Osteosclerosis in hyperparathyroidism

Osteosclerotic and osteolytic manifestations of hyperparathyroidism in a case of Tc99m SestaMIBI positive parathyroid adenoma

Primary hyperparathyroidism is the first differential diagnosis when a patient presents with asymptomatic hypercalcemia. The symptoms of hyperparathyroidism can be as grave as skeletal, cardiovascular, and neuropsychological changes. Skeletal manifestations are relatively common, and patient may present with generalized or focal bone pains, fragility fractures, subperiosteal bone resorption, and osteolytic lesions like brown tumors and salt and pepper appearance of the skull. However, focal osteosclerotic lesions of the skull are rare findings in hyperparathyroidism. Only a few cases of associated osteosclerosis are reported in the literature. Here, we report a case of Tc99m SestaMIBI positive parathyroid adenoma with coexisting osteolytic and osteosclerotic skull lesions on Tc99m methylene diphosphonate bone scan.

Musculoskeletal manifestations of endocrine disorders

Endocrine disorders can lead to disturbances in numerous systems within the body, including the musculoskeletal system. Radiological evaluation of these conditions can demonstrate typical appearances of the bones and soft tissues. Knowledge of these patterns can allow the radiologist to suggest a diagnosis that may not be clinically apparent. This review will highlight the typical musculoskeletal findings of acromegaly, hypercortisolism, hyperthyroidism, hypothyroidism, hyperparathyroidism, pseudo- and pseudopseudohypoparathyroidism, and diabetes mellitus. The radiological manifestations of each of these endocrine disorders, along with a brief discussion of the pathophysiology and clinical implications, will be discussed.

Various musculoskeletal manifestations of chronic renal insufficiency

Musculoskeletal manifestations in chronic renal insufficiency are caused by complex bone metabolism alterations, now described under the umbrella term of chronic kidney disease mineral- and bone-related disorder (CKD-MBD), as well as iatrogenic processes related to renal replacement treatment. Radiological imaging remains the mainstay of disease assessment. This review aims to illustrate the radiological features of CKD-MBD, such as secondary hyperparathyroidism, osteomalacia, adynamic bone disease, soft-tissue calcifications; as well as features associated with renal replacement therapy, such as aluminium toxicity, secondary amyloidosis, destructive spondyloarthropathy, haemodialysis-related erosive arthropathy, tendon rupture, osteonecrosis, and infection.

Bone end sclerosis in renal osteodystrophy simulating osteonecrosis

Osteosclerosis of the bone ends is an unusual manifestation of renal osteodystrophy. In evaluating this finding one should be careful to exclude clinical and radiographic evidence for osteonecrosis. In the two known cases of this entity, bone end sclerosis has been found to develop over one to two years with symmetrical involvement of multiple bones.

Qualitative bone defect in uremic osteosclerosis

Osteosclerosis, an increased volume of trabecular bone, is a common but often misinterpreted feature of uremic osteodystrophy. Despite the apparent radiographic density of osteosclerotic bone, pain and fracture may be associated. If accumulated osteoid and woven bone exceed the volume of lamellar bone removed in chronic renal insufficiency, bone density may be reduced despite increased trabecular volume. Concomitant histomorphometric and photon absorption determinations of transileal bone biopsies were done to investigate the relationship between quantity and quality of bone in uremic and non-uremic osteopenic patients. In osteopenic patients with uremia, bone core density had no significant relationship to trabecular bone volume or mineralized bone volume whereas in non-uremic osteopenic patients, these parameters were directly related (r = 0.867 and r = 0.921, respectively, p less than 0.001). The bone core density in the uremic patients was negatively correlated with the total osteoid volume (r = -0.764, p less than 0.05) and positively related to the serum phosphorus concentration (r = 0.739, p less than 0.05). Serum levels of immunoreactive parathyroid hormone (iPTH) and alkaline phosphatase activity were higher in the patients with radiographic osteosclerosis than in the other uremic patients. The lack of correlation between bone volume and density indicates a qualitative defect in uremic bone. It appears that in uremia, elevated iPTH and serum phosphorus levels may augment bone formation, albeit poorly mineralized with woven architecture. While radiographic density paradoxically increases, the amount of normally mineralized bone may be reduced.

