Working Diagnosis:
1. Low impact fracture of the left fifth metatarsal base secondary to osteoporosis
2. Osteoporosis secondary to emtricitabine-tenofovir

Treatment:
Initially patient was placed in boot and slowly transitioned to post op shoe by orthopedics. Patient was also started on physical therapy. Supplementation was performed with calcium and vitamin D.

Outcome:
Patient was able to slowly return to regular activity and participate and complete the marathon without any complications. He continues to have close monitoring and followup with endocrinologist.

Author's Comments:
Multiple risk factors for bone fragility includes low BMI, Hepatitis C, hypogonadism, HIV and antiretroviral therapy. Individuals less than 30 years of age are at increased risk of bone turnover rates and have not attained their peak bone mass. Emtricitabine-tenofovir is the first line of treatment for HIV prophylaxis, but trials like the ASSERT and ACTG have indicated a significant decrease of 1 to 2 percent more in bone mineral density at 48 weeks compared to abacavir-lamivudine with efavirenz or ritonavir. Possible strategies would include interrupted therapy, with increased risk of AIDS and death; bisphosphonate therapy, with increased risk of pill burden, cost and toxicity; or switching from Tenofovir to Raltegravir or Abacavir-lamivudine, but no long term trials has been performed. It is important to discuss possible bone mineral density loss and possible fracture risk with patients being started on PrEP therapy, in addition to recommending calcium and vitamin D supplementation.

References:
1. McComsey, G. A., Kitch D, et al. Bone Mineral Density and Fractures in Antiretroviral-Naive Persons Randomized to receive Abacavir-Lamivudine or Tenofovir Disoproxil Fumarate-Emtricitabine Along with Efavirenz or Atazanavir-Ritonavir: AIDS Clinical Trials Group A5224s, a Substudy of ACTG A5202. Journal of Infectious Diseases 203.12 (2011): 1791-801.
2. Grant, Philip M, Kitch, D., et al. Differential skeletal impact of tenofovir disoproxil fumarate in young versus old HIV-infected adults. HIV Clinical Trials. 16:2 (2015), 66-71, DOI:10.1179/1528433614Z.0000000010.
3. Bloch, M, Tong, W.W, et al. Switch from Tenofovir to Raltegravir increases Low Bone Mineral Density and Decreases Markers of Bone Turnover over 48 Weeks. HIV Medicine. 15.6 (2014): 373-80.
4. Haskelberg, H., Hoy, J.F., et al. Changes in Bone Turnover and Bone Loss in HIV-infected Patients Changing Treatments to Tenofovir-Emtricitabine or Abacavir-Lamivudine.2012. PLoS ONE 7(6): e38377.doi:10.1371/journal.pone.0038377.

Return To The Case Studies List.