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Whyte MP, Zhang F, Mack KE, Wenkert D, Gottesman GS, Ericson KL, Cole JT, Coburn SP. Pyridoxine challenge reflects pediatric hypophosphatasia severity and thereby examines tissue-nonspecific alkaline phosphatase's role in vitamin B 6 metabolism. Bone 2024; 181:117033. [PMID: 38307176 DOI: 10.1016/j.bone.2024.117033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/28/2023] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
Alkaline phosphatase (ALP) is detected in most human tissues. However, ALP activity is routinely assayed using high concentrations of artificial colorimetric substrates in phosphate-free laboratory buffers at lethal pH. Hypophosphatasia (HPP) is the inborn-error-of-metabolism caused by loss-of-function mutation(s) of the ALPL gene that encodes the ALP isoenzyme expressed in bone, liver, kidney, and elsewhere and is therefore designated "tissue-nonspecific" ALP (TNSALP). Consequently, HPP harbors clues concerning the biological function of this phosphohydrolase that is anchored onto the surface of cells. The biochemical signature of HPP features low serum ALP activity (hypophosphatasemia) together with elevated plasma levels of three natural substrates of TNSALP: i) phosphoethanolamine (PEA), a component of the linkage apparatus that binds ALPs and other proteins to the plasma membrane surface; ii) inorganic pyrophosphate (PPi), an inhibitor of bone and tooth mineralization; and iii) pyridoxal 5'-phosphate (PLP), the principal circulating vitameric form of vitamin B6 (B6). Autosomal dominant and autosomal recessive inheritance involving several hundred ALPL mutations underlies the remarkably broad-ranging expressivity of HPP featuring tooth loss often with muscle weakness and rickets or osteomalacia. Thus, HPP associates the "bone" isoform of TNSALP with biomineralization, whereas the physiological role of the "liver", "kidney", and other isoforms of TNSALP remains uncertain. Herein, to examine HPP's broad-ranging severity and the function of TNSALP, we administered an oral challenge of pyridoxine (PN) hydrochloride to 116 children with HPP. We assayed both pre- and post-challenge serum ALP activity and plasma levels of PLP, the B6 degradation product pyridoxic acid (PA), and the B6 vitamer pyridoxal (PL) that can enter cells. Responses were validated by PN challenge of 14 healthy adults and 19 children with metabolic bone diseases other than HPP. HPP severity was assessed using our HPP clinical nosology and patient height Z-scores. PN challenge of all study groups did not alter serum ALP activity in our clinical laboratory. In HPP, both the post-challenge PLP level and the PLP increment correlated (Ps < 0.0001) with the clinical nosology and height Z-scores (Rs = +0.6009 and + 0.4886, and Rs = -0.4846 and - 0.5002, respectively). In contrast, the plasma levels and increments of PA and PL from the PN challenge became less pronounced with HPP severity. We discuss how our findings suggest extraskeletal TNSALP primarily conditioned the PN challenge responses, and explain why they caution against overzealous B6 supplementation of HPP.
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Affiliation(s)
- Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA; Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Fan Zhang
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA.
| | - Karen E Mack
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA
| | - Deborah Wenkert
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA.
| | - Gary S Gottesman
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA; Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Karen L Ericson
- Department of Chemistry and Biochemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
| | - Jeffrey T Cole
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA.
| | - Stephen P Coburn
- Department of Chemistry and Biochemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
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Okumura G, Yamamoto N, Suzuki H, Ninomiya H, Hirano Y, Tei Y, Tomiyama Y, Shimakura T, Takahashi HE, Imai N, Kawashima H. Histomorphometric analysis of patients with femoral neck fracture and 25-hydroxyvitamin D deficiency: a cross-sectional study. J Bone Miner Metab 2024; 42:214-222. [PMID: 38329506 DOI: 10.1007/s00774-024-01495-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/26/2023] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Vitamin D deficiency causes osteoporosis, bone mineralization disorders, and osteomalacia. Osteomalacia is diagnosed using blood biochemical tests, clinical symptoms, and imaging; however, accurate detection of mineralization disorders requires tissue observation. We investigated the prevalence of bone mineralization disorders and their relationship with serum 25-hydroxyvitamin D (25OHD) levels in patients with untreated osteoporosis with femoral neck fractures. MATERIALS AND METHODS A non-demineralized specimen was prepared from the femoral head removed during surgery in 65 patients. Bone histomorphometry of cancerous bone in the femoral head center was conducted. Osteoid volume per bone volume (OV/BV) and osteoid thickness (O.Th) were measured as indicators of mineralization disorder. RESULTS The mean serum 25OHD level (11.9 ± 5.7 ng/mL) was in the deficiency range (< 12 ng/mL). There were no clinically diagnosed cases of osteomalacia (OV/BV > 10% and O.Th > 12.5 µm); however, one case of mineralization disorder, considered histologically pre-osteomalacia (OV/BV > 5% and O.Th < 12.5 µm), was observed (OB/BV, 17.6%; O.Th, 12.3 µm). Excluding this case, those with severe (25OHD < 12 ng/mL, at risk of osteomalacia; n = 39) and non-severe deficiency (25OHD ≥ 12 ng/mL; n = 25) did not significantly differ in OV/BV (%; 0.77 ± 0.54 vs. 0.69 ± 0.38, p = 0.484) or O.Th (µm; 5.32 ± 1.04 vs. 5.13 ± 0.78, p = 0.410). Further, 25OHD and OV/BV were not significantly correlated (R = - 0.124, p = 0.327). CONCLUSION This is the first study in the twenty-first century to examine serum 25OHD concentrations and bone mineralization disorders in Japanese patients with osteoporosis. The results indicate that vitamin D deficiency does not necessarily cause bone mineralization disorders and rarely leads to osteomalacia.
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Affiliation(s)
- Go Okumura
- Division of Orthopedic Surgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka City, 940-8621, Japan.
| | - Noriaki Yamamoto
- Division of Orthopedic Surgery, Niigata Rehabilitation Hospital, Niigata, Japan
- Niigata Bone Science Institute, Niigata, Japan
| | - Hayato Suzuki
- Division of Orthopedic Surgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka City, 940-8621, Japan
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroshi Ninomiya
- Division of Orthopedic Surgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka City, 940-8621, Japan
| | - Yuki Hirano
- Division of Orthopedic Surgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka City, 940-8621, Japan
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshiaki Tei
- Division of Orthopedic Surgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka City, 940-8621, Japan
- Division of Orthopedic Surgery, Niigata Prefectural Shibata Hospital, Niigata, Japan
| | - Yasuyuki Tomiyama
- Division of Orthopedic Surgery, Niigata Rehabilitation Hospital, Niigata, Japan
- Division of Orthopedic Surgery, Niigata Prefectural Central Hospital, Niigata, Japan
| | | | | | - Norio Imai
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- Division of Comprehensive Musculoskeletal Medicine, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Bi Y, Wang L, Zhang W, Tian K. Management of intraoperative periprosthetic fractures in a patient with osteomalacia induced by chronic use of adefovir dipivoxil: A good treatment outcome with a 5-year follow-up. Asian J Surg 2023; 46:5468-5470. [PMID: 37541872 DOI: 10.1016/j.asjsur.2023.07.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/16/2023] [Indexed: 08/06/2023] Open
Affiliation(s)
- Yingwei Bi
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, 116044, China.
| | - Le Wang
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, 116044, China.
| | - Weiguo Zhang
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, 116044, China.
| | - Kang Tian
- Department of Joint and Sports Medicine, First Affiliated Hospital, Dalian Medical University, Dalian, 116044, China.
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Colazo JM, Quirion J, Judice AD, Halpern J, Schwartz HS, Tanner SB, Lawrenz JM, Dahir KM, Holt GE. Utility of iliac crest tetracycline-labelled bone biopsy in osteoporosis and metabolic bone disease: An evaluation of 95 cases over a period of 25 years. Bone Rep 2023; 19:101715. [PMID: 37811524 PMCID: PMC10558706 DOI: 10.1016/j.bonr.2023.101715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/17/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023] Open
Abstract
Background Metabolic bone diseases (MBD) are typically diagnosed by non-invasive imaging and clinical biomarkers. However, imaging does not provide structural information, and biomarkers can be transiently affected by many systemic factors. Bone biopsy and pathologic evaluation is the gold standard for diagnosis of MBD, however, it is rarely utilized. We describe our technique for iliac crest tetracycline-labelled bone using a cannulated drill and assess the utility of bone biopsies to provide diagnostic and therapeutic guidance. Methods In the 25-year period between March 1998 and January 2023, a total of 95 bone biopsies were performed on 94 patients for an osteological indication at Vanderbilt University Medical Center (VUMC). Patient demographics, bone biopsy indications, complications, diagnostic utility, and subsequent therapeutic guidance were retrospectively reviewed and analyzed. Results The procedure had minimal complications and was well tolerated by patients. This technique provided good quality specimens for pathology, which helped establish a diagnosis and treatment change in most patients. Patients that had biopsy-guided treatment alterations showed significant increases in Dual-Energy X-ray Absorptiometry (DEXA) bone mineral density (BMD) scores post-biopsy and subsequent treatment. Conclusion Despite scientific and technological progress in non-invasive diagnostic imaging, clinical biomarkers, and procedures for MBD, there remains a small but significant subset of patients who may benefit from inclusion of tetracycline-labelled bone biopsy into the diagnostic and therapeutic picture. Future prospective comparison studies are warranted. Mini abstract Tetracycline-labelled bone biopsies are under-utilized. Biopsy led to a histological diagnosis and ensuing treatment alteration in most patients with significant increases in bone mineral density. The biopsy procedure used herein provided good specimens with low pain/adverse events. Bone biopsy remains a valuable tool in a small, though significant, subset of patients.
