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\title{A Patient with Symptomatic Polyostotic Melorheostosis Successfully Treated with Intravenous Zoledronate Injection-A Case Report}
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\date{\small \em Received: 1 January 1970 Accepted: 1 January 1970 Published: 1 January 1970}

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\begin{abstract}
        


Introduction: Melorheostosis is a rare congenital bone disorder present with insidious onset of bone pain. Diagnosing this rare condition and managing it is difficult. Knowledge of this rare entity is important for the physician who is treating patients with musculoskeletal pain.Case Report: A 25-year-old female with right leg pain for a two-year duration. She has been seen by a lot of physicians and could not have been managed properly. Her radiographs were showing hyperostotic left ulna and right tibia. Sinister pathologies were excluded using MRI and biopsy. Her symptoms settled with intravenous Zoledronate. Pain recurred after two years and she responded well after repeated Zoledronate injection.

\end{abstract}


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{{\textit{CrossRef DOI of original article:}} \underline{}}
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\section[{I. INTRODUCTION}]{I. INTRODUCTION}\par
Polyostotic melorheostosis is a rare congenital non-hereditary benign sclerosing mesenchymal dysplasia involving multiple bones \hyperref[b9]{(1)}\hyperref[b1]{(2)}\hyperref[b2]{(3)}\hyperref[b3]{(4)}. Melorheostosis is presented in the second decade of life. The male and female ratio is the same. The classical description of appearance in the radiographs is "flowing candle wax" \hyperref[b9]{(1)}. The axial skeleton is rarely involved. The treatment is mainly non-operative. Surgery is reserved for the lesions complicated with fractures.\par
We present a case report on a patient with symptomatic polyostotic melorheostosis successfully treated with intravenous Zoledronate injection.\par
A 25-year-old female presented to the orthopaedic unit with pain over her right leg left forearm and back for two years duration. She has been seen by a lot of physicians for the same ailment and they could not help her. The pain gradually worsened over time and made her visit us. On examination, the right leg and the left forearm were swollen diffusely. There is no history of back pain.\par
Radiographs show hyperostosis of the right tibia and the left ulna (Figure \hyperref[fig_1]{1}). Technetium 99 bone scan revealed hyperactivity seen on the right tibia, left ulna, left fibula, left femur and the spine (Figure \hyperref[fig_2]{2}).     
\section[{III. DISCUSSION}]{III. DISCUSSION}\par
Melorheostosis is a rare disorder in which sclerosing dysplasia with derangement in endochondral and intramembranous ossification of bones. The summary of demographical details is in Table  {\ref 1}. These lesions can be on one bone (Monostotic), many bones (Polyostotic), involving one limb (Monomelic) or generalized. Axial skeleton involvement is rare. According to the anatomical involvement, severity and the deformity caused by the lesions symptoms and signs will be varied.\par
Commonest symptoms are painful limb swelling, restricted range of motion and contractures of joints (usually asymmetric). Axial skeleton involvement may present with back, and neck pain,radicularpain,scoliosis,stiffness,giddiness,sy mptomsofvertebrobasilarinsufficiencyandeviden ceofcord compression(1).\par
Melorheostosis is not a fatal condition. But it impacts significantly the activity of daily living of patients with this ailment. The management of melorheostosis varies from simple analgesics to surgery. The management depends on the anatomical site, the extent of lesions, the severity of symptoms and the degree of deformity. The primary goal of management is to relieve symptoms and achieve mobility. Pain relief, nerve blocks, braces, and physiotherapy play a vital role. Patients who are not responded to these options will undergo nerve blocks. Surgery deserves for patients with lesions complicated with fractures.\par
There are few case reports on the usage of intravenouszoledronatefor melorheostosis \hyperref[b5]{(6)}\hyperref[b6]{(7)}\hyperref[b7]{(8)}. They reported successful outcomes following treatment after the injection. On our patient single dose of intravenous zoledronic acid (5mg over 30 minutes) has provided remission for two years and it worked for relapse as well after two years. Intravenous zoledronate is an effective treatment for symptomatic polyostotic melorheostosis. Zoledronate is a bisphosphonate which inhibits osteoclasts and reduces bone pain, prevents pathological fracture and reduces blood supply \hyperref[b5]{(6)}\hyperref[b6]{(7)}\hyperref[b7]{(8)}. Bone resorption by osteoclasts, stimulation of pain receptors and increased intraosseous pressure are major reasons for bone pain among patients with melorheostosis (6-8). Thus, zoledronate is a viable option for the ents with melorheostosis causing bone pain. Anyway, careful selection of patients and preparation is necessary before the zoledronate infusion to avoid complications (Avascular necrosis of the jaw, fever, allergic reactions etc). 
\section[{IV. CONCLUSION}]{IV. CONCLUSION}\par
Symptomatic polyostotic melorheostosis may be resistant to symptomatic treatment. Intravenous zoledronate is a viable option for such patients.\begin{figure}[htbp]
\noindent\textbf{6}\includegraphics[]{image-2.png}
\caption{\label{fig_0}6 A}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1}\includegraphics[]{image-3.png}
\caption{\label{fig_1}Figure 1 :A}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2}\includegraphics[]{image-4.png}
\caption{\label{fig_2}Figure 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3}\includegraphics[]{image-5.png}
\caption{\label{fig_3}Figure 3 :}\end{figure}
 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\bibitem[Case report of a rare disease: Melorheostosis Journal of Medical Case Reports and Case Series (2021)]{b4}\label{b4} 	 		‘Case report of a rare disease: Melorheostosis’.  	 	 		\textit{Journal of Medical Case Reports and Case Series}  		2021 Dec 10.  	 
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\bibitem[Hollick et al. ()]{b6}\label{b6} 	 		‘Melorheostosis and its treatment with intravenous zoledronic acid’.  		 			R J Hollick 		,  		 			A Black 		,  		 			D Reid 		.  	 	 		Case Reports  		2010 Apr 5. 2010. apr05 1. p. .  	 
\bibitem[Drr et al. (2018)]{b1}\label{b1} 	 		‘Melorheostosis: Case report of rare disease’.  		 			Mehrotra Drr 		,  		 			Kumar Drp 		,  		 			Chaudhary Drd 		,  		 			Patel Drp 		,  		 			Singh Dra 		.  	 	 		\textit{International Journal of Orthopaedics Sciences}  		2018 Jan 1. 4  (1g)  p. .  	 
\bibitem[Slimani et al. ()]{b5}\label{b5} 	 		\textit{Successful treatment of pain in melorheostosis with zoledronate, with improvement on bone scintigraphy. Case Reports},  		 			S Slimani 		,  		 			A Nezzar 		,  		 			H Makhloufi 		.  		2013 Jun 21. 2013. jun21 2. 2013009820. p. 2013009820.  	 
\bibitem[Slimani et al. (2013)]{b7}\label{b7} 	 		\textit{Successful treatment of pain in melorheostosis with zoledronate, with improvement on bone scintigraphy. Case Reports},  		 			S Slimani 		,  		 			A Nezzar 		,  		 			H Makhloufi 		.  		2013 Jun 21. 2013. jun212. 2013009820. p. 2013009820.  	 
\end{bibitemlist}
 			 		 	 
\end{document}