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Abstract
Juvenile Paget disease (JPD) is a rare disorder, mainly caused by mutations in the gene TNFRSF11B that encodes osteoprotegerin (OPG). Loss of OPG action causes generalized, extremely rapid bone turnover. The clinical manifestations are both skeletal - progressive skeletal deformity that develops in childhood - and extra-skeletal, including hearing loss, retinopathy, vascular calcification and internal carotid artery aneurysm formation. The severity of the phenotype seems to be related to the severity of TNFRSF11B gene deactivation. JPD is characterized biochemically by very high alkaline phosphatase activity, as well as other bone turnover markers. Bisphosphonates are commonly used to reduce the greatly accelerated bone turnover and can ameliorate the skeletal phenotype, if started early enough in childhood and continued at least until growth is complete. Limited evidence from patients treated with recombinant OPG or denosumab also provided favorable results. Recombinant OPG would represent a replacement treatment, but it is unavailable for clinical use. It seems that life-long treatment with anti-resorptives is required, since the disease is reactivated after treatment discontinuation. An international collaborating network for the continuous registration and follow-up of JPD patients could be helpful in the future.
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Affiliation(s)
- Stergios A Polyzos
- First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Tim Cundy
- Department of Medicine, Faculty of Medical & Health Sciences, University of Auckland, New Zealand
| | - Christos S Mantzoros
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Whyte MP, Tau C, McAlister WH, Zhang X, Novack DV, Preliasco V, Santini-Araujo E, Mumm S. Juvenile Paget's disease with heterozygous duplication within TNFRSF11A encoding RANK. Bone 2014; 68:153-61. [PMID: 25063546 PMCID: PMC4189967 DOI: 10.1016/j.bone.2014.07.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 07/08/2014] [Accepted: 07/15/2014] [Indexed: 02/09/2023]
Abstract
Mendelian disorders of RANKL/OPG/RANK signaling feature the extremes of aberrant osteoclastogenesis and cause either osteopetrosis or rapid turnover skeletal disease. The patients with autosomal dominant accelerated bone remodeling have familial expansile osteolysis, early-onset Paget's disease of bone, expansile skeletal hyperphosphatasia, or panostotic expansile bone disease due to heterozygous 18-, 27-, 15-, and 12-bp insertional duplications, respectively, within exon 1 of TNFRSF11A that encodes the signal peptide of RANK. Juvenile Paget's disease (JPD), an autosomal recessive disorder, manifests extremely fast skeletal remodeling, and is usually caused by loss-of-function mutations within TNFRSF11B that encodes OPG. These disorders are ultra-rare. A 13-year-old Bolivian girl was referred at age 3years. One femur was congenitally short and curved. Then, both bowed. Deafness at age 2years involved missing ossicles and eroded cochleas. Teeth often had absorbed roots, broke, and were lost. Radiographs had revealed acquired tubular bone widening, cortical thickening, and coarse trabeculation. Biochemical markers indicated rapid skeletal turnover. Histopathology showed accelerated remodeling with abundant osteoclasts. JPD was diagnosed. Immobilization from a femur fracture caused severe hypercalcemia that responded rapidly to pamidronate treatment followed by bone turnover marker and radiographic improvement. No TNFRSF11B mutation was found. Instead, a unique heterozygous 15-bp insertional tandem duplication (87dup15) within exon 1 of TNFRSF11A predicted the same pentapeptide extension of RANK that causes expansile skeletal hyperphosphatasia (84dup15). Single nucleotide polymorphisms in TNFRSF11A and TNFRSF11B possibly impacted her phenotype. Our findings: i) reveal that JPD can be associated with an activating mutation within TNFRSF11A, ii) expand the range and overlap of phenotypes among the Mendelian disorders of RANK activation, and iii) call for mutation analysis to improve diagnosis, prognostication, recurrence risk assessment, and perhaps treatment selection among the monogenic disorders of RANKL/OPG/RANK activation.
