe refractory celiac disease and extremely low BMD, a bone biopsy was obtained from the right iliac crest (Fig. 3a-c).