Recurrent vertebral fractures in a young adult: a closer look at bone health in type 1 diabetes mellitus

The association between type 1 diabetes mellitus (T1DM) and bone health has garnered interest over the years. Fracture risk is known to be increased in individuals with T1DM, although bone health assessment is not often performed in the clinical setting. We describe the case of a 21-year-old male with longstanding T1DM with multilevel vertebral fractures on imaging, after presenting with acute back pain without apparent trauma. Dual-energy X-ray absorptiometry (DXA) revealed significantly reduced bone mineral density at the lumbar spine and femoral neck. Extensive investigations for other secondary or genetic causes of osteoporosis were unremarkable, apart from moderate vitamin D deficiency. High-resolution peripheral quantitative computed tomography and bone biospy revealed significant alterations of trabecular bone microarchitecture. It later transpired that the patient had sustained vertebral fractures secondary to unrecognised nocturnal hypoglycaemic seizures. Intravenous zoledronic acid was administered for secondary fracture prevention. Despite anti-resorptive therapy, the patient sustained a new vertebral fracture after experiencing another hypoglycaemic seizure in his sleep. Bone health in T1DM is complex and not well understood. There are significant challenges in the assessment and management of osteoporosis in T1DM, particularly in young adults, where fracture prediction tools have not been validated. Clinicians should be aware of hypoglycaemia as a significant risk factor for fracture in patients with T1DM. Learning points: Type 1 diabetes mellitus (T1DM) is a secondary cause of osteoporosis, characterised by reduced bone mass and disturbed bone microarchitecture. Hypoglycaemic seizures generate sufficient compression forces along the thoracic column and can cause fractures in individuals with compromised bone quality. Unrecognised hypoglycaemic seizures should be considered in patients with T1DM presenting with fractures without a history of trauma. Patients with T1DM have increased fracture risk and risk factors should be addressed. Evaluation of bone microarchitecture may provide further insights into mechanisms of fracture in T1DM. Further research is needed to guide the optimal screening and management of bone health in patients with T1DM. Background Type 1 diabetes mellitus (T1DM) is an immune-mediated condition culminating in the destruction of pancreatic beta cells, which are necessary for insulin production. T1DM is commonly diagnosed in childhood and young adults, thus reflecting the burden of this chronic disease in a young population, who are ultimately at risk of the long-term complications of diabetes. In recent years, there has been growing interest and awareness of the pathophysiology and mechanisms behind diabetic bone disease. Although T1DM is an established risk factor for osteoporosis and fracture, bone health in patients with T1DM is not routinely assessed. This may be in part due to the lack of guidelines for fracture risk assessment and management of such patients, particularly in children and young adults. We present the challenges in diagnosis and management of recurrent fractures secondary to hypoglycaemic seizures in a patient with T1DM.