{"id":2214,"date":"2019-09-09T19:42:53","date_gmt":"2019-09-09T19:42:53","guid":{"rendered":"https:\/\/www.mc.vanderbilt.edu\/vanderbiltmedicine\/?p=2214"},"modified":"2021-08-11T19:36:21","modified_gmt":"2021-08-11T19:36:21","slug":"pain-weakness-fractures","status":"publish","type":"post","link":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/pain-weakness-fractures\/","title":{"rendered":"Broken"},"content":{"rendered":"

\"\"<\/a><\/p>\n

David Covington didn\u2019t want to leave behind his hometown of Iowa City to move to Nashville, but when his wife, Natalie, wanted to follow her PhD adviser to Vanderbilt University School of Medicine and continue her education in Tennessee, Covington supported her.<\/p>\n

Little did he know then the move might dramatically alter the fate of his health.<\/p>\n

Shortly after the couple packed up their belongings and headed south in July 2016, Covington noticed unusual symptoms. He was having trouble keeping up while walking, had mild pain in his lower back and felt a noticeable discomfort and weakness throughout his body.<\/p>\n

\u201cWe went back to my parents\u2019 house in Iowa for Thanksgiving that year, and I was trying to mow their lawn, and I couldn\u2019t get the lawnmower started,\u201d said Covington.<\/p>\n

A high school history and psychology teacher at East Nashville Magnet High School, Covington was only 26 and had no prior medical conditions.<\/p>\n

As soon as the symptoms became concerning, he scheduled an appointment with a local orthopaedist, who diagnosed him with a degenerative disk in his lower back and referred him to physical therapy. Several rounds of therapy proved unsuccessful, and his pain was worsening.<\/p>\n

Covington saw a second orthopaedist, whose X-rays discovered fractures in his hips. He was told the fractures were only slight and should heal themselves.<\/p>\n

As the pain intensified, he saw a rheumatologist, who, after six months of careful watching, diagnosed him with psoriatic arthritis. Covington underwent several months of treatment only to find that a marker in his blood that should have decreased dramatically had only increased.<\/p>\n

In less than two years, what began as proximal weakness in his abs and hips turned into an unexplained inability to walk.<\/p>\n

\u201cHonestly, I thought I was crazy and that it was all in my head. It was really hard for my wife and me,\u201d said Covington, who had become so weak he began falling, causing more fractures throughout his body. With fractures in his ribs, ankles and femur, his condition limited his teaching abilities to his chair for the 2017-2018 school year, and he had to roll himself around the room to hand out papers. His weak state also caused him to fall in front of his class.<\/p>\n

 <\/p>\n

Diagnosing a rare disease<\/strong><\/p>\n

When Covington was referred to Kathryn Dahir, MD, an endocrinologist at Vanderbilt University Medical Center, at the end of March 2018 \u2014 almost two years after his symptoms began \u2014 he was ready for answers.<\/p>\n

\u201cBy the time I got to Dr. Dahir, I was just ready to get a diagnosis of some sort. She was really comforting, because she would write everything down on a sheet of paper while she was talking to us and explain it all. For the first time, I felt like there was an appropriate level of confidence,\u201d said Covington.<\/p>\n

\"\"<\/a>
Kathryn Dahir, MD. Photo by Joe Howell.<\/figcaption><\/figure>\n

\u201cWhat was interesting about David was that he was a young, otherwise healthy man who had become progressively and rapidly disabled. His degree of disability was profound for somebody of his age,\u201d said Dahir. \u201cHe was someone who required the use of assistive walking devices to even come into clinic, and he had so much proximal weakness that he couldn\u2019t get up on the exam table by himself.\u201d<\/p>\n

Dahir recognized that symptoms this severe meant something unusual was likely happening with Covington\u2019s bone metabolism. She ran a series of blood tests to check his levels of phosphorous and FGF23 \u2014 a hormone normally made by bone cells to regulate phosphorous levels, preventing an excess. Covington showed a relatively low phosphorous level and an elevated level of FGF23, hinting that a tissue other than bone may have been inappropriately depleting phosphorous.<\/p>\n

Because bones are made from a mix of calcium, phosphorous and magnesium, low levels of phosphorous cause the skeletal matrix to become soft, leading to fractures and causing pain in the affected bones. The condition is known as osteomalacia.<\/p>\n