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Affiliation(s)
- Juan M. Colazo
- Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Julia Quirion
- Division of Musculoskeletal Oncology, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony D. Judice
- Division of Musculoskeletal Oncology, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Halpern
- Division of Musculoskeletal Oncology, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Herbert S. Schwartz
- Division of Musculoskeletal Oncology, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - S. Bobo Tanner
- Department of Medicine, Division of Rheumatology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joshua M. Lawrenz
- Division of Musculoskeletal Oncology, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kathryn M. Dahir
- Department of Medicine, Division of Endocrinology and Diabetes, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ginger E. Holt
- Division of Musculoskeletal Oncology, Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Kim S, Kim SW, Lee BC, Kim DH, Sung DH. Adult-onset hypophosphatemic osteomalacia as a cause of widespread musculoskeletal pain: A retrospective case series of single center experience. World J Clin Cases 2023; 11:7785-7794. [DOI: 10.12998/wjcc.v11.i32.7785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/14/2023] [Accepted: 10/30/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Osteomalacia (OM) is frequently confused with various musculoskeletal or other rheumatic diseases, especially in patients with adult-onset widespread musculoskeletal pain because of its low prevalence and non-specific manifestations.
AIM To facilitate the early diagnosis and etiology-specific treatment of adult-onset hypophosphatemic OM.
METHODS A retrospective review of medical records was performed to screen adult patients who visited a physiatry locomotive medicine clinic (spine and musculoskeletal pain clinic) primarily presenting with widespread musculoskeletal pain at a single tertiary hospital between January 2011 and December 2019. We enrolled patients with hypophosphatemia, high serum bone-specific alkaline phosphatase levels, and at least one imaging finding suggestive of OM.
RESULTS Eight patients with adult-onset hypophosphatemic OM were included. The back was the most common site of pain. Proximal dominant symmetric muscle weakness was observed in more than half of the patients. Bone scintigraphy was the most useful imaging modality for diagnosing OM because radiotracer uptake in OM showed characteristic patterns. Six patients were diagnosed with adefovir (ADV)-induced Fanconi syndrome, and the other two patients were diagnosed with tumor-induced OM and light-chain nephropathy, respectively. After phosphorus and vitamin D supplementation and treatment for the underlying etiologies, improvements in pain, muscle strength, and gait were observed in all patients.
CONCLUSION Mechanical pain characteristics, hypophosphatemia, and distinctive bone scintigraphy patterns are the initial diagnostic indicators of adult-onset hypophosphatemic OM. ADV-induced Fanconi syndrome is the most common etiology of hypophosphatemic OM in hepatitis B virus-endemic countries.
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Affiliation(s)
- Sungwon Kim
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Sun Woong Kim
- Department of Physical and Rehabilitation Medicine, Jungdap Hospital, Suwon 16480, South Korea
| | - Byung Chan Lee
- Physical Medicine and Rehabilitation, Chung-Ang University Hospital, Seoul 06973, South Korea
| | - Du Hwan Kim
- Physical Medicine and Rehabilitation, Chung-Ang University, Seoul 06973, South Korea
| | - Duk Hyun Sung
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Seoul 06351, South Korea
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Mohamed FF, Hoac B, Phanrungsuwan A, Tan MH, Giovani PA, Ghiba S, Murshed M, Foster BL, McKee MD. Contributions of increased osteopontin and hypophosphatemia to dentoalveolar defects in osteomalacic Hyp mice. Bone 2023; 176:116886. [PMID: 37634682 PMCID: PMC10529969 DOI: 10.1016/j.bone.2023.116886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/10/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
X-linked hypophosphatemia (XLH) is an inherited disorder caused by inactivating mutations in the PHEX gene leading to renal phosphate wasting, rickets and osteomalacia. XLH is also associated with dentoalveolar mineralization defects in tooth enamel, dentin and cementum, and in alveolar bone, which lead to an increased prevalence of dental abscesses, periodontal disease and tooth loss. Genetic mouse experiments, and deficiencies in XLH patient therapies where treatments do not fully ameliorate mineralization defects, suggest that other pathogenic mechanisms may exist in XLH. The mineralization-inhibiting, secreted extracellular matrix phosphoprotein osteopontin (OPN, gene Spp1) is a substrate for the PHEX enzyme whereby extensive and inactivating degradation of inhibitory OPN by PHEX facilitates mineralization. Conversely, excess OPN accumulation in skeletal and dental tissues - for example in XLH where inactivating mutations in the PHEX gene limit degradation of inhibitory OPN, or as occurs in Fgf23-null mice - contributes to mineralization defects. We hypothesized that Spp1/OPN ablation in Hyp mice (a mouse model for XLH) would reduce dentoalveolar mineralization defects. Immunostaining revealed increased OPN in Hyp vs. wild-type (WT) alveolar bone, particularly in osteocyte lacunocanalicular networks where Hyp mice have characteristic hypomineralized peri-osteocytic lesions (POLs). Micro-computed tomography and histology showed that ablation of Spp1 in Hyp mice (Hyp;Spp1-/-) on a normal diet did not ameliorate bulk defects in enamel, dentin, or alveolar bone. On a high-phosphate diet, both Hyp and Hyp;Spp1-/- mice showed improved mineralization of enamel, dentin, and alveolar bone. Silver staining indicated Spp1 ablation did not improve alveolar or mandibular bone osteocyte POLs in Hyp mice; however, they were normalized by a high-phosphate diet in both Hyp and Hyp;Spp1-/- mice, although inducing increased OPN. Collectively, these data indicate that despite changes in OPN content in the dentoalveolar mineralized tissues, there exist other compensatory mineralization mechanisms that arise from knockout of Spp1/OPN in the Hyp background.
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Affiliation(s)
- Fatma F Mohamed
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Betty Hoac
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada
| | | | - Michelle H Tan
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | | | - Sana Ghiba
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Monzur Murshed
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada; Department of Medicine, Faculty of Medicine, McGill University, Montreal, QC, Canada; Shriners Hospital for Children, Montreal, QC, Canada
| | - Brian L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA.
| | - Marc D McKee
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada; Department of Anatomy and Cell Biology, School of Biomedical Sciences, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.
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Ariceta G, Beck-Nielsen SS, Boot AM, Brandi ML, Briot K, de Lucas Collantes C, Emma F, Giannini S, Haffner D, Keen R, Levtchenko E, Mӓkitie O, Mughal MZ, Nilsson O, Schnabel D, Tripto-Shkolnik L, Liu J, Williams A, Wood S, Zillikens MC. The International X-Linked Hypophosphatemia (XLH) Registry: first interim analysis of baseline demographic, genetic and clinical data. Orphanet J Rare Dis 2023; 18:304. [PMID: 37752558 PMCID: PMC10523658 DOI: 10.1186/s13023-023-02882-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) is a rare, hereditary, progressive, renal phosphate-wasting disorder characterized by a pathological increase in FGF23 concentration and activity. Due to its rarity, diagnosis may be delayed, which can adversely affect outcomes. As a chronic disease resulting in progressive accumulation of musculoskeletal manifestations, it is important to understand the natural history of XLH over the patient's lifetime and the impact of drug treatments and other interventions. This multicentre, international patient registry (International XLH Registry) was established to address the paucity of these data. Here we present the findings of the first interim analysis of the registry. RESULTS The International XLH Registry was initiated in August 2017 and includes participants of all ages diagnosed with XLH, regardless of their treatment and management. At the database lock for this first interim analysis (29 March 2021), 579 participants had entered the registry before 30 November 2020 and are included in the analysis (360 children [62.2%], 217 adults [37.5%] and 2 whose ages were not recorded [0.3%]; 64.2% were female). Family history data were available for 319/345 (92.5%) children and 145/187 (77.5%) adults; 62.1% had biological parents affected by XLH. Genetic testing data were available for 341 (94.7%) children and 203 (93.5%) adults; 370/546 (67.8%) had genetic test results; 331/370 (89.5%) had a confirmed PHEX mutation. A notably longer time to diagnosis was observed in adults ≥ 50 years of age (mean [median] duration 9.4 [2.0] years) versus all adults (3.7 [0.1] years) and children (1.0 [0.2] years). Participants presented with normal weight, shorter length or height and elevated body mass index (approximately - 2 and + 2 Z-scores, respectively) versus the general population. Clinical histories were collected for 349 participants (239 children and 110 adults). General data trends for prevalence of bone, dental, renal and joint conditions in all participants were aligned with expectations for a typical population of people with XLH. CONCLUSION The data collected within the International XLH Registry, the largest XLH registry to date, provide substantial information to address the paucity of natural history data, starting with demographic, family history, genetic testing, diagnosis, auxology and baseline data on clinical presentation.
