Case description A 63-year-old female recently presented to metabolic bone clinic with vertebral fractures at L4 and L5. DEXA scan showed osteoporosis with T-scores at the spine −4.0 and left hip −3.8. Patient was commenced on weekly Alendronic acid 70 mg, calcium and vitamin D supplements. Patient had severe vitamin D deficiency and was commenced on treatment at primary care. She is on analgesics and physiotherapy for back pain, which was of moderate severity.

She was on oral prednisolone for 5 years for polymyelgia rheumatica in the past and weaned off year ago. Other past medical history includes coronary artery disease; a myocardial infarction requiring coronary artery bypass graft 3 years back. She does not have diabetes or hypertension. She has hypercholeterolaemia; probably polygenic in origin and is on lipid lowering medications since the age of 50 years.

Her alcohol intake is minimal, and is a non-smoker. There is no family history of osteoporosis or cardiovascular disease. Her milk consumption accounted for 300 mg of calcium per day. She has reached menapuase at 43 years of age and has not been on hormonal replacement therapy. Her current medications are Aspirin, Atorvastatin, Bisoprolol and Omeprazole. There is no history of indigestion or dental concerns.

Except mild local tenderness at L4–5 region, rest of the clinical examination is unremarkable.

Recent blood investigations showed normal calcium, inorganic phosphate, PTH and vitamin D. Alkaline phosphatase (195 IU/L) and P1NP (55 ug/L) were raised. Renal functions showed normal creatinine with eGFR of 62 mL/min. Full blood count is unremarkable. Serum and urine electrophoresis excluded multiple myeloma.

Summary This is a case of severe osteoporosis involving vertebral fractures requiring osteoporosis treatment. Possible causes for osteoporosis would be previous use of oral steroids for long time and severe undiagnosed vitamin D deficiency. Hypercholesterolaemia and significant history of ischaemic heart disease are other concomitant diagnoses.

Disclosure of Interest None declared