Idiopathic multicentric osteolysis

A case report of multicentric carpotarsal osteolysis syndrome: Depiction of a debilitating disease course

Multicentric carpotarsal osteolysis syndrome (MCTO) is a rare skeletal disorder characterized by progressive osteolysis involving the carpal and tarsal bones, and often associated with nephropathy. It is caused by heterozygous mutation in the MAF bZIP transcription factor B (MAFB) gene. Heterogeneous clinical manifestation and wide spectrum of disease severity have been observed in patients with MCTO. Here, we report a case of a male patient who presented with kidney failure in childhood with progressive disabling skeletal deformity. He was diagnosed with MCTO at 31-years-old, where a de novo pathogenic heterozygous variant in NM_005461.5:c.212C>A: p.(Pro71His) of the MAFB gene was identified. While there has been little data on the long-term prognosis and life expectancy of this disease, this case report sheds light on the debilitating disease course with multiple significant morbidities of a patient with MCTO throughout his lifetime of 33 years.

Identification of a novel mutation in the MAFB gene in a pediatric patient with multicentric carpotarsal osteolysis syndrome using next-generation sequencing

Multicentric carpotarsal osteolysis syndrome (MCTO) is a rare form of skeletal dysplasia characterized by progressive bone resorption, in the carpal and tarsal bones. Patients may develop chronic kidney disease, which eventually advances to end-stage renal disease (ESRD). Both sporadic and familial cases of autosomal-dominant inheritance are reported in literature. Here, we report a case of a 10.5-year-old boy who presented with CKD stage V, and who suffered from bone deformities and difficulty in walking at a younger age. He was diagnosed with MCTO and subjected to genetic analysis. We identified a novel mutation (NM_005461.5:c.173C > G) in the exon 1 of MAFB using next-generation sequencing. However, the mutation was not detected in his asymptomatic parents or siblings. This novel heterozygous mutation has not been reported previously. Our results show that the new mutation broadens the spectrum of disease phenotypes. This mutation may be helpful to confirm the potential cases of MCTO, which although can be identified through radiographic findings, stand a high chance of being misdiagnosed as rheumatological disease or as a metabolic bone disease secondary to CKD.

Multicentric carpotarsal osteolysis syndrome: long-term follow-up of three patients

Multicentric carpotarsal osteolysis (MCTO) is a rare skeletal disorder characterized by progressive carpal and tarsal destruction. The upper and lower limbs may be involved, leading to deformities and joint limitation. These anatomic features may be associated with progressive renal failure. The radiographs obtained during childhood showed a carpal and tarsal osteolysis and an asymmetrical involvement. Here, we report on the long-term clinical and radiological findings of three patients with skeletal manifestations of MCTO.

Trio Clinical Exome Sequencing in a Patient With Multicentric Carpotarsal Osteolysis Syndrome: First Case Report in the Balkans

Exome sequencing can interrogate thousands of genes simultaneously and it is becoming a first line diagnostic tool in genomic medicine. Herein, we applied trio clinical exome sequencing (CES) in a patient presenting with undiagnosed skeletal disorder, minor facial abnormalities, and kidney hypoplasia; her parents were asymptomatic. Testing the proband and her parents led to the identification of a de novo mutation c.188C>T (p.Pro63Leu) in the MAFB gene, which is known to cause multicentric carpotarsal osteolysis syndrome (MCTO). The c.188C>T mutation lies in a hotspot amino acid stretch within the transactivation domain of MAFB, which is a negative regulator of RANKL-induced osteoclastogenesis. MCTO is an extremely rare autosomal dominant (AD) disorder that typically arises spontaneously and causes carpotarsal osteolysis, often followed by nephropathy. To the best of our knowledge, this is the first study reporting genetically diagnosed MCTO in the Balkans.

[Multicentric carpotarsal osteolysis in a rheumatologist's practice]

Multicentric carpotarsal osteolysis (MCTO) syndrome is a rare skeletal dysplasia associated with missense mutation in the MAFB gene, usually manifesting in young childhood, and showing variative phenotypic signs and course. The clinical manifestations of the syndrome include aggressive osteolysis predominantly of carpal and tarsal bones, progressive nephropathy, and mild craniofacial anomalies. The similarity between the initial clinical manifestations of MCTO and the symptoms of childhood inflammatory joint diseases makes a diagnosis very difficult, in the early stages of the disease in particular, and frequently leads to the ungrounded use of long-term immunosuppressive therapy. The paper describes a familial case of MCTO without affecting the kidneys in the mother and daughter.