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Affiliation(s)
- Gema Ariceta
- Department of Pediatric Nephrology, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, Barcelona, Spain.
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Aarhus University Hospital, Åarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Åarhus, Denmark
| | - Annemieke M Boot
- Department of Pediatrics, Division of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Karine Briot
- Hôpital Cochin, Service de Rhumatologie, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate Filière OSCAR, AP-HP, Paris, France
| | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Rome, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padua, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Elena Levtchenko
- Department of Pediatric Nephrology and Development and Regeneration, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Outi Mӓkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University Hospital's NHS Trust, Manchester, UK
| | - Ola Nilsson
- Division of Pediatric Endocrinology and Center for Molecular Medicine, Department of Women's and Children's Health, Karolinska Institutet and University Hospital, Stockholm, Sweden
- School of Medical Sciences and Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charité, University Medicine Berlin, Berlin, Germany
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Sue Wood
- Kyowa Kirin International, Marlow, UK
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Samões B, Silva B, Martins A, Oliveira D, Rajão Martins F, Fonseca D, Costa L, Bernardes M. Hypophosphatemic osteomalacia induced by intravenous iron therapy: a case report. Joint Bone Spine 2023; 90:105586. [PMID: 37127260 DOI: 10.1016/j.jbspin.2023.105586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/05/2023] [Accepted: 04/18/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Osteomalacia is an uncommon, overlooked and debilitating metabolic bone disease with numerous aetiologies. Herein, we report an atypical cause of osteomalacia - intravenous iron therapy. METHODS Description of a case report of hypophophatemic osteomalacia induced by ferric carboxymaltose infusions. RESULTS A 70-year-old male with Rendu-Osler-Weber syndrome requiring repeated infusions of ferric carboxymaltose was admitted for disabling lower limb pain associated with persistent hypophosphatemia (1.6mg/dL) and increased urinary fractional excretion of phosphate (43%, UP04=118.3mg/dL), serum fibroblast growth factor 23 (324UA/mL), intact parathyroid hormone (110pg/mL) and bone alkaline phosphatase (40.1mcg/L). X-ray and CT of the feet showed severe diffuse bone demineralization. Feet MRI displayed a subchondral fracture of the cuneiform-navicular joints. Spine X-ray revealed dorsolumbar vertebral flattening. Somatostatin receptor PET scan excluded an occult tumor. Bone biopsy with histomorphometry confirmed the presence of osteomalacia. After excluding other causes, a diagnosis of hypophosphatemic osteomalacia induced by frequent ferric carboxymaltose infusions was made. The iron formulation was replaced by saccharated ferric oxide infusions and progressive titration of calcitriol up to 1.5mg/day and oral disodium phosphate up to 5740mg/day was started. After 6 months, there was a clear clinical and analytical improvement. CONCLUSION Osteomalacia may be a consequence of prolonged hypophosphatemia induced by recurrent ferric infusions, which is an uncommon and neglected bone adverse event of this therapy. Phosphate levels and bone symptoms should be monitored during repetitive iron infusions, maintaining a high level of suspicion for osteomalacia as it is important to identify and treat it in a timely manner, minimizing its severe morbidity.
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Affiliation(s)
- Beatriz Samões
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal.
| | - Bruna Silva
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Ana Martins
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Daniela Oliveira
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, R. Dr. Plácido da Costa, 4200-450 Porto, Portugal
| | - Frederico Rajão Martins
- Rheumatology Department, Centro Hospitalar Universitário do Algarve, R. Leão Penedo, 8000-386 Faro, Portugal
| | - Diogo Fonseca
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal
| | - Lúcia Costa
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Miguel Bernardes
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
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Mirghaderi P, Mortezaei A, Parry JA, Salimi M, Mirghaderi R, Moharrami A, Mortazavi SMJ. Osteomalacia Prevalence, Biochemical Profile, and Histology in Patients with Low-Energy Hip Fractures Over the Age of 45. Calcif Tissue Int 2023; 113:257-265. [PMID: 37326840 DOI: 10.1007/s00223-023-01103-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/25/2023] [Indexed: 06/17/2023]
Abstract
Our objective was to determine the prevalence of osteomalacia in low-energy hip fracture patients over the age of 45, based on biochemical and histological measures. This cross-sectional study included 72 patients over 45 with low-energy mechanism hip fractures. Samples of fasting venous blood were taken for hemograms and serum biochemistry analyses. Bicortical biopsies of the iliac crest were obtained, processed, and evaluated by an expert pathologist for osteomalacia. Biochemical osteomalacia (b-OM) is defined according to a distinct criterion. A low level of serum calcium, phosphorus, albumin, and 25OHD was found in 43.1, 16.7, 73.6, and 59.7% of patients, respectively. 50.0% of patients had high serum alkaline phosphatase (ALP) levels. b-OM was found in 30 (41.7%), and no significant association was found with PTH, Cr, Alb, age, sex, fracture type, side of the trauma, and season were not associated with osteomalacia. Osteomalacia was diagnosed on histopathological analysis in 19/72 (26.7%), and 54/72 (75.0%) of all cases fulfilled b-OM criteria. In the histologic evaluation, osteoid seam width, osteoid surface, and osteoid volume were 28.5 µm, 25.6, and 12.1%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the biochemical test for detecting osteomalacia were 73.6, 64.2, 42.4, 87.2, and 66.7%, respectively. Up to 30% of elderly patients with low-energy hip fractures are affected by osteomalacia. A biochemical screening along with a bone biopsy and histopathologic evaluation may be logical in a high-risk population for osteomalacia diagnosis.
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Affiliation(s)
- Peyman Mirghaderi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Mortezaei
- Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Joshua A Parry
- Department of Orthopaedic Surgery, Denver Health Medical Center, Denver, USA
| | - Maryam Salimi
- Department of Orthopaedic Surgery, Denver Health Medical Center, Denver, USA
| | - Reza Mirghaderi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Moharrami
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - S M Javad Mortazavi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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Schild CO, Boabaid FM, Olivera LGS, Armendano JI, Saravia A, Custodio A, Algorta J, Alvarez C, Jaurena M, Dixon RM, Riet-Correa F. Response of cows with osteomalacia grazing sub-tropical native pastures to phosphorus supplementation with loose mineral mix or feed blocks. Vet J 2023; 298-299:106013. [PMID: 37355009 DOI: 10.1016/j.tvjl.2023.106013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 06/26/2023]
Abstract
Osteomalacia outbreaks often occur in cattle grazing native pastures in regions with endemic phosphorous (P) deficiency. This study evaluated the responses of two groups of cows, initially with clinical signs of chronic P deficiency, to P supplements (100 g P/kg) offered ad libitum for 13 weeks as a loose mineral mix (LMM group) or the same mineral mix offered as blocks (BMM group). Half of the cows in each group were categorized as 'with' or 'without' severe osteopenia according to a test that depended on the resistance to penetration of a needle through the left lateral process of the L4-L5 lumbar vertebra. The groups grazed two paddocks that were switched each 3 weeks. The liveweight, supplement intakes, and the P-concentrations in soil, forage, blood, and external cortical bone (ECB) of the ribs were measured. The bicarbonate-extractable P in soil was 3.5 mg/kg. The mean of total P in forage (0.95 g/kg/DM), inorganic P in serum (iP, 0.96 mmol/L), and total P in the ECB of the ribs (85 mg/mL) at the beginning of the experiment were all low and consistent with severe chronic P deficiency. The P supplementation allowed clinical recovery in 18/20 cows with their serum and ECB P and calcium approaching normal values and in the two remaining cows the only sign was abnormal gait. Cows consumed more of the LMM than BMM supplement (means 8.3 and 6.6 g P/day, respectively). After 13 weeks cows initially classified as 'with severe osteopenia' and supplemented with LMM had higher (P < 0.05) final liveweight (difference = 21.6 kg), iP (difference = 0.74 mmol/L), bone Ca (difference = 65.7 mg/mL) and bone P (difference = 26.5 mg/mL) concentrations and lower (P < 0.01) final serum Ca/iP ratio (difference = -0.65) than cows with severe osteopenia but supplemented with BMM. The treatment of severe P deficiency cows grazing P deficient sub-tropical grasslands by P supplementation for 13 weeks was more effective with LMM than BMM.