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Affiliation(s)
- Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA,; Division of Bone and Mineral Diseases, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Cristina Tau
- Metabolismo Calcico y Oseo, Endocrinology, Hospital Pediatrics J.P. Garrahan, Buenos Aires, Argentina.
| | - William H McAlister
- Department of Pediatric Radiology, Mallinckrodt Institute of Radiology at St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA,.
| | - Xiafang Zhang
- Division of Bone and Mineral Diseases, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Deborah V Novack
- Division of Bone and Mineral Diseases, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA; Department of Pathology, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Virginia Preliasco
- Department of Pediatric Integral Odontology, Faculty of Dentistry, University of Buenos Aires, Buenos Aires, Argentina.
| | | | - Steven Mumm
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA,; Division of Bone and Mineral Diseases, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
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Brunetti G, Marzano F, Colucci S, Ventura A, Cavallo L, Grano M, Faienza MF. Genotype-phenotype correlation in juvenile Paget disease: role of molecular alterations of the TNFRSF11B gene. Endocrine 2012; 42:266-71. [PMID: 22638612 DOI: 10.1007/s12020-012-9705-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 05/11/2012] [Indexed: 12/23/2022]
Abstract
Juvenile Paget disease (JPD) {MIM 239000} is a rare inherited bone disease that affects children. The patients affected with JPD present an altered bone turnover, therefore, show a phenotype characterized by progressive bone deformities, fractures, and short stature. Deletions or missense mutations of the TNFRSN11B gene are common in these children. This gene encodes a soluble protein, the osteoprotegerin, which leads to uncontrolled osteoclastogenesis when mutated. JPD is characterized by a strong genotype-phenotype correlation, so depending on the alteration of the TNFRSN11B gene, the phenotype is variable. This review describes the different clinical features which are characteristic of JPD and the correspondence with the different molecular alterations of the TNFRSN11B gene.
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Affiliation(s)
- Giacomina Brunetti
- Department of Basic Medical Sciences, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
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Whyte MP. Paget's Disease of Bone and Genetic Disorders of RANKL/OPG/RANK/NF- B Signaling. Ann N Y Acad Sci 2006; 1068:143-64. [PMID: 16831914 DOI: 10.1196/annals.1346.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Identification of the RANKL/OPG/RANK/NF-kB (receptor activator of nuclear factor kappa-B ligand / osteoprotegerin) signaling pathway as the major regulatory system for osteoclastogenesis began with discovery of these ligands and receptors in the tumor necrosis factor (TNF) superfamily. Subsequently, genetically altered mice revealed physiologic roles for these proteins in bone biology. However, full appreciation of their significance for the human skeleton came from clinical characterization of several extremely rare, heritable disorders followed by discovery of their genetic bases. Familial expansile osteolysis (FEO) is an autosomal dominant disorder featuring constitutive activation of RANK due to an 18-bp tandem duplication in its gene (TNFRSF11A). A similar, 27-bp duplication causes what has been called a familial form of early-onset Paget's disease of bone (PDB2). Expansile skeletal hyperphosphatasia (ESH) is allelic to FEO and PDB2 and involves a 15-bp tandem duplication in TNFRSF11A. Autosomal recessive inheritance of deactivating mutations of the gene encoding OPG (TNFRSF11B) causes most cases of juvenile Paget disease. These disorders feature high bone turnover, deafness during early childhood, "idiopathic external lysis" of adult teeth, and sometimes focal lesions in appendicular bones that mimic active PDB. Biochemical markers indicate rapid skeletal remodeling. In FEO, osteolysis progresses to fat-filled bone rather than to osteosclerosis. Antiresorptive therapy with bisphosphonates can be effective for each disorder.
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Affiliation(s)
- Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children, 2001 South Lindbergh Boulevard, St. Louis, MO 63131, USA.
