Can I write a case report about this 64‑year‑old female nurse with primary hyperparathyroidism, hypothyroidism, adrenal incidentaloma, osteoporosis managed with alendronate, ibandronate, denosumab, and romosozumab who developed an atypical subtrochanteric femur fracture, and is such a report worth publishing?

Is This Case Worth Publishing?

Yes, this case is absolutely worth publishing as it represents a rare and clinically significant intersection of primary hyperparathyroidism (PHPT), prolonged denosumab therapy, and atypical femoral fracture (AFF) in a bisphosphonate-exposed patient, with the added complexity of subsequent parathyroidectomy and transition to romosozumab therapy.

Why This Case Merits Publication

Unique Clinical Features

This case presents several noteworthy elements that distinguish it from existing literature:

The Denosumab-AFF Connection in PHPT Context

• While AFFs have been reported with denosumab 1, the combination of denosumab-associated AFF in a patient with concurrent untreated PHPT is exceptionally rare
• Your patient had 5+ years of denosumab exposure (2018-2020, then restarted September 2024) with prior bisphosphonate exposure (alendronate, ibandronate), developing bilateral pedicle fractures and ultimately an atypical subtrochanteric femur fracture in April 2026
• Only 8 bisphosphonate-naïve patients with denosumab-associated AFF have been reported 1, and your case adds to the limited literature on denosumab AFFs in bisphosphonate-exposed patients with metabolic bone disease

The PHPT Management Dilemma

• Your patient had documented PHPT since 2018 (PTH 110-193, calcium 9.2-10.5) that was managed expectantly for 8 years before parathyroidectomy in 2026
• The progression from "normocalcemic" hyperparathyroidism to overt hypercalcemia (calcium 10.5) with declining renal function (GFR 48) and rising PTH (193) demonstrates the natural history of untreated PHPT
• The development of AFFs while PHPT remained untreated raises important questions about whether the metabolic milieu of PHPT contributed to fracture risk beyond antiresorptive therapy alone

The Therapeutic Sequence Challenge

• The case illustrates the complex decision-making around timing of parathyroidectomy relative to denosumab dosing 2
• Post-parathyroidectomy transition to romosozumab represents cutting-edge management, with only two prior case reports of romosozumab after parathyroidectomy 3
• The rheumatology note's concern about performing parathyroidectomy while on romosozumab due to hypocalcemia risk highlights a genuine clinical dilemma not well-addressed in guidelines

Novel Contributions to Literature

Bilateral Pedicle Fractures as Harbingers

• The bilateral L3 and L4 pedicle fractures in January 2025 preceded the classic subtrochanteric AFF by 15 months
• This progression pattern in the setting of denosumab and untreated PHPT has not been well-described
• The neurosurgeon's note correctly identified these as "unusual and likely related to osteoporosis," but the connection to impending AFF was not recognized prospectively

Denosumab Discontinuation and Rebound

• Your patient had denosumab stopped in 2020 (when T-scores improved to osteopenia range) but was restarted in September 2024
• The 4-year gap without transition therapy likely contributed to rebound bone loss, as evidenced by worsening T-scores on 2024 DXA
• This illustrates the critical importance of transitioning to alternative therapy after denosumab cessation 4, a concept that was not well-established in 2020

The Romosozumab Decision

• Romosozumab is contraindicated in patients with unrepaired atypical femur fractures per FDA labeling 5
• Your patient received romosozumab starting May 2026, one month after surgical repair of bilateral atypical femur fractures
• The timing of romosozumab initiation post-AFF repair and post-parathyroidectomy represents a management approach not well-described in literature

Key Clinical Lessons This Case Teaches

Lesson 1: PHPT Should Not Be Managed Expectantly in Patients Requiring Antiresorptive Therapy

The 2018 surgical consultation noted the patient "meets none of the absolute indications for surgery (except for osteoporosis which is improving)" and recommended expectant management. However:

• Progressive hyperparathyroidism (PTH 110→159→193) over 8 years
• Development of hypercalcemia (calcium 10.5)
• Declining renal function (GFR 48)
• Multiple fractures despite "improving" bone density on denosumab

This case argues that PHPT requiring potent antiresorptive therapy represents a relative indication for parathyroidectomy, as the metabolic consequences of untreated PHPT may compound fracture risk.

Lesson 2: Denosumab Discontinuation Requires Mandatory Transition Therapy

The 2020 decision to stop denosumab without transition therapy (because T-scores had "improved to osteopenia") violated what we now understand about rebound bone loss 4. The subsequent:

• Worsening T-scores by 2024
• Need to restart denosumab
• Development of AFFs shortly after restarting

This sequence illustrates the dangers of denosumab discontinuation without bridging therapy, even when BMD appears adequate.