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Affiliation(s)
- C O Schild
- Instituto Nacional de Investigación Agropecuaria (INIA), Plataforma de Investigación en Salud Animal (PSA), Estación Experimental (EE) Tacuarembó, Ruta 5, km 386, Tacuarembó 45000, Uruguay; California Animal Health Food Safety, University of California Davis, 105 W Central Ave, San Bernardino, CA 92408, USA
| | - F M Boabaid
- Polo de Desarrollo Universitario, Instituto Superior de la Carne, Sede Tacuarembó, CENUR Noreste, Universidad de la República, Ruta 5, km 386, Tacuarembó 45000, Uruguay
| | - L G S Olivera
- Instituto Nacional de Investigación Agropecuaria (INIA), Plataforma de Investigación en Salud Animal (PSA), Estación Experimental (EE) Tacuarembó, Ruta 5, km 386, Tacuarembó 45000, Uruguay
| | - J I Armendano
- Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires, Paraje Arroyo Seco S/N, Tandil 7000, Argentina
| | - A Saravia
- INIA, PSA, EE La Estanzuela, Ruta 50 km 11, Colonia 70000, Uruguay
| | - A Custodio
- Instituto Nacional de Investigación Agropecuaria (INIA), Plataforma de Investigación en Salud Animal (PSA), Estación Experimental (EE) Tacuarembó, Ruta 5, km 386, Tacuarembó 45000, Uruguay
| | - J Algorta
- Barraca Deambrosi S.A., Av. Rondeau 2257, Montevideo 11800, Uruguay
| | - C Alvarez
- Laboratorio Analítico Agroindustrial, Ruta 90 km 5, Paysandú 60000, Uruguay
| | - M Jaurena
- INIA, Programa Nacional de Investigación en Pasturas y Forrajes, EE Tacuarembó, Uruguay
| | - R M Dixon
- Queensland Alliance for Agriculture and Food Innovation, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - F Riet-Correa
- Programa de pós-graduação em Ciência Animal nos Trópicos, Escola de Medicina Veterinária e Zootecnia, Universidade Federal da Bahia, Salvador 41405-000, Brazil.
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Chacur C, Gonzalez E, Peris P. X-linked hypophosphatemic osteomalacia (XLH): Study of 5 adult patients. Med Clin (Barc) 2023; 160:218-21. [PMID: 36517274 DOI: 10.1016/j.medcli.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND X-linked hypophosphatemic osteomalacia (XLH) is an inherited disorder that can cause highly disabling musculoskeletal comorbidities in adulthood. OBJECTIVE To analyze the clinical-radiological characteristics, comorbidities and complications associated with the disease and treatment in an adult population with XLH. METHOD Retrospective study of patients treated for XLH in a rheumatology department in the last 10 years, evaluating the clinical-radiological findings, comorbidities and associated complications. RESULTS Five patients between 39 and 75 years of age were included. All had short stature, osteoarticular symptoms and radiological enthesopathy. Four patients had early degenerative arthropathy of the knees and hips, and dental alterations associated with their disease. All patients older than 50 years required some type of prosthetic replacement. Two patients had femoral stress fractures, one had renal lithiasis and another developed tertiary hyperparathyroidism. CONCLUSIONS Musculoskeletal manifestations are frequent and disabling in the adult population with XLH, so proper diagnosis and management from childhood are essential to prevent the development of complications in adulthood associated with this disease.
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Riancho JA. Diagnostic Approach to Patients with Low Serum Alkaline Phosphatase. Calcif Tissue Int 2023; 112:289-296. [PMID: 36348061 DOI: 10.1007/s00223-022-01039-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Increased serum levels of alkaline phosphatase (ALP) are widely recognized as a biochemical marker of many disorders affecting the liver or bone. However, the approach for patients with low ALP phosphatase is not well-established. Low serum ALP is an epiphenomenon of many severe acute injuries and diseases. Persistently low serum ALP may be secondary to drug therapy (including antiresorptives) or a variety of acquired disorders, such as malnutrition, vitamin and mineral deficiencies, endocrine disorders, etc. Hypophosphatasia, due to pathogenic variants of the ALPL gene, which encodes tissue non-specific ALP, is the most common genetic cause of low serum ALP. Marked bone hypomineralization is frequent in severe pediatric-onset cases. However, adult forms of hypophosphatasia usually present with milder manifestations, such as skeletal pain, chondrocalcinosis, calcific periarthritis, dental problems, and stress fractures. The diagnostic approach to these patients is discussed. Measuring several ALP substrates, such as pyrophosphate, pyridoxal phosphate, or phosphoethanolamine, may help to establish enzyme deficiency. Gene analysis showing a pathogenic variant in ALPL may confirm the diagnosis. However, a substantial proportion of patients show normal results after sequencing ALPL exons. It is still unknown if those patients carry unidentified mutations in regulatory regions of ALPL, epigenetic changes, or abnormalities in other genes.
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Affiliation(s)
- Jose A Riancho
- Departamento de Medicina y Psiquiatría, Universidad de Cantabria, Servicio de Medicina Interna, Hospital UM Valdecilla-IDIVAL, Av Valdecilla sn, 39008, Santander, Spain.
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Affiliation(s)
- Amit Agarwal
- From the Departments of Radiology (A.A.) and Neuroradiology (V.G.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, Mayo Clinic, Rochester, Minn (G.B.)
| | - Girish Bathla
- From the Departments of Radiology (A.A.) and Neuroradiology (V.G.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, Mayo Clinic, Rochester, Minn (G.B.)
| | - Vivek Gupta
- From the Departments of Radiology (A.A.) and Neuroradiology (V.G.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, Mayo Clinic, Rochester, Minn (G.B.)
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Abstract
UNLABELLED Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumoral overproduction of FGF-23. Due to local recurrence, we describe the long-term efficacy and safety profile of burosumab, an anti-FGF-23 monoclonal antibody, in a TIO patient after three unsuccessfully surgical attempts. INTRODUCTION TIO is a rare paraneoplastic syndrome caused by tumoral overproduction of fibroblast growth factor 23 (FGF23), resulting in hyperphospaturia, hypophosphatemia, and osteomalacia. Surgery is the only definitive treatment, but tumor can locally recur, even after years from primary surgery. Furthermore, some tumors cannot be removed by surgery due to their location. METHODS We describe the case of a 54-year-old woman affected by recurrent TIO who, after three unsuccessful surgical attempts of tumor removal, was treated with burosumab, an anti-FGF-23 monoclonal antibody. RESULTS The patient was referred to our Bone Unit after experiencing several fractures in different sites, both traumatic and non-traumatic. At the time of first evaluation, at the age of 46, serum-phosphate (SP) was 1.2 mg/dL (reference range (RR) 2.5-4.5), 24-h urinary phosphate was 842 mg (RR 400-1000), and intact-FGF-23 was 117 pg/mL (RR 25-45). Imaging showed a metabolic pre-sacral lesion that firstly underwent to exploratory laparotomy. Then, patient underwent to surgical excision of tumor. After 18 months of well-being, tumor relapsed and even the subsequent surgery was not able to completely remove it. Since 2015, patient was maintained in phosphorus supplements and 1,25(OH)2vitamin D3, but SP levels never normalized. In September 2019, she was started on burosumab, initially at the dose of 0.3 mg/kg/month, progressively increased to the current 0.8 mg/kg/month, with great improvement of pain, physical performance, and normalization of SP levels. Burosumab was temporary and cautionary discontinued for COVID-19 pneumonia, with a worsening of SP. After restart of burosumab, biochemistry returned to normal. CONCLUSIONS To our knowledge, this is the first European patient affected by TIO treated with burosumab for more than 2 years. Burosumab is a promising therapy in the medical treatment of TIO refractory or not eligible for definitive surgery, with good efficacy and safety profile.
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Affiliation(s)
- C Crotti
- Department of Rheumatology, ASST-Pini-CTO, Milan, Italy
| | - F Zucchi
- Department of Rheumatology, ASST-Pini-CTO, Milan, Italy
| | - C Alfieri
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Nephrology, Dialysis and Renal Transplant, Foundation Ca' Granda IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - R Caporali
- Department of Rheumatology, ASST-Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Varenna
- Department of Rheumatology, ASST-Pini-CTO, Milan, Italy.