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Middleton-Hardie C, Zhu Q, Cundy H, Lin JM, Callon K, Tong PC, Xu J, Grey A, Cornish J, Naot D. Deletion of aspartate 182 in OPG causes juvenile Paget's disease by impairing both protein secretion and binding to RANKL. J Bone Miner Res 2006; 21:438-45. [PMID: 16491292 DOI: 10.1359/jbmr.051104] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Revised: 10/13/2005] [Accepted: 11/11/2005] [Indexed: 11/18/2022]
Abstract
UNLABELLED Mutations in the OPG gene cause idiopathic hyperphosphatasia. We characterized the effects of one such mutation and found that the mutant OPG is poorly secreted and has reduced biological activity compared with the wildtype protein. Therefore, correct structure and cellular processing of OPG is essential for normal bone remodeling. INTRODUCTION Inactivating mutations in osteoprotegerin (OPG) cause juvenile Paget's disease (JPD). We recently reported a family with JPD in which affected members were homozygous for an in-frame mutation resulting in the deletion of aspartate 182 in OPG. Here we report the structural and functional characterization of the OPGdeltaD182 mutant protein. MATERIALS AND METHODS Inhibition of osteoclastogenesis by the recombinant OPG proteins was studied in a murine bone marrow culture. Binding of wildtype and mutant OPG to RANKL was measured in two experimental systems: glutathione-S-transferase (GST) pull-down assay and surface plasmon resonance. Site-directed mutagenesis was used to study the glycosylation of OPGdeltaD182 in two potential glycosylation sites adjacent to the deleted aspartate residue at position 182. ELISA and Western blots were used to determine OPG concentrations in cell lysates and conditioned media from transiently transfected cells. RESULTS OPGdeltaD182 inhibited the generation of osteoclasts less effectively than the wildtype protein and had a reduced ability to bind to RANKL. The apparent higher molecular weight of OPGdeltaD182 compared with the wildtype is a result of hyperglycosylation of asparagine residues at positions 178 and 183. Glycosylation at N183 has the potential to disrupt OPG structure by interfering with disulphide bond formation and correct protein folding. Transient transfection experiments in SaOS2 cells suggest that OPGdeltaD182 is retained within the cell, a typical response to unstable or incorrect protein folding. CONCLUSIONS Taken together, these data suggest that the deletion of aspartate 182 impairs both the secretion and activity of OPG, which in turn provides an explanation for the increased osteoclastogenesis and high bone turnover observed in JPD patients with this mutation.
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Janssens K, de Vernejoul MC, de Freitas F, Vanhoenacker F, Van Hul W. An intermediate form of juvenile Paget's disease caused by a truncating TNFRSF11B mutation. Bone 2005; 36:542-8. [PMID: 15777670 DOI: 10.1016/j.bone.2004.12.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2004] [Revised: 11/25/2004] [Accepted: 12/01/2004] [Indexed: 11/25/2022]
Abstract
Juvenile Paget's disease (JPD) is a rare condition with an autosomal recessive mode of inheritance. Typically presenting in infancy or early childhood, the disorder is characterized by a generalized widening of the long bones and thickening of the skull combined with sustained elevation of serum alkaline phosphatase levels. The extremely rapid bone turnover results in osteopenia, fractures, and progressive skeletal deformity. In 2002, mutations in TNFRSF11B, the gene encoding osteoprotegerin, were described as underlying JPD. We evaluated a patient with JPD at the clinical, biochemical, radiological, and molecular level. Mutation analysis of TNFRSF11B revealed a homozygous insertion/deletion in exon 5, predicted to result in truncation of the protein at amino acid 325. The residual activity of the mutated protein product was investigated by Western blotting and ELISA upon transient overexpression. Absence of the C-terminal domain abolished homodimerization and was shown to lead to a decreased capacity of the mutant protein to bind its ligand RANKL. We conclude that truncation of the C-terminal part of osteoprotegerin negatively affects functional activity. As a consequence, osteoclast formation and function are up-regulated, causing the increased bone turnover seen in this patient.