From her extensive experience in endocrinology, Dahir knew that a possible cause of osteomalacia is a small benign tumor hiding somewhere in the body, typically in the hands, feet or nasal cavities. Known as tumor-induced osteomalacia (TIO), the condition is rare, and each case is often a medical mystery unto itself.<\/p>\n

A PET scan confirmed Dahir\u2019s suspicions \u2014 a small section the size of the tip of a pinky finger lit up in Covington\u2019s brain directly under his temporal lobe, indicating a mass. The tumor\u2019s location caused Dahir to think twice about TIO being the correct diagnosis.<\/p>\n

\u201cHere, you have a really rare disease in and of itself coupled with the rarest place you can find a tumor like this,\u201d said Dahir.<\/p>\n

No matter where the tumor is located, it can have the same effect on the bones. Dahir referred Covington to Reid Thompson, MD, William F. Meacham Professor of Neurological Surgery and chair of the department, for a second opinion.<\/p>\n

\u201cDr. Dahir sent me a message saying, \u2018I have a patient who I think may have TIO and has an intracranial mass. Would you see him?\u2019 I had never heard of TIO,\u201d said Thompson.<\/p>\n

Despite his opinion that Covington\u2019s condition was outside the realm of anything a neurosurgeon would ever see, Thompson visited with Covington less than a week later. A brief look at his MRI convinced him that Covington\u2019s tumor was nothing more than a benign meningioma \u2014 a condition that encompasses roughly 90% of the patients Thompson sees in his clinic. Because they are benign, many meningiomas may be safely monitored without surgery.<\/p>\n

\u201cMy thought was that I\u2019d go into David\u2019s room and say, \u2018This looks like a meningioma to me. We\u2019re not going to do an operation to take out this small benign tumor because that\u2019s invasive brain surgery. We\u2019ll do another MRI in six months like we do with other patients with incidentally discovered meningiomas.\u2019<\/p>\n

\u201cBut, something stopped me before I went into the room,\u201d said Thompson.<\/p>\n

 <\/p>\n

Right place, right time, right spouse<\/strong><\/p>\n

Acknowledging his lack of understanding about TIO \u2014 the presumed diagnosis Dahir had sent over with Covington\u2019s case \u2014 Thompson and a resident Googled the condition. The search only yielded three or four articles.<\/p>\n

\u201cThe synopsis was that these tumors can masquerade as meningiomas and occur in the skull base,\u201d said Thompson. \u201cBut the key thing in these reports that stood out to me was a statement saying, \u2018You can\u2019t miss this diagnosis, because if you remove the tumor and it is truly pumping out FGF23, you can cure these patients.\u2019<\/p>\n

\u201cI went into David\u2019s room, and we talked about it, and I said, \u2018If you asked 99 neurosurgeons what this is, they would tell you it\u2019s a meningioma, and that\u2019s kind of what I think it could be too. But, if it really is the culprit, we should surgically remove it, because it could cure you.\u201d<\/p>\n

Unbeknownst to Dahir and Thompson, Covington\u2019s wife, Natalie, who is earning a PhD as a researcher, had brought a manila folder filled with PubMed articles about TIO to both appointments, prior to the potential diagnosis ever being raised.<\/p>\n

\"\"<\/a>
Natalie Covington, a PhD candidate in Hearing and Speech Sciences, was determined to find the cause of her husband, David\u2019s, debilitating bone fractures. Photo by Joe Howell.<\/figcaption><\/figure>\n

\u201cMy wife had read all about tumor-induced osteomalacia even before we received the diagnosis. She brought 11 case studies to my appointment with Dr. Thompson. She somehow found it online,\u201d said Covington. \u201cTalk about being fortunate \u2014 if anyone else was my wife, the outcome could have been completely different.\u201d<\/p>\n

\u201cNatalie was tenacious about this. She had studied and researched it, and she was going to figure this out. She was determined to get David the right care. Her determination struck me from the beginning,\u201d said Thompson.<\/p>\n

Covington agreed to the surgery, and on July 12, 2018, his tumor was removed. The results of his pathology required a week of waiting, but Covington began feeling better immediately. His FGF23 levels dropped back to normal, and everything else normalized with it. He was released to Vanderbilt Stallworth Rehabilitation Hospital five days later, where he spent three weeks recovering before continuing outpatient treatment at the Vanderbilt Dayani Center.<\/p>\n