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Chiloiro S, Giampietro A, Gagliardi I, Bondanelli M, Veleno M, Ambrosio MR, Zatelli MC, Pontecorvi A, Giustina A, De Marinis L, Bianchi A. Impact of the diagnostic delay of acromegaly on bone health: data from a real life and long term follow-up experience. Pituitary 2022; 25:831-841. [PMID: 35922724 PMCID: PMC9362053 DOI: 10.1007/s11102-022-01266-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Acromegaly is a chronic disease with systemic complications. Disease onset is insidious and consequently typically burdened by diagnostic delay. A longer diagnostic delay induces more frequently cardiovascular, respiratory, metabolic, neuropsychiatric and musculoskeletal comorbidities. No data are available on the effect of diagnostic delay on skeletal fragility. We aimed to evaluate the effect of diagnostic delay on the frequency of incident and prevalent of vertebral fractures (i-VFs and p-VFs) in a large cohort of acromegaly patients. PATIENTS AND METHODS A longitudinal, retrospective and multicenter study was conducted on 172 acromegaly patients. RESULTS Median diagnostic delay and duration of follow-up were respectively 10 years (IQR: 6) and 10 years (IQR: 8). P-VFs were observed in 18.6% and i-VFs occurred in 34.3% of patients. The median estimated diagnostic delay was longer in patients with i-VFs (median: 11 years, IQR: 3), in comparison to those without i-VFs (median: 8 years, IQR: 7; p = 0.02). Age at acromegaly diagnosis and at last follow-up were higher in patients with i-VFs, with respect to those without i-VFs. The age at acromegaly diagnosis was positively associated with the diagnostic delay (p < 0.001, r = 0.216). A longer history of active acromegaly was associated with a high frequency of i-VFs (p = 0.03). The logistic regression confirmed that patients with a diagnostic delay > 10 years had 1.5-folds increased risk of developing i-VFs (OR: 1.5; 95%CI: 1.1-2; p = 0.017). CONCLUSION Our data showed that the diagnostic delay in acromegaly has a significant impact on VF risk, further supporting the clinical relevance of an early acromegaly diagnosis.
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Affiliation(s)
- Sabrina Chiloiro
- Endocrinology and Diabetology Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Endocrinology and Diabetology Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Irene Gagliardi
- Section of Endocrinology, Geriatrics & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Marta Bondanelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Miriam Veleno
- Endocrinology and Diabetology Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Rosaria Ambrosio
- Section of Endocrinology, Geriatrics & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Alfredo Pontecorvi
- Endocrinology and Diabetology Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele, Vita-Salute University and IRCCS Hospital, Milan, Italy
| | - Laura De Marinis
- Endocrinology and Diabetology Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Endocrinology and Diabetology Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
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Nischal N, Utkarsh S, Nadkarni B. Isolated bilateral fibular insufficiency fractures: Case report of an unusual entity. J Clin Orthop Trauma 2022; 35:102066. [PMID: 36387935 PMCID: PMC9647555 DOI: 10.1016/j.jcot.2022.102066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
Insufficiency fractures are a type of stress fractures that occur due to physiological stress on weakened bones. These have certain sites of predilection of which an uncommon site is fibular shaft. Isolated bilateral fibular fractures have previously only been reported twice, where the causes were repeated trauma and fatigue fracture. Insufficiency fractures of both fibula in isolation have not previously been reported. We present this case where a young patient presented with these fractures and was found to have vitamin D deficiency on subsequent investigations.
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Affiliation(s)
- N. Nischal
- Departments of Radiology, Holy Family Hospital, New Delhi, India
| | - S. Utkarsh
- Departments of Radiology, Holy Family Hospital, New Delhi, India
| | - B. Nadkarni
- Departments of Orthopaedics, Holy Family Hospital, New Delhi, India
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Modest J, Sheth H, Gohh R, Aaron R. Osteomalacia and Renal Osteodystrophy. R I Med J (2013) 2022; 105:22-27. [PMID: 36173905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Osteomalacia is defined by the undermineralization of newly formed bone due to a lack of available calcium, phosphorus, or vitamin D. Causative factors of osteomalacia include nutritional deficiency, diminished absorptive capabilities (often due to gastrointestinal disorders), and renal insufficiency. Renal osteodystrophy is a specific form of metabolic bone disease defined by the presence of osteomalacia and associated hyperparathyroidism secondary to a malfunction in, or absence of, renal parenchyma. This reduces the conversion of vitamin D to its active form, thus leading to a cascade of effects that negatively impact the stability of the skeleton. Osteomalacia occurs across a spectrum of severity and can produce severe consequences for specific populations, including patients with dietary, nutritional, and absorptive deficiencies. Renal osteodystrophy affects patients with chronic kidney disease, those undergoing dialysis, and renal transplant patients. Special considerations must be taken into account when assessing the bone health of patients fitting these criteria.
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Affiliation(s)
- Jacob Modest
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Himesh Sheth
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Reginald Gohh
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Roy Aaron
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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Bosman A, Palermo A, Vanderhulst J, De Beur SMJ, Fukumoto S, Minisola S, Xia W, Body JJ, Zillikens MC. Tumor-Induced Osteomalacia: A Systematic Clinical Review of 895 Cases. Calcif Tissue Int 2022; 111:367-379. [PMID: 35857061 PMCID: PMC9474374 DOI: 10.1007/s00223-022-01005-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/01/2022] [Indexed: 11/24/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare and largely underdiagnosed paraneoplastic condition. Previous reviews often reported incomplete data on clinical aspects, diagnosis or prognosis. The aim of this study was to present a systematic clinical review of all published cases of TIO. A search was conducted in Pubmed, Embase, Web of Science from inception until April 23rd, 2020. We selected case reports and case series of patients diagnosed with TIO, with information on tumor localization and serum phosphate concentration. Two reviewers independently extracted data on biochemical and clinical characteristics including bone involvement, tumor localization and treatment. 468 articles with 895 unique TIO cases were included. Median age was 46 years (range 9 months-90 years) and 58.3% were males. Hypophosphatemia and inappropriately low or normal 1,25-dihydroxyvitamin D levels, characteristic for TIO, were present in 98% of cases. Median tumor size was 2.7 cm (range 0.5 to 25.0 cm). Serum fibroblast growth factor 23 was related to tumor size (r = 0.344, P < 0.001). In 32% of the cases the tumor was detected by physical examination. Data on bone phenotype confirmed skeletal involvement: 62% of cases with BMD data had a T-score of the lumbar spine ≤ - 2.5 (n = 61/99) and a fracture was reported in at least 39% of all cases (n = 346/895). Diagnostic delay was longer than 2 years in more than 80% of cases. 10% were reported to be malignant at histology. In conclusion, TIO is a debilitating disease characterized by a long diagnostic delay leading to metabolic disturbances and skeletal impairment. Increasing awareness of TIO should decrease its diagnostic delay and the clinical consequences.
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Affiliation(s)
- Ariadne Bosman
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Andrea Palermo
- Unit of Metabolic Bone and Thyroid Disorders, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Julien Vanderhulst
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiological and Cardiological Sciences, "Sapienza" Rome University, 00161, Rome, Italy
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, The National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Mishra S, Mishra D, Mahajan B, Mantan M, Khan AM. Effect of Daily Vitamin D Supplementation on Serum Vitamin D Levels in Children with Epilepsy Receiving Sodium Valproate Monotherapy: A Randomized, Controlled Trial. Indian J Pediatr 2022. [PMID: 35763213 DOI: 10.1007/s12098-022-04225-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/07/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To compare the change in serum vitamin D levels and to compare the changes in serum levels of calcium, phosphate, alkaline phosphatase and parathyroid hormone in vitamin D supplemented and unsupplemented groups after 3 mo. METHODS In this randomized, parallel group, nonblinded, controlled trial, 40 children, 2-12 y of age with newly diagnosed epilepsy, and vitamin D sufficient status, and started on valproate monotherapy, were randomized into the intervention group (n = 20), which was given daily oral 600 IU vitamin D supplementation, and the control group (n = 20), which was not given any supplementation. Changes in the biochemical parameters was measured in the two groups after 3 mo. RESULTS There was a significant reduction in the median (IQR) vitamin D levels in the control group as compared to an increase seen in the intervention group [-6.64 (-8.4, -2.65) vs. 5.66 (1.81, 7.12); p < 0.001]. In the control group, 37.5% children developed vitamin D insufficiency and 12.5% developed deficiency whereas only 5% of the intervention group developed vitamin D insufficiency (p = 0.005). There was a significant decrease in ionized calcium (p = 0.02), increase in serum phosphate (p = 0.02), and alkaline phosphatase level (p = 0.003) in the unsupplemented group as compared to the supplemented group. CONCLUSION Vitamin D supplementation can reduce the valproate-associated decline in vitamin D levels and the negative impact on other markers of bone mineral metabolism. TRIAL REGISTRATION TCTR20200621002, 19.06.2020, retrospectively registered.