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Affiliation(s)
- K Janssens
- Department of Medical Genetics, University of Antwerp, CDE, T6, Universiteitsplein 1, 2610 Antwerp, Belgium
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Tau C, Mautalen C, Casco C, Alvarez V, Rubinstein M. Chronic idiopathic hyperphosphatasia: normalization of bone turnover with cyclical intravenous pamidronate therapy. Bone 2004; 35:210-6. [PMID: 15207759 DOI: 10.1016/j.bone.2004.03.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Chronic idiopathic hyperphosphatasia (CIH), or juvenile Paget disease, is a rare disorder characterized by increased bone turnover and progressive enlargement of bones. We report a girl, 6 1/2 years old, with a history of three fractures, short stature, delayed eruption of teeth, and poor hair growth. She had a waddling gait, bone deformities, kyphoscoliosis, hyperlordosis, genu valgum and curvature of her limbs. She also had progressive hearing loss but other cranial nerves were unaffected. Laboratory studies indicated high bone turnover: serum alkaline phosphatase: 4047 IU/l (normal value: 150-550), urinary hydroxyproline: 1205 mg/g creatinine (n.v.: 60-160), and urinary CrossLaps: 4360 microg/mmol creatinine (n.v.: 450-2100). Radiographs demonstrated generalized skeletal involvement with osteoectasia (expansion) of long bones, diffuse sclerosis, cotton wool appearance of the skull, absence of mastoid pneumatization, and crushed dorsal and lumbar vertebrae. Iliac crest biopsy was compatible with CIH. Cyclical intravenous pamidronate (1 mg/kg/day during 3 h, 3 consecutive days at 2- to 3-month intervals) was administered during 2 years with oral calcium 500 mg and vitamin D 1000 IU/day. Oral pamidronate was added after 11 months of i.v. therapy. Treatment-induced remarkable clinical and radiographic improvement with normalization of bone markers of osteoblastic and osteoclastic activity, including bone alkaline phosphatase, urinary hydroxyproline, and urinary CrossLaps.
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Affiliation(s)
- Cristina Tau
- Metabolismo Cálcico y Oseo, Endocrinología, Buenos Aires, Argentina.
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Cundy T, Wheadon L, King A. Treatment of idiopathic hyperphosphatasia with intensive bisphosphonate therapy. J Bone Miner Res 2004; 19:703-11. [PMID: 15068492 DOI: 10.1359/jbmr.040127] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2003] [Revised: 12/18/2003] [Accepted: 01/16/2004] [Indexed: 01/06/2023]
Abstract
UNLABELLED In a family with IH, a rare high turnover bone disease, two older siblings were wheelchair-bound with severe skeletal deformity by age 15. Their youngest affected sibling was treated intensively with intravenous bisphosphonates for 3 years. The treatment was well tolerated and prevented the development of deformity and disability. INTRODUCTION Idiopathic hyperphosphatasia (IH, also known as juvenile Paget's disease) is a rare genetic bone disease characterized by very high bone turnover and progressive bony deformity. Inhibitors of bone resorption have been used to suppress bone turnover in the short term, but there is no published data on long-term efficacy. MATERIALS AND METHODS An 11-year-old girl with IH, who had two severely affected older siblings, presented with progressive deformity and deafness and long bone fractures. Conventional pediatric doses of pamidronate had failed to prevent clinical deterioration or suppress bone turnover completely. Intensive bisphosphonate therapy (frequent 5-mg ibandronate infusions) was given to try and arrest progression of the skeletal disease. Growth and development, pure tone audiometry, biochemistry, radiology, densitometry (DXA), and bone histology were monitored. RESULTS A total of 45 mg ibandronate was given over 3 years until skeletal maturity was reached (20, 15, and 10 mg for years 1-3, respectively). Ibandronate treatment was well tolerated, and biochemical markers of bone turnover suppressed to within the age-appropriate normal range There was some progression of her thoracic kyphosis, but she had no further fractures and remained mobile and active at an age when her siblings had become wheelchair-bound. A significant recovery of hearing (p < 0.01) was documented, particularly at low frequencies. Radiographs showed improvement in spinal osteoporosis and cortical bone dimensions and arrest of progressive acetabular protrusion. Areal bone density increased substantially (lumbar spine z-score from -2.2 to + 1.8). Tetracycline-labeled bone biopsy specimens were taken before and after 18 months of intensive treatment. The second biopsy showed suppression of bone turnover and a doubling of trabecular thickness, with no mineralization defect, and no osteopetrosis. CONCLUSIONS Intensive bisphosphonate treatment prevented the development of deformity and disability and improved hearing in this child with IH. The dose of bisphosphonate, which is substantially greater than is usually used in pediatric bone disease, had no adverse effects, in particular on bone mineralization.