\u201cBy the time I left Stallworth, I was able to climb a flight of stairs, which was great, because we live on the second floor of our building without an elevator. My first week at Stallworth, I remember being told we should consider moving,\u201d said Covington.<\/p>\n

By September, he was back to teaching, and a month later, he finished physical therapy altogether.<\/p>\n

\u201cMy body was just ready to go \u2014 it wanted to be well,\u201d said Covington. \u201cI started running this summer, which I had never done before. My wife and I have gone to some swing dances. It felt good to feel like I could be an active participant in my own classroom again.\u201d<\/p>\n

\u201cIn six months, David went from walker, to cane, to nothing, to square dancing. He is healing his osteomalacia and has corrected all of his metabolic abnormalities due to low phosphorous levels. It has been so rewarding to see someone get better so quickly,\u201d said Dahir, noting that many cases of TIO likely go undiagnosed for far longer than two years. Serum phosphorous levels are not often checked on a comprehensive metabolic profile, making the condition easy to miss for anyone who has never seen it before.<\/p>\n

\u201cI think we all got lucky because David and Natalie both pressed for a diagnosis and did their research. They have been such active participants in David\u2019s care. It doesn\u2019t get more patient-centered than that,\u201d said Dahir. \u201cI am so grateful to have been a part of David and Natalie\u2019s journey.\u201d<\/p>\n

 <\/p>\n

A humbling experience<\/strong><\/p>\n

For Thompson, the takeaways from Covington\u2019s case go far beyond a lesson in TIO.<\/p>\n

\"\"<\/a>
Reid Thompson, MD. Photo by Joe Howell.<\/figcaption><\/figure>\n

\u201cThis experience was humbling for me. Can you imagine me walking into David\u2019s room and saying, \u2018I\u2019m an expert, and you have a meningioma?\u2019 We can consider ourselves experts, but there are a lot of things we don\u2019t know, and that\u2019s the lesson I\u2019ve tried to teach our residents,\u201d said Thompson, who has been practicing medicine for 30 years.<\/p>\n

\u201cYou have to take the time to get as much information as you can before you walk into a room, meet a patient and develop a plan, especially if it\u2019s going to involve an operation. You need to be humble enough to say, \u2018I\u2019ve never heard of TIO. I better learn something about it.\u2019 You have to continually re-educate yourself. That\u2019s medicine. And if you do that, good things can happen.\u201d<\/p>\n

Covington\u2019s latest scans in March 2019 showed his bone density level has returned to normal, and his fractures have healed. He has a one-year follow-up scheduled for August, and his brain will continue to be monitored for changes out of caution.<\/p>\n

He feels lucky to have been in the right place at the right time.<\/p>\n

\u201cI was pretty bummed when we had to move to Nashville, but then being here turned out to be exactly where I needed to be \u2014 in a city where there\u2019s a hospital with Dr. Dahir and Dr. Thompson,\u201d said Covington. \u201cBoth of them were so friendly, and we were impressed with the quick diagnosis. They really blew us away. I\u2019m so grateful.\u201d n<\/p>\n

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David Covington didn\u2019t want to leave behind his hometown of Iowa City to move to Nashville, but when his wife, Natalie, wanted to follow her PhD adviser to Vanderbilt University School of Medicine and continue her education in Tennessee, Covington supported her. Little did he know then the move might dramatically alter the fate of…<\/p>\n","protected":false},"author":211,"featured_media":2440,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2},"_links_to":"","_links_to_target":""},"categories":[13,14,15],"tags":[],"class_list":["post-2214","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-fall-2019","category-vm-features","category-vm-homepage-highlights"],"acf":[],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/cdn.vanderbilt.edu\/t2-main\/medschool-prd\/wp-content\/uploads\/sites\/82\/2019\/09\/slide7-1.jpg","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/pcDnub-zI","_links":{"self":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts\/2214","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/users\/211"}],"replies":[{"embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/comments?post=2214"}],"version-history":[{"count":1,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts\/2214\/revisions"}],"predecessor-version":[{"id":2961,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/posts\/2214\/revisions\/2961"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/media\/2440"}],"wp:attachment":[{"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/media?parent=2214"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/categories?post=2214"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/wp-json\/wp\/v2\/tags?post=2214"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}