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Gleich J, Kußmaul AC, Steiner E, Böcker W, Neuerburg C, Linhart C. High prevalence of missed information related on bone health in orthogeriatric patients with fragility fractures of the pelvis-an institutional register-based analysis. Osteoporos Int 2022; 33:901-907. [PMID: 34817618 PMCID: PMC8930908 DOI: 10.1007/s00198-021-06246-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 11/18/2021] [Indexed: 11/26/2022]
Abstract
UNLABELLED This is the first study that highlighted the amount of missed information related on bone health in orthogeriatric patients suffering fragility fractures of the pelvis and also evaluated its prevalence and differing etiology in the assessed patients, regarding osteoporosis and/or osteomalacia, based on laboratory and instrumental measurements. This evaluation should become a standardized procedure in the treatment of orthogeriatric patients presenting with a FFP. INTRODUCTION Fragility fractures of the pelvis (FFP) are common in orthogeriatric patients. Secondary fracture prevention regarding evaluation and treatment of an underlying osteoporosis or osteomalacia is still often neglected. The purpose of this study was to evaluate the amount of missed information related on bone health in older adult FFP patients, the prevalence of vitamin D deficiency in assessed patients, and if fracture type-dependent distribution patterns could be observed. METHODS A retrospective analysis of prospectively collected data of an institutional register was performed. Patients aged 80 years and older (n = 456) admitted with a FFP from 01/2003 until 12/2019 to a level I trauma center were included. RESULTS In 456 patients, FFP type II were leading (66.7%). Diagnostics were conducted in 37.1% of the patients regarding measurement of vitamin D levels and 21.7% regarding DXA measurements; vitamin D deficiency was observed in 62.7%, indicators for an underlying osteomalacia in 45.8%, and an osteoporosis in 46.5% of the assessed patients. CONCLUSION Although FFP are common and will increase, there is still a lack of secondary fracture prevention, starting with information related on bone health. In the assessed patients, a high prevalence of vitamin D deficiency was present, but no significant correlation between vitamin D level and type of fracture was observed. Ongoing education for varying etiology and specific treatment of these fractures is necessary, as surgical treatment was unified, but drug therapy remains different.
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Affiliation(s)
- J Gleich
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - A Cavalcanti Kußmaul
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - E Steiner
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - W Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - C Neuerburg
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - C Linhart
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
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Abstract
Metabolic bone diseases are serious health issues worldwide, since several million individuals over the age of 50 are at risk of bone damage and should be worried about their bone health. One in every two women and one in every four men will break a bone during their lifetime due to a metabolic bone disease. Early detection, raising bone health awareness, and maintaining a balanced healthy diet may reduce the risk of skeletal fractures caused by metabolic bone diseases. This review compiles information on the most common metabolic bone diseases (osteoporosis, primary hyperparathyroidism, osteomalacia, and fluorosis disease) seen in the global population, including their symptoms, mechanisms, and causes, as well as discussing their prevention and the development of new drugs for treatment. A large amount of research literature suggests that balanced nutrition and balanced periodic supplementation of calcium, phosphate, and vitamin D can improve re-absorption and the regrowth of bones, and inhibit the formation of skeletal fractures, except in the case of hereditary bone diseases. Meanwhile, new and improved drug formulations, such as raloxifene, teriparatide, sclerostin, denosumab, and abaloparatide, have been successfully developed and administered as treatments for metabolic bone diseases, while others (romososumab and odanacatib) are in various stages of clinical trials.
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Affiliation(s)
- Vijayakumar Natesan
- Department of Biochemistry and Biotechnology, Faculty of Science, Annamalai University, Annamalainagar 608002, Tamil Nadu, India
| | - Sung-Jin Kim
- Department of Pharmacology and Toxicology, Metabolic Diseases Research Laboratory, School of Dentistry, Kyung Hee University, Seoul 02447, Republic of Korea
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Abstract
PURPOSE OF REVIEW This review provides suggestions for the evaluation of patients with osteoporosis in order to assure that the diagnosis is correct, to identify potentially correctable conditions contributing to skeletal fragility and fracture risk, and to assist in individualizing management decisions. RECENT FINDINGS Some patients who appear to have osteoporosis have another skeletal disease, such as osteomalacia, that requires further evaluation and treatment that is different than for osteoporosis. Many patients with osteoporosis have contributing factors (e.g., vitamin D deficiency, high fall risk) that should be addressed before and after starting treatment to assure that treatment is effective and safe. Evaluation includes a focused medical history, skeletal-related physical examination, assessment of falls risk, appropriate laboratory tests, and rarely transiliac double-tetracycline labeled bone biopsy. Evaluation of patients with osteoporosis before starting treatment is essential for optimizing clinical outcomes.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, 300 Oak St. NE, Albuquerque, NM, 87106, USA.
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Aligail K, Dave JA, Ross IL. Tumor-induced osteomalacia: a case report. J Med Case Rep 2022; 16:22. [PMID: 35016725 PMCID: PMC8752187 DOI: 10.1186/s13256-021-03220-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 12/03/2021] [Indexed: 11/30/2022] Open
Abstract
Background Tumor-induced osteomalacia is a rare, acquired paraneoplastic syndrome, including hypophosphatemia, high serum alkaline phosphatase, reduced active vitamin D, suboptimal bone mineral density, bone pain, fragility fractures, and muscle weakness. Case presentation We report a case of 74–year–old male of mixed ancestry with hypophosphatemia resistant to treatment despite optimal compliance, associated with profound reduction of bone mineral density and multiple nontraumatic fractures, including bilateral rib fractures, lower-thoracic (T11, T12) vertebrae, and two fractures involving the surgical and anatomical neck of the right humerus. We discuss an approach to identifying the underlying cause of hypophosphatemia associated with fragility fractures, and options for management of this rare condition. Conclusion Although rare, tumor-induced osteomalacia can be diagnosed if a logical stepwise approach is implemented. Surgery could be curative if the tumor is properly located and is resectable.
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Affiliation(s)
- Khalid Aligail
- Division of Endocrinology, Department of Medicine, Faculty of Health Sciences, Groote Schuur Hospital and University of Cape Town, J47-85 Old Main Building, Private Bag X3, Observatory, Cape Town, 7935, South Africa
| | - Joel A Dave
- Division of Endocrinology, Department of Medicine, Faculty of Health Sciences, Groote Schuur Hospital and University of Cape Town, J47-85 Old Main Building, Private Bag X3, Observatory, Cape Town, 7935, South Africa
| | - Ian Louis Ross
- Division of Endocrinology, Department of Medicine, Faculty of Health Sciences, Groote Schuur Hospital and University of Cape Town, J47-85 Old Main Building, Private Bag X3, Observatory, Cape Town, 7935, South Africa.
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24
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Whyte MP, Zhang F, Wenkert D, Mack KE, Bijanki VN, Ericson KL, Coburn SP. Hypophosphatasia: Vitamin B 6 status of affected children and adults. Bone 2022; 154:116204. [PMID: 34547524 DOI: 10.1016/j.bone.2021.116204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 12/20/2022]
Abstract
Hypophosphatasia (HPP) is the heritable dento-osseous disease caused by loss-of-function mutation(s) of the gene ALPL that encodes the tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP). TNSALP is a cell-surface homodimeric phosphomonoester phosphohydrolase expressed in healthy people especially in the skeleton, liver, kidneys, and developing teeth. In HPP, diminished TNSALP activity leads to extracellular accumulation of its natural substrates including inorganic pyrophosphate (PPi), an inhibitor of mineralization, and pyridoxal 5'-phosphate (PLP), the principal circulating form of vitamin B6 (B6). Autosomal dominant and autosomal recessive inheritance involving >450 usually missense defects scattered throughout ALPL largely explains the remarkably broad-ranging severity of this inborn-error-of-metabolism. In 1985 when we identified elevated plasma PLP as a biochemical hallmark of HPP, all 14 investigated affected children and adults had markedly increased PLP levels. However, pyridoxal (PL), the dephosphorylated form of PLP that enters cells to cofactor many enzymatic reactions, was not low but often inexplicably elevated. Levels of pyridoxic acid (PA), the B6 degradation product quantified to assess B6 sufficiency, were unremarkable. Canonical signs or symptoms of B6 deficiency or toxicity were absent. B6-dependent seizures in infants with life-threatening HPP were later explained by their profound deficiency of TNSALP activity blocking PLP dephosphorylation to PL and diminishing gamma-aminobutyric acid synthesis in the brain. Now, there is speculation that altered B6 metabolism causes further clinical complications in HPP. Herein, we assessed the plasma PL and PA levels accompanying previously reported elevated plasma PLP concentrations in 150 children and adolescents with HPP. Their mean (SD) plasma PL level was nearly double the mean for our healthy pediatric controls: 66.7 (59.0) nM versus 37.1 (22.2) nM (P < 0.0001), respectively. Their PA levels were broader than our pediatric control range, but their mean value was normal; 40.2 (25.1) nM versus 39.3 (9.9) nM (P = 0.7793), respectively. In contrast, adults with HPP often had plasma PL and PA levels suggestive of dietary B6 insufficiency. We discuss why the B6 levels of our pediatric patients with HPP would not cause B6 toxicity or deficiency, whereas in affected adults dietary B6 insufficiency can develop.