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Affiliation(s)
- Tim Cundy
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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Chong B, Hegde M, Fawkner M, Simonet S, Cassinelli H, Coker M, Kanis J, Seidel J, Tau C, Tüysüz B, Yüksel B, Love D. Idiopathic hyperphosphatasia and TNFRSF11B mutations: relationships between phenotype and genotype. J Bone Miner Res 2003; 18:2095-104. [PMID: 14672344 DOI: 10.1359/jbmr.2003.18.12.2095] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Homozygous mutations in TNFRSF11B, the gene encoding osteoprotegerin, were found in affected members from six of nine families with idiopathic hyperphosphatasia. The severity of the phenotype was related to the predicted effects of the mutations on osteoprotegerin function. INTRODUCTION Idiopathic hyperphosphatasia (IH) is a rare high bone turnover congenital bone disease in which affected children are normal at birth but develop progressive long bone deformities, fractures, vertebral collapse, skull enlargement, and deafness. There is, however, considerable phenotypic variation from presentation in infancy with severe progressive deformity through to presentation in late childhood with minimal deformity. Two recent reports have linked idiopathic hyperphosphatasia with deletion of, or mutation in, the TNFRSF11B gene that encodes osteoprotegerin (OPG), an important paracrine modulator of RANKL-mediated bone resorption. MATERIALS AND METHODS We studied subjects with a clinical diagnosis of IH and unaffected family members from nine unrelated families. Clinical, biochemical, and radiographic data were collected, and genomic DNA examined for mutations in TNFRSF11B. The relationship between the mutations, their predicted effects on OPG function, and the phenotype were then examined. RESULTS Of the nine families studied, affected subjects from six were homozygous for novel mutations in TNFRSF11B. Their parents were heterozygous, consistent with autosomal recessive inheritance. Four of the six mutations occurred in the cysteine-rich ligand-binding domain and are predicted to disrupt binding of OPG to RANKL. Missense mutations in the cysteine residues, predicted to cause major disruption to the ligand-binding region, were associated with a severe phenotype (deformity developing before 18 months age and severe disability), as was a large deletion mutation. Non-cysteine missense mutations in the ligand-binding domain were associated with an intermediate phenotype (deformity recognized around the age of 5 years and an increased rate of long bone fracture). An insertion/deletion mutation at the C-terminal end of the protein was associated with the mildest phenotype. CONCLUSION Mutations in TNFRSF11B account for the majority of, but not all, cases of IH, and there are distinct genotype-phenotype relationships.
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Affiliation(s)
- Belinda Chong
- Molecular Genetics Laboratory, LabPlus, Auckland Hospital, Auckland, New Zealand
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Whyte MP, Mills BG, Reinus WR, Podgornik MN, Roodman GD, Gannon FH, Eddy MC, McAlister WH. Expansile skeletal hyperphosphatasia: a new familial metabolic bone disease. J Bone Miner Res 2000; 15:2330-44. [PMID: 11127198 DOI: 10.1359/jbmr.2000.15.12.2330] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We describe a new familial metabolic bone disease characterized by expanding hyperostotic long bones, early onset deafness, premature tooth loss, and episodic hypercalcemia. The condition affects a mother and daughter studied at the age of 36 years and 11 years, respectively. Both individuals lost all hearing in early childhood and suffered premature shedding of teeth. Skeletal pains began just before puberty. Swelling and aching of most middle phalanges in the hands is an especially troublesome manifestation. The mother also had episodes of symptomatic hypercalcemia first documented in late childhood and subsequently during intercurrent illness and postpartum lactation. Radiographs show hyperostosis and/or osteosclerosis predominantly in the skull and appendicular skeleton. Long bones also are expanded considerably, especially the middle phalanges in the fingers. The mother's skeletal abnormalities are more severe. Biochemical parameters of bone turnover, including serum alkaline phosphatase (ALP) activity, are elevated substantially. In the proposita, dynamic histomorphometry of nondecalcified sections of iliac crest revealed rapid skeletal remodeling. In the mother, who had been treated with bisphosphonates, electron microscopy (EM) showed disorganized collagen bundles as well as necrotic and apoptotic bone cells but no osteocytic osteolysis. Measles virus gene transcripts were not detected in peripheral blood monocytes. Karyotyping was normal, 46,XX. Hyperphosphatasia with bone disease previously has been reported as either a sporadic or autosomal recessive condition. Expansile skeletal hyperphosphatasia (ESH) is probably inherited as an autosomal dominant trait with a high degree of penetrance.
