Diffuse non-localized bone pain

Specialty: General.

• generalized bone pain
• diffuse bone discomfort
• skeletal pain

Why it occurs

• Osteomalacia or severe and prolonged vitamin D deficiency (which prevents adequate mineralization of the osteoid matrix, causing a bone that is soft and painful to touch and pressure)
• Multiple myeloma or diffuse neoplastic infiltration of the bone marrow (clonal proliferation of plasma cells that secrete osteoclast-activating factors)
• Primary or secondary hyperparathyroidism (excessive secretion of PTH that stimulates accelerated bone resorption by releasing calcium into the bloodstream)
• Chronic multifocal osteomyelitis or systemic fungal infections with bone tissue involvement
• Paget's disease of bone with polyostotic presentation (abnormal, disorganized and accelerated bone remodeling).

Initial workup

Dosage of 25-hydroxyvitamin D, serum and urinary calcium, serum phosphorus, total alkaline phosphatase and its bone fraction, intact parathyroid hormone (iPTH), serum protein electrophoresis and immunofixation (to rule out myeloma), and complete radiographic bone series or bone scan with Technetium 99.

Standard management

• Cholecalciferol — vitamin D3, 50,000 IU orally once a week for 8 weeks if severe vitamin D deficiency is confirmed, followed by maintenance
• Calcium carbonate — 500 to 1000 mg per day orally as a mineralization substrate
• Zoledronic acid or bisphosphonates (4 mg intravenously, indicated if the pain is secondary to tumor bone resorption or severe osteoporosis, under close monitoring of renal function).