Idiopathic multicentric osteolysis: upper extremity manifestations and surgical considerations during childhood

PURPOSE

Idiopathic multicentric osteolysis (IMO) is an uncommon disease presenting during childhood with resorption of the carpus and tarsus with nephropathy. The few case reports and literature reviews do not focus on the upper extremity disease manifestations or surgical treatment options. We review our experience with the upper extremity in IMO.

METHODS

We evaluated 8 affected children, specifically assessing early disease manifestations, misdiagnoses, radiographic progression, and surgical treatments rendered.

RESULTS

Wrist pain and swelling are typically the first manifestations of IMO. Characteristic upper extremity findings, once the disease has progressed, include metacarpophalangeal joint hyperextension, wrist ulnar deviation and flexion, and loss of elbow extension. Radiographically, there is osteolysis of the carpus and proximal metacarpals with resorption of the elbow joint in some patients. Surgical treatments, including soft tissue release with pinning or joint arthrodesis, may offer pain relief and improve alignment, but outcomes are inconsistent.

CONCLUSIONS

Children with IMO are almost always misdiagnosed initially, and the correct diagnosis may be delayed by years. The hand surgeon is ideally suited to provide an accurate diagnosis of IMO, because wrist pain and swelling and thumb interphalangeal joint contracture are common early manifestations.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Multicentric carpotarsal osteolysis is caused by mutations clustering in the amino-terminal transcriptional activation domain of MAFB

Multicentric carpotarsal osteolysis (MCTO) is a rare skeletal dysplasia characterized by aggressive osteolysis, particularly affecting the carpal and tarsal bones, and is frequently associated with progressive renal failure. Using exome capture and next-generation sequencing in five unrelated simplex cases of MCTO, we identified previously unreported missense mutations clustering within a 51 base pair region of the single exon of MAFB, validated by Sanger sequencing. A further six unrelated simplex cases with MCTO were also heterozygous for previously unreported mutations within this same region, as were affected members of two families with autosomal-dominant MCTO. MAFB encodes a transcription factor that negatively regulates RANKL-induced osteoclastogenesis and is essential for normal renal development. Identification of this gene paves the way for development of novel therapeutic approaches for this crippling disease and provides insight into normal bone and kidney development.

A Rare Case Report of Extensive Polyostotic Gorham's Disappearing Bone Disease Involving the Upper Extremity

Gorham's disease is a rare disorder involving the proliferation of endothelial channels resulting in resorption and disappearance of bone. An unusual case of polyostotic Gorham's disease affecting the scapula, humerus, radius, and ulna in a 39-year-old woman is described. The patient had extensive disease spreading across both the glenohumeral and humeroulnar joints. This is the first report of Gorham's disease spreading across multiple joints in the upper extremity.

Gorham's disease of the fibula: a case report

Gorham's disease, or massive osteolysis, is a rare condition characterized by the spontaneous onset of osteolysis in an otherwise healthy individual. Such osteolysis is related to localized endothelial proliferation of lymphatic vessels (lymphangiomatous osteolysis) resulting in destruction and absorption of bone, and is commonly thought to affect primarily cancellous bone. In this article, we describe a case of Gorham's disease involving the fibula in a 13-year-old boy with a 2-year history of pain and a 1-year history of muscle atrophy. The patient was treated with analgesics and anti-inflammatory drugs, and a period of immobilization. At the 3-year follow-up visit, the patient was ambulating without restrictions, although he experienced occasional episodes of pain and swelling localized to the left ankle; and follow-up radiographs revealed no further progression of the disease. Current literature suggests that the fibula, being primarily cortical bone, is not likely to be affected by Gorham's disease and that fibular grafts may be used in the treatment of the disorder. However, since this case depicts the disorder localizing to the distal fibula, we believe further studies are needed to validate the usefulness of fibular grafts in the treatment of the condition. Because the course of the disease is unpredictable and may arrest spontaneously, and based on the results observed in the patient described in this article, conservative treatment may be appropriate for Gorham's disease localized to the distal fibula.

LEVEL OF CLINICAL EVIDENCE

4.