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Affiliation(s)
- M P Whyte
- Metabolic Research Unit, Shriners Hospital for Children, St. Louis, Missouri 63131, USA
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Demir E, Bereket A, Ozkan B, Topçu M. Effect of alendronate treatment on the clinical picture and bone turnover markers in chronic idiopathic hyperphosphatasia. J Pediatr Endocrinol Metab 2000; 13:217-21. [PMID: 10711670 DOI: 10.1515/jpem.2000.13.2.217] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic idiopathic hyperphosphatasia (CIH), also known as juvenile Paget's disease, is characterized by increased bone turnover, persistently elevated serum alkaline phosphatase concentrations and progressive bone deformities. The pathogenesis of the disease is unknown. Currently, there is no specific treatment and agents that reduce bone turnover have been tried in some cases with limited success. In this report, we present our experience with alendronate treatment in a 17 year-old boy with CIH. Ten weeks of treatment with alendronate resulted in marked clinical improvement and normalization of serum alkaline phosphatase activity. Serum osteocalcin and urinary deoxypyridinoline levels were decreased approximately 50% compared to pretreatment values, indicating decreased bone turnover rate. Alendronate seems to be a promising and safe agent for treatment of CIH.
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Affiliation(s)
- E Demir
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
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Abstract
A 17-year-old male patient was admitted because of progressive hearing loss since the age of six. His former blood and radiology investigation had revealed idiopathic hyperphosphatasia. On ENT examination bilateral thickened tympanic membranes with severe mixed-type hearing loss was diagnosed. Computerized tomography (CT) demonstrated expansion of the calvarial bones, including the temporal bones, except for the otic capsule. Middle-ear exploration revealed thickened middle-ear mucosa and a stone hard, immobile bony mass instead of the normal ossicular chain at the posterior superior part of the mesotympanum. No ossicular reconstruction could be attempted and the patient was rehabilitated with a hearing aid.
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Affiliation(s)
- L Sennaroğlu
- Department of Otolaryngology Head and Neck Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Golob DS, McAlister WH, Mills BG, Fedde KN, Reinus WR, Teitelbaum SL, Beeki S, Whyte MP. Juvenile Paget disease: life-long features of a mildly affected young woman. J Bone Miner Res 1996; 11:132-42. [PMID: 8770706 DOI: 10.1002/jbmr.5650110118] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Unusually mild Juvenile Paget Disease (JPD) was extensively investigated in a mentally retarded 21-year-old white woman. Progressive bowing deformitity of her lower limbs began at age 1 1/2 years. Nontraumatic fractures of both femora and both tibias occurred between ages 9 and 14 years. During adulthood, cortical thickening, osteosclerosis, and bowing affected these bones. Serum alkaline phosphatase (ALP) activity was persistently elevated. We found her serum osteocalcin and urinary hydroxyproline and pyridinoline/deoxypyridinoline to also be increased. The iliac crest histology, at ages 14 and 21 years, showed wide cortices and enhanced skeletal remodeling yet the bone was exclusively lamellar. Features of classic Paget Bone Disease (PBD)--such as hypermultinucleated osteoclasts, peritrabecular fibrosis, and mosaic or woven bone--were absent. Electron microscopy revealed no cytoplasmic or nuclear inclusions. Her dermal fibroblasts in culture synthesized unremarkable levels of ALP with proper membrane topography and lipid anchoring; ALP released into the medium also appeared normal. Six months of synthetic human calcitonin therapy daily appeared to reduce here lower limb pain and warmth, but the radiographs, biochemical parameters of skeletal turnover, and bone scintigraphy were unaltered. Lamellar bone has been reported in JPD but accompanied by excessive amounts of woven bone. Our patient reveals that lamellar bone without features of PBD can characterize the skeletal histopathology of the especially rare case of mild JPD.