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Affiliation(s)
- Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA; Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Fan Zhang
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Deborah Wenkert
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Karen E Mack
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Vinieth N Bijanki
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Karen L Ericson
- Department of Chemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
| | - Stephen P Coburn
- Department of Chemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
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Schaefer B, Tobiasch M, Wagner S, Glodny B, Tilg H, Wolf M, Zoller H. Hypophosphatemia after intravenous iron therapy: Comprehensive review of clinical findings and recommendations for management. Bone 2022; 154:116202. [PMID: 34534708 DOI: 10.1016/j.bone.2021.116202] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/06/2021] [Accepted: 09/10/2021] [Indexed: 12/19/2022]
Abstract
Contemporary intravenous iron formulations allow administration of high doses of elemental iron and enable correction of total iron deficit in one or two infusions. An important but underappreciated complication of certain formulations is hypophosphatemia caused by increased secretion of the phosphaturic hormone, fibroblast growth factor 23 (FGF23). The pathophysiology of FGF23-induced hypophosphatemia due to certain intravenous iron formulations has been recently investigated in prospective clinical trials. To reach the correct diagnosis, clinicians must recognize the typical clinical manifestations of intravenous iron-induced hypophosphatemia and identify a specific pattern of biochemical changes (hyperphosphaturic hypophosphatemia triggered by high FGF23 that causes low 1,25 (OH)2 vitamin D, hypocalcemia and secondary hyperparathyroidism). Physicians and patients should be aware of hypophosphatemia as a common complication of intravenous iron therapy and monitor serum phosphate concentrations in patients receiving repeated doses of specific intravenous iron formulations. Symptoms of hypophosphatemia are associated with severity and duration. Persistent hypophosphatemia can occur with iron therapy and can cause debilitating diseases including myopathy, osteomalacia and fractures. This review summarizes the current understanding of the iron-phosphate axis as well as complications of intravenous iron-induced hypophosphatemia.
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Affiliation(s)
- Benedikt Schaefer
- Medical University of Innsbruck, Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Innsbruck, Austria; Christian Doppler Laboratory on Iron and Phosphate Biology, Austria
| | - Moritz Tobiasch
- University Teaching Hospital of Hall in Tirol, Department of Medicine, Hall, Austria
| | - Sonja Wagner
- Medical University of Innsbruck, Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Innsbruck, Austria; Christian Doppler Laboratory on Iron and Phosphate Biology, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Herbert Tilg
- Medical University of Innsbruck, Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Innsbruck, Austria
| | - Myles Wolf
- Department of Medicine, Division of Nephrology, Duke University, Durham, NC, United States of America
| | - Heinz Zoller
- Medical University of Innsbruck, Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Innsbruck, Austria; Christian Doppler Laboratory on Iron and Phosphate Biology, Austria.
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26
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Abstract
Rickets is a disease of the growing child arising from alterations in calcium and phosphate homeostasis resulting in impaired apoptosis of hypertrophic chondrocytes in the growth plate. Its symptoms depend on the patients' age, duration of disease, and underlying disorder. Common features include thickened wrists and ankles due to widened metaphyses, growth failure, bone pain, muscle weakness, waddling gait, and leg bowing. Affected infants often show delayed closure of the fontanelles, frontal bossing, and craniotabes. The diagnosis of rickets is based on the presence of these typical clinical symptoms and radiological findings on X-rays of the wrist or knee, showing metaphyseal fraying and widening of growth plates, in conjunction with elevated serum levels of alkaline phosphatase. Nutritional rickets due to vitamin D deficiency and/or dietary calcium deficiency is the most common cause of rickets. Currently, more than 20 acquired or hereditary causes of rickets are known. The latter are due to mutations in genes involved in vitamin D metabolism or action, renal phosphate reabsorption, or synthesis, or degradation of the phosphaturic hormone fibroblast growth factor 23 (FGF23). There is a substantial overlap in the clinical features between the various entities, requiring a thorough workup using biochemical analyses and, if necessary, genetic tests. Part I of this review focuses on the etiology, pathophysiology and clinical findings of rickets followed by the presentation of a diagnostic approach for correct diagnosis. Part II focuses on the management of rickets, including new therapeutic approaches based on recent clinical practice guidelines.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany. .,Hannover Medical School, Pediatric Research Center, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany ,Hannover Medical School, Pediatric Research Center, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Andrea Grund
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany ,Hannover Medical School, Pediatric Research Center, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, University Medicine, Charitè Berlin, Germany
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27
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Herrou J, Picaud AS, Lassalle L, Pacot L, Chaussain C, Merzoug V, Hervé A, Gadion M, Rothenbuhler A, Kamenický P, Roux C, Linglart A, Duplan MB, Briot K. Prevalence of Enthesopathies in Adults With X-linked Hypophosphatemia: Analysis of Risk Factors. J Clin Endocrinol Metab 2022; 107:e224-e235. [PMID: 34406383 DOI: 10.1210/clinem/dgab580] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Enthesopathies are the determinant of a poor quality of life in adults with X-linked hypophosphatemia (XLH). OBJECTIVE To describe the prevalence of patients with enthesopathies and to identify the risk factors of having enthesopathies. METHODS Retrospective study in the French Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism between June 2011 and December 2020. Adult XLH patients with full body X-rays performed using the EOS® low-dose radiation system and clinical data collected from medical records. The main outcome measures were demographics, PHEX mutation, conventional treatment, and dental disease with the presence of enthesopathies. RESULTS Of the 114 patients included (68% women, mean age 42.2 ± 14.3 years), PHEX mutation was found in 105 patients (94.6%), 86 (77.5%) had been treated during childhood. Enthesopathies (spine and/or pelvis) were present in 67% of the patients (n = 76). Patients with enthesopathies were significantly older (P = .001) and more frequently reported dental disease collected from medical records (P = .03). There was no correlation between the PHEX mutations and the presence of enthesopathies. Sixty-two patients had a radiographic dental examination in a reference center. Severe dental disease (number of missing teeth, number of teeth endodontically treated, alveolar bone loss, and proportion of patients with 5 abscesses or more) was significantly higher in patients with enthesopathies. CONCLUSION Adult XLH patients have a high prevalence of enthesopathies in symptomatic adults patients with XLH seen in a reference center. Age and severe dental disease were significantly associated with the presence of enthesopathies.
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Affiliation(s)
- Julia Herrou
- INSERM UMR 1153, Université de Paris, APHP Centre, Paris, France
- APHP Centre, Department of Rheumatology, Cochin Hospital, Paris, France
| | - Axelle Salcion Picaud
- APHP Centre, Department of Rheumatology, Cochin Hospital, Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
| | - Louis Lassalle
- APHP, Department of Radiology, Cochin Hospital, Paris, France
| | - Laurence Pacot
- APHP, Department of Genetics, Cochin Hospital, Paris, France
| | - Catherine Chaussain
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Université de Paris, Medical and Dental Schools, Paris, France
- APHP, Department of Odontology, Bretonneau Hospital, HUPNVS, Paris, France
| | - Valérie Merzoug
- APHP, Department of Pediatric Radiology, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
| | - Agathe Hervé
- APHP, Department of Odontology, Bretonneau Hospital, HUPNVS, Paris, France
| | - Margaux Gadion
- APHP, Department of Odontology, Bretonneau Hospital, HUPNVS, Paris, France
| | - Anya Rothenbuhler
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- APHP, Department of Endocrinology and Diabetes for Children, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
- APHP, Plateforme d'expertise Paris Saclay maladies rares, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
| | - Peter Kamenický
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre,France
| | - Christian Roux
- INSERM UMR 1153, Université de Paris, APHP Centre, Paris, France
- APHP Centre, Department of Rheumatology, Cochin Hospital, Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
| | - Agnès Linglart
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- APHP, Department of Endocrinology and Diabetes for Children, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
- APHP, Plateforme d'expertise Paris Saclay maladies rares, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
| | - Martin Biosse Duplan
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Université de Paris, Medical and Dental Schools, Paris, France
- APHP, Department of Odontology, Bretonneau Hospital, HUPNVS, Paris, France
| | - Karine Briot
- INSERM UMR 1153, Université de Paris, APHP Centre, Paris, France
- APHP Centre, Department of Rheumatology, Cochin Hospital, Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
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Jannin A, Kerlan V, Desailloud R. Endocrinology of bone mineralization: an update. Ann Endocrinol (Paris) 2021:S0003-4266(21)01108-2. [PMID: 34921812 DOI: 10.1016/j.ando.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 11/20/2022]
Abstract
Throughout the world, millions of people suffer from fragilizing osteopathies such as osteomalacia and osteoporosis.Osteomalacia is a rare disorder, corresponding to mineralization abnormalities in adult bone, as opposed to rickets in children. Renal phosphate loss and hypophosphatasia are the main causes of vitamin-resistant osteomalacia. Diagnosis is based on clinical history, phosphocalcic metabolism assessment and, if necessary, molecular characterization, and must be rapid in order to initiate the most appropriate treatment and consider new treatments such as burosumab if necessary.Osteoporosis is characterized by reduced bone mass and strength, which increases the risk of fragility fracture. Fracture-related burden is expected to increase over the coming decades linked to the aging of population and a treatment gap. In order to reduce this treatment gap, it is important to develop two strategies: improvement of screening and of treatment. Systematic screening using the FRAX® fracture risk assessment tool could be useful to increase anti-osteoporosis medical treatment and reduce fracture rates. The question of treatment sequencing in osteoporosis is another challenge, notably after denosumab cessation, complicated by a decrease in bone mineral density and increased risk of fracture. New treatments are also available, including romosozumab, a humanized monoclonal antibody which promotes bone formation and inhibits bone resorption by inhibiting sclerostin. Romosozumab is approved in several countries, including France, for treating severe osteoporosis in postmenopausal women at high risk of fracture and free of cardiovascular comorbidity.Endocrinologists need to be aware of these fragilizing osteopathies in order to improve both diagnosis and treatment.