The pathogenesis of infantile malignant osteopetrosis: bone mineral metabolism and complications in five infants

Bone mineral metabolism was studied in five infants aged 8 to 22 months with severe osteopetrosis. There were findings consistent with biochemical osteomalacia. These included hypocalcemia, hypophosphatemia, high serum acid phosphatase and alkaline phosphatase activity, high levels of serum parathyroid hormone, and high urinary cyclic AMP. Serum 1,25(OH)2 vitamin D3 level was high in the one patient tested. Radiographs in all infants revealed rachitic changes in the metaphyses. However, dense bones on radiographs, calcium balance studies, and radio-calcium absorption studies demonstrated markedly positive calcium balance. Iliac crest bone biopsies showed increased quantity of woven bone with abundant numbers of osteoclasts, excessive amounts of osteoid, myelofibrosis, and a decreased number of Howship's lacunae. The wide bands of unmineralized osteoid did not take up tetracycline. In vitro bone resorbing activity due to osteoclast activating factor from cultured stimulated leukocytes was normal. Bone turnover however, was now as evidenced by low urinary hydroxyproline levels. We interpret these findings as indicating there is decreased bone remodeling and resorption in spite of increased humoral stimuli and osteoclasts. Since calcitonin levels were normal for age, the most likely cause of the impaired bone remodeling sequence was defective osteoclast function. We postulate that there may be a common genetic defect in phagocyte cells, including monocytes, neutrophils and osteoclasts, which accounts for the abnormalities of mineral metabolism and previously reported hematologic, neurologic, and infectious complications.

[The use of photon absorptiometry in renal osteodystrophy (author's transl)]

In 58 patients with end-stage renal failure before commencement of regular hemodialyses treatment (RTD) and 58 patients under RTD bone mineral content (BMC) was determined by the use of the photon absorptiometry. Further the effect of a treatment with bitamin D3 and 5,6-trans-25-OH-vitamin D3 on BMC was studied. There existed a negative correlation between the duration of chronic renal failure or of RDT as well as of the serum parathyroid hormone level to BMC. No correlation was found between BMC and serum calcium level. During a 14 months-course treatment with vitamin D3 or 5,6-trans-25-OH-vitamin D3 BMC increased. The method of photon absorptiometry presented itself as an easy and well reproducible technique for routine examinations.

Bone disease in long-term haemodialysis: the association of radiological with histological abnormalities

The radiological findings in the skeletal surveys of 70 patients receiving long-term haemodialysis for chronic renal failure have been correlated with histological findings in a specimen obtained by biopsy of the iliac crest. Many significant associations were found, and the ones presented are those thought to be most useful in the interpretation of the radiological abnormalities. The main conclusions are that fractures and severe medullary rarefaction appear to be most commonly the result of osteomalacia; subperiosteal erosions are associated with the more severe grades of osteitis fibrosa; cortical striations and sclerosis are associated with an increased amount of osteoid, and sclerosis is diagnosed more frequently by radiological means than by iliac-crest biopsy.

Periosteal new bone formation developing during haemodialysis for chronic renal failure

Periosteal new bone formation in the pelvis is reported in five patients on maintenance haemodialysis for chronic renal failure. In two of the cases the shafts of long bones were also involved. The associated radiological and biochemical findings suggest that this unusual radiological feature may be a manifestation of secondary hyperparathyroidism. In one patient in whom the plasma phosphate and calcium X phosphate [Ca X P1] product were reduced there was partial incorporation of the periosteal new bone into the underlying cortex.

Osteosclerosis in primary hyperparathyroidism

Osteosclerosis in adults with primary hyperparathyoidism is rare; the usual skeletal manifestation, when presented, is diffuse osteropenia. We describe a patient with generalized osteosclerosis in association with primary hyperparathyroidism. The findings are documented by conventional and fine-detail radiography, absorptiometric bone mineral analysis, quantitative microradiography and histologic examination of bone. The unique features are contrasted with the manifestations recorded in a recently studied group of 87 hyperparathyroid patients. The data presented here support a causal relationship in this patient between parathyroid hormone excess and the development of densely sclerotic bones.