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Affiliation(s)
- D S Golob
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Singer F, Siris E, Shane E, Dempster D, Lindsay R, Parisien M. Hereditary hyperphosphatasia: 20 year follow-up and response to disodium etidronate. J Bone Miner Res 1994; 9:733-8. [PMID: 8053403 DOI: 10.1002/jbmr.5650090519] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We provide a 20 year follow-up of a family with three siblings affected by hereditary hyperphosphatasia (HH). An iliac crest bone biopsy was performed on one of the siblings following double-tetracycline labeling, with results reported quantitatively in a standard histomorphometric format. Biochemical parameters of disease activity were monitored in the patient before and after treatment with oral etidronate disodium, 20 mg/kg/day taken for 5 weeks. Biochemical evidence of intense disease activity continued 20 years after the initial diagnosis of HH in the sibling studied. His bone biopsy specimen also revealed extremely high bone turnover but low cancellous bone volume and osteoclasts unlike those found in Paget's disease. Treatment with etidronate disodium resulted in a temporary 40% reduction in serum alkaline phosphatase and 24 h urine hydroxyproline excretion, with reduction in serum osteocalcin from two times the upper limit of normal to a subnormal level. We conclude that disease activity in HH can continue unabated for two decades. Our bone biopsy finding of low cancellous bone volume, the consistent lack of pagetic-looking osteoclasts in our and other studies, plus the clinical features of HH (childhood onset and extremely diffuse disease with gross skeletal deformation) serve to distinguish HH from Paget's disease. Bisphosphonates may be of value in treating HH.
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Affiliation(s)
- F Singer
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
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Antoniades K, Karakasis D, Kapetanos G, Lasaridis N, Tzarou V. Chronic idiopathic hyperphosphatasemia. Case report. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1993; 76:200-4. [PMID: 8361732 DOI: 10.1016/0030-4220(93)90205-i] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Chronic idiopathic hyperphosphatasemia, or juvenile Paget disease is a very rare syndrome that is characterized by fragile bones, bowing deformities, shortness of stature, large head, premature loss of teeth, radiographic evidence of expanded osteoporotic long bones with coarse trabeculations, and widened bones of the skull. Increased levels of serum alkaline phosphatase and increased levels of urinary total hydroxyproline are notable. We present a case of juvenile Paget disease that was associated with a history of precocious puberty. The patient had odontogenic osteomyelitis of the mandible that was treated by drainage, surgical debridement and antibiotic therapy.
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Affiliation(s)
- K Antoniades
- Department of Oral and Maxillofacial Surgery, Aristotle University of Thessaloniki, Greece
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Cassinelli HR, Mautalen CA, Heinrich JJ, Miglietta A, Bergada C. Familial idiopathic hyperphosphatasia (FIH): response to long-term treatment with pamidronate (APD). BONE AND MINERAL 1992; 19:175-84. [PMID: 1422313 DOI: 10.1016/0169-6009(92)90924-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 5-year-old child suffering from familial idiopathic hyperphosphatasia (FIH) was treated by: (1) intravenous infusion of pamidronate (APD) (3 h) (0.75 mg/kg/day) for 5 days; and (2) oral administration of APD (8 mg/kg/day) for 1 year, in association with calcium (1 g/day) as calcium gluconate. A decrease of both serum calcium and phosphate, and a slight PTH increase were observed immediately after the IV treatment; serum alkaline phosphatase did not change, but a marked and rapid decline in the hydroxyprolinuria was observed: basal 659 +/- 207 during IV treatment 169 +/- 59 (mean +/- SD mg/24 h, P < 0.005). At the end of one year of oral APD treatment clinical and radiological findings showed a remarkable improvement. Serum calcium, phosphate and PTH returned to the initial values. Plasma alkaline phosphatase levels showed a 70% decrease: basal 1370 IU/l, 1 year 410 IU/l whereas the hydroxyprolinuria values were similar to those determined at the end of the intravenous treatment (212 +/- 13 mg/24 h), but still significantly lower than the basal levels (P < 0.01). No side-effects were observed. APD appears to be a promising treatment for patients with FIH.