Loss of MMP-2 disrupts skeletal and craniofacial development and results in decreased bone mineralization, joint erosion and defects in osteoblast and osteoclast growth

The 'vanishing bone' or inherited osteolysis/arthritis syndromes represent a heterogeneous group of skeletal disorders characterized by mineralization defects of affected bones and joints. Differing in anatomical distribution, severity and associated syndromic features, gene identification in each 'vanishing bone' disorder should provide unique insights into genetic/molecular pathways contributing to the overall control of skeletal growth and development. We previously described and then demonstrated that the novel autosomal recessive osteolysis/arthritis syndrome, multicentric osteolysis with arthritis (MOA) (MIM #605156), was caused by inactivating mutations in the MMP2 gene [Al Aqeel, A., Al Sewairi, W., Edress, B., Gorlin, R.J., Desnick, R.J. and Martignetti, J.A. (2000) Inherited multicentric osteolysis with arthritis: A variant resembling Torg syndrome in a Saudi family. Am. J. Med. Genet., 93, 11-18.]. These in vivo results were counterintuitive and unexpected since previous in vitro studies suggested that MMP-2 overexpression and increased activity, not deficiency, would result in the bone and joint features of MOA. The apparent lack of a murine model [Itoh, T., Ikeda, T., Gomi, H., Nakao, S., Suzuki, T. and Itohara, S. (1997) Unaltered secretion of beta-amyloid precursor protein in gelatinase A (matrix metalloproteinase 2)-deficient mice. J. Biol. Chem., 272, 22389-22392.] has hindered studies on disease pathogenesis and, more fundamentally, in addressing the paradox of how functional loss of a single proteolytic enzyme results in an apparent increase in bone loss. Here, we report that Mmp2-/- mice display attenuated features of human MOA including progressive loss of bone mineral density, articular cartilage destruction and abnormal long bone and craniofacial development. Moreover, these changes are associated with markedly and developmentally restricted decreases in osteoblast and osteoclast numbers in vivo. Mmp2-/- mice have approximately 50% fewer osteoblasts and osteoclasts than control littermates at 4 days of life but these differences have nearly resolved by 4 weeks of age. In addition, despite normal cell numbers in vivo at 8 weeks of life, Mmp2-/- bone marrow cells are unable to effectively support osteoblast and osteoclast growth and differentiation in culture. Targeted inhibition of MMP-2 using siRNA in human SaOS2 and murine MC3T3 osteoblast cell lines resulted in decreased cell proliferation rates. Taken together, our findings suggest that MMP-2 plays a direct role in early skeletal development and bone cell growth and proliferation. Thus, Mmp2-/- mice provide a valuable biological resource for studying the pathophysiological mechanisms underlying the human disease and defining the in vivo physiological role of MMP-2.

Inherited multicentric osteolysis with carpal-tarsal localisation mimicking juvenile idiopathic arthritis

Five patients with multicentric carpal-tarsal osteolysis are presented: a mother and her three children with an autosomal dominant mode of inheritance and one of the children with nephropathy, the fifth a sporadic case also with renal involvement. The main findings common to these five patients are symptoms and signs simulating arthritis of the wrists and/or ankles starting at a young age and mimicking juvenile idiopathic arthritis. Early signs of osteolysis and shortening of the carpus or tarsus are radiological characteristic. The disease may be associated with a peculiar face, but most importantly with nephropathy. The pathogenesis is still unknown.

CONCLUSION

Recognition of this disease and differentiation from juvenile idiopathic arthritis is important to avoid unnecessary investigations and treatment. Follow-up of renal function is indicated.

Osteólise carpo-tarsal: relato de caso

Os autores relatam um caso de paciente do sexo masculino, com 42 anos de idade, com queixa de poliartralgia de caráter progressivo, iniciada na infância. O quadro evoluiu com deformidades de mãos e pés, impedindo-o de deambular. Não havia alterações associadas em outros sistemas. As radiografias das mãos e pés mostraram lise dos ossos do carpo, do tarso, metacarpais e metatarsais. A osteólise carpo-tarsal é uma síndrome rara, que necessita de uma melhor abordagem clínica, diagnóstica e terapêutica diante de novos casos.

Adult-onset idiopathic progressive acro-osteolysis with proximal symphalangism

We experienced a 57-year-old female with adult-onset non-congenital idiopathic acro-osteolysis combined with proximal symphalangism. At the age of 36, she developed severe pain and swelling of the toe base of both feet and underwent Clayton surgery. However, the size of her toes diminished progressively over the 5-year period after surgery. At the age of 41, she suffered pain and swelling of the proximal interphalangeal (PIP) joints of fingers of both hands. These PIP joints became rigid and inflexible. Subsequently, she noticed shortening of the little finger of both hands, followed later by shortening of the index, middle, and ring fingers. At the age of 57, the thumbs began to shorten. Laboratory and endocrinological examinations were not abnormal. Finally, we diagnosed her with acro-osteolysis combined with proximal symphalangism by radiological examination. In this case, previously unreported mutations of the Noggin gene were identified. This is the first case report of adult-onset, non-congenital idiopathic acro-osteolysis combined with proximal symphalangism.

Talo-patello-scaphoid osteolysis, synovitis, and short fourth metacarpals in sisters: a new syndrome?

