Background/Purpose: Pernicious anemia (PA) has been associated with both low spine BMD and increased fracture risk in retrospective cohort studies.  The cause of these observations is obscure.  The purpose of this study is to describe and compare the clinical details of a cohort of PA patients who presented with subacute vertebral compression fractures (SVCF) to one without PA.

Methods: A retrospective cohort study was conducted from a population of 165 patients presenting with SVCF to an outpatient fracture clinic.  The clinical characteristics of 30 PA patients diagnosed at the time of presentation, based on low vitamin B12 levels and the presence of either intrinsic factor (IF) or anti-parietal cell antibodies (APCA), was compared to the remaining 135 without PA.  A complete history and physical exam including review of past medical records and current and past radiographs was performed.  CBC, sedimentation rate, chemistry profile, TSH, urinalysis, vitamin B12, PTH, 25-OH vitamin D, and serum protein electrophoresis was done in all patients.

Results: There were 23 female and 7 male PA patients, ranging in age from 66-96 (mean 79.8 years) with a BMI of 15-31 (mean 25.3).  15 patients were taking thyroid hormone and 10 were on protein pump inhibitors (PPI). 16 patients had previous fractures.  Fractures occurred after falling in 22, lifting in 3, and were spontaneous in 5.  The location of the fracture was between T-11 and L-2 in 65% of the cases and 8 patients presented with multiple fractures.  25 out of the 30 patients with PA had evidence of peripheral neuropathy.  IF was present in 17 patients, APCA in 5, and 8 had both.  25-OH vitamin D was < 20 ng/ml in 8 patients and PTH was >65 pg/ml in 6. A monoclonal gammopathy of undetermined significance (MGUS) was found in 6 PA patients.  There was an increased incidence  of peripheral neuropathy (p=0.002), 25-OH vitamin D < 20 ng/dl (p=0.01), use of PPI (p=0.006), thyroid disease (p=0.01), and MGUS (p=0.05) in the patients with PA.  Age, gender, diabetes, previous fractures, BMI, PTH, fracture location, occurrence of multiple fractures, spontaneous fractures and those occurring with falling or lifting did not differ between the two cohorts.

Conclusion: This cohort of SVCF patients with PA had a higher incidence of peripheral neuropathy, vitamin D deficiency, PPI use, thyroid disease, and MGUS than SVCF patients without PA.  These observations may explain the higher incidence of fractures and low BMD found in previous studies of PA patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/factors-contributing-to-fracture-in-pernicious-anemia-patients-presenting-with-symptomatic-subacute-vertebral-compression-fractures/