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Affiliation(s)
- H R Cassinelli
- Division de Endocrinologia, Hospital de Niños R. Gutierrez, Buenos Aires, Argentina
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Chosich N, Long F, Wong R, Topliss DJ, Stockigt JR. Post-partum hypercalcemia in hereditary hyperphosphatasia (juvenile Paget's disease). J Endocrinol Invest 1991; 14:591-7. [PMID: 1940065 DOI: 10.1007/bf03346877] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Hereditary hyperphosphatasia is a rare bone disorder characterized by increased bone turnover, elevated alkaline phosphatase (ALP) and bone deformity. We describe a patient with a mild form of hereditary hyperphosphatasia who was initially hypercalcemic in childhood with remission after puberty. Symptomatic hypercalcemia recurred during lactation after each of two pregnancies, associated with increased bone turnover (rise in ALP, osteocalcin, and urine hydroxyproline excretion) which appeared to be independent of changes in major calcium-regulating hormones. The mechanism for the development of post-partum hypercalcemia remains unclear but may relate to the relative estrogen deficiency of lactation. We postulate that acute estrogen withdrawal may result in hypercalcemia in the presence of markedly increased bone turnover.
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Affiliation(s)
- N Chosich
- Ewen Downie Metabolic Unit, Alfred Hospital, Melbourne, Vic, Australia
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Cole DE, Fraser FC, Glorieux FH, Jequier S, Marie PJ, Reade TM, Scriver CR. Panostotic fibrous dysplasia: a congenital disorder of bone with unusual facial appearance, bone fragility, hyperphosphatasemia, and hypophosphatemia. AMERICAN JOURNAL OF MEDICAL GENETICS 1983; 14:725-35. [PMID: 6846403 DOI: 10.1002/ajmg.1320140414] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We report a boy with unusual facial appearance, melanotic patches ("coast-of-Maine" type), myelofibrosis, recurrent femoral fractures, and widespread fibrous dysplasia of bone. Biochemical findings included raised serum alkaline phosphatase (bone isozyme) and 1,25-(OH)2 vitamin D, and low serum phosphorus levels. Elevated urinary excretion rates of total hydroxyproline, glycylproline, and gamma-carboxyglutamic acid indicated increased turnover of bone matrix. Transiliac bone biopsy showed a dearth of marrow elements, greatly increased bone turnover, and absence of normal trabecular organization. Serial radiographs showed progressive cortical thinning and loss of bony trabeculae. Calcitonin and etidronate treatments had no lasting effect on the progressive bone disease. The term "panostotic fibrous dysplasia" is suggested for this condition.
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Kraszeski JL, Avramides A, Wallach S, Hussain MN. Three adult cases resembling hereditary bone dysplasia. METABOLIC BONE DISEASE & RELATED RESEARCH 1981; 3:9-16. [PMID: 7266369 DOI: 10.1016/s0221-8747(81)80017-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Hereditary bone dysplasia with hyperphosphatasemia is a generalized disorder of bone formation which begins in infancy, uniformly involves the skull and long bones and results in progressive deformities and short stature. This entity has been described 27 times under various names, including juvenile Paget's disease, but only two case reports have described the condition in adults. In the present report two siblings and an unrelated individual are described with features resembling hereditary bone dysplasia. In all three the condition developed in infancy but was first recognized in middle age. Clinical and radiographic features of short stature, extensive thickening of the calvarium with areas of "cotton wool sclerosis", and bowed deformities of the long bones were present. The serum alkaline phosphatase was elevated in one case and normal in two. One patient demonstrated a marked clinical and biochemical response to a six month course of disodium etidronate after failing to respond to a trial of salmon calcitonin. There were significant differences between these three cases and classic hereditary bone dysplasia as described in infants and children. The patients themselves also had variable features. These observations suggest that either hereditary bone dysplasia is indeed variable, especially as afflicted children pass into adulthood, or different skeletal diseases are presently being included under the general term hereditary bone dysplasia with hyperphosphatasemia.
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Enderle A, von Gumppenberg S. [Osteitis deformans (Paget)--or a tarda-type of a hereditary hyperphosphatasia (author's transl)]. ARCHIVES OF ORTHOPAEDIC AND TRAUMATIC SURGERY. ARCHIV FUR ORTHOPADISCHE UND UNFALL-CHIRURGIE 1979; 94:127-34. [PMID: 383043 DOI: 10.1007/bf00433578] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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