Osteolysis syndromes are characterized by resorption of affected bones with associated swelling and pain. Various forms of multicentric osteolysis syndromes including autosomal dominant and recessive carpal-tarsal osteolysis, Torg, François, Whyte-Hemingway, Hajdu-Cheney, Winchester, and other forms have been described. Most present in pre-school years with extensive involvement and destruction of multiple bones. We present a sister-pair, both of whom presented in early teenage, i.e., 13 and 15.5 years, respectively, with bilateral ankle, knee, and later, wrist pain. Radiological examination revealed bilateral osteolysis of tali, scaphoids, and patellae, and short fourth metacarpals in both sisters. Further investigation revealed absence of renal involvement, a normal excretion of amino acids, mucopolysaccharides and oligosaccharides, and presence of chronic synovitis in both sisters. Both parents and a younger brother were without radiographic or clinical evidence of the disease and there was no history of consanguinity. Thus, our sister-pair presented with the same carpal and tarsal bone involvement at a much later age, with evidence of chronic synovitis, along with short fourth metacarpals (brachydactyly type E changes) and without renal disease, suggesting a new syndrome with probable autosomal recessive inheritance.

Occlusal rehabilitation of a patient with hereditary multicentric osteolysis

This article describes the fixed prosthodontic rehabilitation of a 53-year-old male patient with multicentric osteolysis. Before treatment, the patient exhibited signs and symptoms of temporomandibular disorder and had recurrent tension-type headaches and pain in the neck and shoulder area. One of his chief complaints was frequent fracture of restorations. After extensive occlusal rehabilitation, occurrence of headache and pain ceased, and other signs and symptoms of TMD diminished. The long-term prognosis depends on the stage of the genetic disorder, which cannot be determined.

Desmoid tumors in a woman with idiopathic multicentric osteolysis: result of three etiologic factors or coincidence?

Desmoid tumors developed on the toes of a young woman with idiopathic multicentric osteolysis (IMO) after amputation of the toenails. A summary of IMO is given, and a review of literature for the etiologic factors of desmoid tumors is added.

Inherited multicentric osteolysis with arthritis: a variant resembling Torg syndrome in a Saudi family

The autosomal recessive multicentric osteolytic disorders of childhood-Torg, Winchester, and François syndromes-predominantly affect the carpal, tarsal, and interphalangeal joints, and their progressive bone loss and crippling arthritic deformities mimic severe juvenile rheumatoid arthritis. In a consanguineous Saudi Arabian family two affected sibs with facial anomalies and short stature displayed a distal arthropathy of the metacarpal, metatarsal, and interphalangeal joints starting in the first few months of life that eventually progressed to the proximal joints and resulted in crippling ankylosis and severe generalized osteopenia. Facial changes included proptosis, a narrow nasal bridge, bulbous nose, and micrognathia. In addition, they had large, painful fibrocollagenous palmar and plantar pads and mild body hirsutism. Affected individuals were of normal intelligence and had normal renal function. Routine hematologic, chemistry, and rheumatoid studies were within normal limits. Histologic examination of bone marrow and an interphalangeal joint biopsy were not informative. The autosomal recessive inheritance, clinical, and radiologic characteristics of the affected sibs suggested that they had a form of multicentric osteolysis most closely resembling the Torg syndrome, but with a unique facial appearance, fibrocollagenous pads, and body hirsutism not noted in the original description of the syndrome.

Idiopathic multicentric osteolysis principally affecting the phalanges of the hands and feet

The case of a 64-year-old man with idiopathic symmetrical osteolysis affecting both hands and feet is presented. The phalanges were principally affected, with relative sparing of the carpus and tarsus. The relevant literature has been reviewed and this reveals that the distribution of osteolysis in this case is unique. We suggest that this case represents a different disease entity, which has not been described previously.

Abnormal glomerular basement membrane in idiopathic multicentric osteolysis

The primary cause of nephropathy in idiopathic multicentric osteolysis is as yet unknown. We report a young girl with idiopathic multicentric osteolysis and nephropathy. An abnormal glomerular basement membrane was the only abnormality found in a renal biopsy taken 2 years before the development of end-stage renal failure. We believe that this biopsy finding represents or is related to the unknown primary lesion causing nephropathy in idiopathic multicentric osteolysis.

Winchester syndrome. A case report and literature review

The mucopolysaccharidoses are a group of inherited lysosomal storage diseases that are caused by a deficiency of specific enzymes. The acid mucopolysaccharides are stored in tissue and excreted in large quantities in the urine. The storage of this material leads to effects on a wide variety of tissues and to remarkable changes in morphologic features. Winchester syndrome is a rare disorder in the group of mucopolysaccharidoses. This article is a report of a case with classic clinical, radiologic, and biochemical characteristics of the Winchester syndrome.