Lesson 3: Bilateral Pedicle Fractures May Herald Atypical Femur Fractures

The bilateral L3 and L4 pedicle fractures in January 2025 were unusual and should have prompted:

• Immediate evaluation for incomplete atypical femur fractures
• Consideration of denosumab discontinuation
• Acceleration of parathyroidectomy planning

Instead, denosumab was continued, and the patient developed bilateral atypical femur fractures 15 months later.

Lesson 4: Romosozumab After Parathyroidectomy Shows Promise

The two prior case reports of romosozumab after parathyroidectomy showed remarkable BMD gains (25-30% in lumbar spine) 3. Your case adds:

• Romosozumab use after both parathyroidectomy AND atypical femur fracture repair
• Management of the hypocalcemia risk when combining recent parathyroidectomy with romosozumab
• Long-term outcomes (if you have follow-up data)

Specific Recommendations for Your Case Report

Structure Your Report Around These Key Points

Title Suggestion: "Atypical Femoral Fractures Following Denosumab Therapy in Untreated Primary Hyperparathyroidism: A Case Highlighting the Importance of Timely Parathyroidectomy and Transition Therapy"

Key Sections to Emphasize:

1. The 8-year natural history of expectantly managed PHPT while on potent antiresorptives

   • Document the progressive biochemical worsening
   • Correlate with fracture events
   • Discuss whether earlier parathyroidectomy might have prevented AFFs

2. The denosumab discontinuation without transition (2020-2024)

   • Explain the 2020 decision-making
   • Document the consequences (worsening BMD, fractures after restart)
   • Contrast with current guidelines 4

3. The bilateral pedicle fractures as sentinel events

   • Describe the radiographic features
   • Discuss why these should have prompted AFF evaluation
   • Propose a screening algorithm for patients on long-term antiresorptives with unusual fractures

4. The therapeutic sequence post-AFF

   • Timing of parathyroidectomy relative to denosumab dosing
   • Decision to use romosozumab post-parathyroidectomy
   • Management of hypocalcemia risk
   • Outcomes (if available)

Address These Clinical Questions

1. Did untreated PHPT increase AFF risk beyond denosumab alone?

   • Discuss the theoretical mechanisms (altered bone remodeling, cortical porosity)
   • Compare to the limited literature on AFFs in metabolic bone disease

2. Should PHPT be considered a relative contraindication to long-term denosumab?

   • Or conversely, should PHPT requiring antiresorptives be an indication for parathyroidectomy?

3. What is the optimal management sequence for patients with PHPT who develop AFFs on antiresorptives?

   • Propose an algorithm based on your experience and the literature

Potential Journals

High-Impact Options:

• Journal of Bone and Mineral Research (JBMR) - Case Reports section
• Osteoporosis International - accepts complex case reports
• Journal of Clinical Endocrinology & Metabolism (JCEM) - Case Reports

Specialty Options:

• AACE Clinical Case Reports - published similar cases 3
• Bone - accepts case reports with mechanistic insights
• Endocrine Practice - case reports with practice implications

Caveats and Limitations to Acknowledge

Be Transparent About Uncertainties

Causality Questions:

• Cannot definitively prove denosumab caused the AFFs (though highly likely given radiographic features and exposure duration)
• Cannot isolate the contribution of PHPT versus antiresorptive therapy to fracture risk
• Cannot prove earlier parathyroidectomy would have prevented AFFs

Management Decisions:

• The 2018 decision for expectant PHPT management was reasonable by contemporary guidelines
• The 2020 denosumab discontinuation reflected evolving understanding of rebound risk
• The romosozumab choice represents expert opinion rather than evidence-based practice

Missing Data:

• Bone turnover markers during critical periods
• Detailed femoral geometry analysis
• Genetic testing for collagen disorders or other predisposing factors

Discuss Alternative Interpretations

Could This Have Been Prevented?

The European Calcified Tissue Society guidelines 1 recommend:

• Discontinuing antiresorptives after AFF diagnosis
• Considering teriparatide for AFF healing (though evidence is limited)
• Avoiding denosumab after AFF due to reports of recurrent fractures 1

Your case challenges this by using romosozumab (not teriparatide) and raises the question of whether parathyroidectomy should have been performed earlier.

Bottom Line

This case is highly publishable because it:

1. Documents a rare complication (denosumab-associated AFF) in a complex patient (untreated PHPT, multiple antiresorptive exposures)

2. Illustrates critical clinical lessons about denosumab discontinuation, PHPT management in osteoporosis, and recognition of sentinel fractures

3. Describes novel management (romosozumab after parathyroidectomy and AFF repair) with limited precedent 3

4. Raises important questions about optimal sequencing of therapies and whether PHPT should influence antiresorptive selection

5. Has clear practice implications for endocrinologists, rheumatologists, and orthopedic surgeons managing complex osteoporosis

The key to a successful publication is framing this not just as "here's what happened" but as "here's what we learned and how it should change practice." Focus on the decision points where different choices might have altered outcomes, and propose evidence-based algorithms for similar future cases.