Background
Medication related osteonecrosis of the jaw (MRONJ) is a rare complication of antiresorptive medications such as bisphosphonates and denosumab which are frequently used in the treatment of malignancy and osteoporosis. We describe a case of stage 3 MRONJ initially treated with teriparatide complicated by persistent hypercalcaemia.
Case Presentation
A 79-year-old women presented to the emergency department with a 1 week history of worsening right submandibular mass on a background of osteoporosis treated with denosumab for 7 years and recent nephrectomy for renal cell carcinoma. She did not undergo any recent dental procedures but had ill-fitting top and bottom dentures. Her initial corrected calcium was 2.55 mmol/L. She was diagnosed as stage 3 MRONJ and received
incision and drainage, antibiotics and commenced on a course of teriparatide 20mcg daily. She represented 1 month later with symptomatic PTH-independent hypercalcaemia which persisted despite cessation of teriparatide. Her corrected calcium at representation was 2.89 mmol/L with a PTH of 1.5 mmol/L. After exclusion of malignancy, hypercalcaemia in the setting of denosumab cessation and rebound phenomenon was considered.
Conclusions
We describe a challenging case of severe osteoporosis complicated by MRONJ and at risk of vertebral fracture following sudden cessation of denosumab. Further treatment with teriparatide remains contraindicated in the setting of persistent hypercalcaemia and use of antiresorptives for her hypercalcaemia is restricted due to concurrent MRONJ.