Primary idiopathic osteolysis: description of a family

A clinical, analytical, and radiological study was carried out on three members of the same family with multicentric idiopathic osteolysis. Transmission appeared to be via the dominant autosome present in the mother and two daughters. In the daughters osteolysis was seen in the carpal and tarsal bones, whereas in the mother radiology showed it to be in the phalanges of the hands and feet.

Essential osteolysis associated with nephropathy, corneal opacity, and pulmonary stenosis

We report on 5-year-old girl with essential osteolysis, nephropathy, corneal opacity, and valvular pulmonary stenosis. The patient was initially seen for evaluation of flexion contractures at wrists, elbows, and knees. Radiographic examination showed osteolytic changes primarily involving the hands and feet. She had persistent proteinuria; renal biopsy disclosed focal glomerulosclerosis in 1/3 of glomeruli. Electron microscopic study of skin fibroblast showed dilated and vacuolated rough endoplasmic reticulum. To our knowledge essential osteolysis associated with the aforementioned disorders has not been previously reported.

Multicentric/massive idiopathic osteolysis in a 17-year-old girl

An unusual case of multicentric/multifocal osteolysis with unique clinical and radiographic features in a 17-year-old girl is reported. The brother of the patient who was probably also affected could not be examined.

Idiopathic multicentric osteolysis: report of two new cases and a review of the literature

Idiopathic multicentric osteolysis is a rare skeletal disorder, usually presenting in early childhood with a clinical picture mimicking juvenile rheumatoid arthritis. Progressive destruction of the carpal and tarsal bones usually occurs and other bones may also be involved. Chronic renal failure is a frequent component of this syndrome. Mental retardation and minor facial abnormalities have been noted in some patients. We report on 2 unrelated, sporadic cases, one with facial anomalies and the other with nephropathy. Our second patient is the first black child to be diagnosed with this disease. The mode of presentation, differential diagnosis, and natural history of this disorder are briefly reviewed.

The radiographic differential diagnosis of juvenile chronic arthritis

In conclusion, this short communication has emphasized that the well known radiographic features of juvenile chronic arthritis are by no means pathognomonic of this entity. A large differential diagnosis must be considered, including haemophilia, idiopathic multicentric osteolysis, the mucopolysaccharidoses, a variety of skeletal dysplasias, infection, and synovial haemangioma. Correlation of radiographic observations with clinical findings will permit the establishment of an accurate and specific diagnosis in most instances, underscoring the need for close communication between the paediatric radiologist and practising paediatrician.

Multicentric osteolysis: report of the second successful renal transplant

A patient with end stage renal disease due to sporadic idiopathic multicentric osteolysis (type 3 multicentric osteolysis) is described. His pre-transplant course was similar to those of previously described patients, while his post-transplant course has been uncomplicated. The pathology and pathogenesis of the nephropathy of sporadic idiopathic multicentric osteolysis is not well characterized. The short term outcome of renal transplantation is excellent in our patient and in the other similar case known to have been transplanted.

Familial vanishing limbs: four generations of idiopathic multicentric osteolysis

A family is described which has exhibited in four generations a bizarre form of arthritis mutilans and osteolysis, the features of which seem to fit most closely with a diagnosis of hereditary multicentric osteolysis, a subgroup of idiopathic multicentric osteolysis. The differential diagnosis of arthritis mutilans associated with osteolysis is discussed; this includes a wide variety of disorders ranging from rheumatoid arthritis to rare conditions such as the Winchester syndrome.

Carpal and tarsal osteolysis

This report describes the symptoms, clinical course and radiological features in three cases of idiopathic carpotarsal osteolysis. Before signs of extensive osteolysis were noted, one of our patients showed flattening, loss of harmonious curvature and minimal osteoporosis of carpal and tarsal bones, all early radiological signs which have not been described previously. We discuss the findings, classification and our ideas as to the cause of the disorder.

Acro-osteolysis occurring in a patient with idiopathic multicentric osteolysis

The first report of acro-osteolysis occurring in a patient with idiopathic multicentric osteolysis is presented. In addition to lysis of the shafts and tufts of thd distal phalanges, erosions developed in the interphalangeal, metacarpophalangeal, wrist, hip, knee, ankle, and metatarsophalangeal joints. Acroosteolysis can be part of the spectrum of bony erosions present with idiopathic multicentric osteolysis. A modification of a previous classification of idiopathic multicentric osteolysis is presented based upon a review of the literature.