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Hidaka N, Kato H, Koga M, Katsura M, Oyama Y, Kinoshita Y, Fukumoto S, Makita N, Nangaku M, Ito N. Induction of FGF23-related hypophosphatemic osteomalacia by alcohol consumption. Bone Rep 2021; 15:101144. [PMID: 34901334 DOI: 10.1016/j.bonr.2021.101144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 02/03/2023] Open
Abstract
Context Fibroblast growth factor (FGF) 23 is a hormone that regulates serum phosphate levels, the excess action of which causes chronic hypophosphatemic rickets/osteomalacia. To date, there are only two identified causes of acquired FGF23-related hypophosphatemic osteomalacia: tumor-induced osteomalacia (TIO) and osteomalacia induced by the intravenous infusion of some forms of iron preparations. In the current study, two cases of FGF23-related hypophosphatemia probably induced by chronic alcohol consumption were first introduced. Case description Case 1 and case 2 had been drinking high amounts of alcohol for more than twenty years until they were admitted to the hospital. Case 1 was a 43-year-old man with progressive worsening multiple pains and muscle weakness who exhibited chronic hypophosphatemia with increased intact FGF23 levels. A week after admission, the serum phosphate level recovered to the reference range, and the intact FGF23 level declined. Case 1 resumed drinking after discharge, and hypophosphatemia concomitant with high intact FGF23 levels recurred. The alleviation of FGF23-related hypophosphatemia was observed each time he temporarily abstained from drinking for a short period. Case 2 was a 60-year-old man with recurrent fractures and exacerbation of pain in multiple joints who also exhibited hypophosphatemia with increased intact FGF23 levels. After admission, the serum phosphate level gradually increased to the lower limit of the normal range. The intact FGF23 level decreased, but it was still higher than 30 pg/ml, and causative FGF23-producing tumors were not identified even with thorough examinations, including somatostatin receptor scintigraphy, fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) and systemic venous FGF23 sampling. He completely abstained from alcohol after discharge. Along with the serum phosphate level, intact FGF23 was subsequently decreased and had been normalized for 5 months. Both patients had no genetic mutation related to hereditary FGF23-related hypophosphatemic rickets/osteomalacia, including autosomal dominant hypophosphatemic rickets/osteomalacia (ADHR). Conclusion Two cases of FGF23-related hypophosphatemia probably induced by alcohol were first introduced in this study. Identifying this reversible condition among acquired FGF23-related hypophosphatemic osteomalacia is critical to obtain better patient outcomes and save medical resources. This condition is similar to iron infusion-induced FGF23-related hypophosphatemia in terms of the dysregulation of FGF23 due to exogenous factors. Future research to elucidate the precise mechanism of these conditions is warranted. Two adults with acquired FGF23-related hypophosphatemic osteomalacia were studied. Tumor-induced osteomalacia was suspected initially, but no tumor was identified. Cessation of alcohol led to recovery from FGF23-related hypophosphatemia. Alcohol is a well-recognized cause of hypophosphatemia, but osteomalacia is uncommon. Alcohol-induced FGF23-related osteomalacia is a totally new and distinct phenomenon.
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McKee MD, Buss DJ, Reznikov N. Mineral tessellation in bone and the stenciling principle for extracellular matrix mineralization. J Struct Biol 2021; 214:107823. [PMID: 34915130 DOI: 10.1016/j.jsb.2021.107823] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 11/21/2022]
Abstract
We review here the Stenciling Principle for extracellular matrix mineralization that describes a double-negative process (inhibition of inhibitors) that promotes mineralization in bone and other mineralized tissues, whereas the default condition of inhibition alone prevents mineralization elsewhere in soft connective tissues. The stenciling principle acts across multiple levels from the macroscale (skeleton/dentition vs soft connective tissues), to the microscale (for example, entheses, and the tooth attachment complex where the soft periodontal ligament is situated between mineralized tooth cementum and mineralized alveolar bone), and to the mesoscale (mineral tessellation). It relates to both small-molecule (e.g. pyrophosphate) and protein (e.g. osteopontin) inhibitors of mineralization, and promoters (enzymes, e.g. TNAP, PHEX) that degrade the inhibitors to permit and regulate mineralization. In this process, an organizational motif for bone mineral arises that we call crossfibrillar mineral tessellation where mineral formations - called tesselles - geometrically approximate prolate ellipsoids and traverse multiple collagen fibrils (laterally). Tesselle growth is directed by the structural anisotropy of collagen, being spatially restrained in the shorter transverse tesselle dimensions (averaging 1.6 × 0.8 × 0.8 μm, aspect ratio 2, length range 1.5-2.5 μm). Temporo-spatially, the tesselles abut in 3D (close ellipsoid packing) to fill the volume of lamellar bone extracellular matrix. Poorly mineralized interfacial gaps between adjacent tesselles remain discernable even in mature lamellar bone. Tessellation of a same, small basic unit to form larger structural assemblies results in numerous 3D interfaces, allows dissipation of critical stresses, and enables fail-safe cyclic deformations. Incomplete tessellation in osteomalacia/odontomalacia may explain why soft osteomalacic bones buckle and deform under loading.
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Abstract
PURPOSE OF REVIEW X-linked hypophosphatemia and tumor-induced osteomalacia are diseases characterized by hypophosphatemia with impaired proximal tubular phosphate reabsorption. Complete resection of responsible tumors is the first-line therapy for patients with tumor-induced osteomalacia. In contrast, phosphate and active vitamin D have been used for patients with X-linked hypophosphatemia and inoperable ones with tumor-induced osteomalacia. The purpose of this review is to summarize the pathogenesis of these diseases and discuss about the new treatment. RECENT FINDINGS Excessive FGF23 production has been shown to underline several kinds of hypophosphatemic rickets/osteomalacia including X-linked hypophosphatemia and tumor-induced osteomalacia. Burosumab, an anti-FGF23 monoclonal antibody, was approved for clinical use, while the indications of burosumab are different depending on countries. The inhibition of excessive FGF23 activity has been approved as a new therapy for several kinds of hypophosphatemic diseases. Further studies are necessary to clarify the long-term effects and safety of burosumab.
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Affiliation(s)
- Yuichi Takashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Seiji Fukumoto
- Department of Molecular Endocrinology, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan.
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Huertas-Quintero JA, Losada-Trujillo N, Cuellar-Ortiz DA, Velasco-Parra HM. Hypophosphatemic Rickets in Colombia: A Prevalence-Estimation Model in Rare Diseases. 2018. Lancet Reg Health Am 2021; 7:100131. [PMID: 36777652 PMCID: PMC9904046 DOI: 10.1016/j.lana.2021.100131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Hypophosphatemic rickets is a rare, genetic syndrome with multisystem involvement. It causes skeletal abnormalities, painful enthesopathies, increased risk of fracture, and short stature; leading to a substantial burden of disease, disability, and worsening of quality of life. To improve health conditions of people living with this disease, it is essential to know its prevalence which is currently unknown in Colombia. This study aimed to estimate the prevalence of hypophosphatemic rickets in Colombia by using a mathematical model and national statistic records. Methods We executed a model to estimate probabilities of transitions between health, disease, and death states (Markov chains). The model was fed with international prevalences taken from original studies (systematic review) and administrative records' data from SISPRO (a national health information system) using the International Classification of Diseases (ICD-10) E833 code, vital statistics, and census data. World Health Organization's (WHO) DISMOD II software was used to develop the model. Findings The estimated overall prevalence of hypophosphatemic rickets in Colombia in 2018 was 2·03 cases per 100 000 people (981 affected people), with a sensitive range of 1·97 to 2·09. The estimated prevalence by sex was 2·61 (645 people) and 1·43 (336 people) cases per 100 000 women and men, respectively. Interpretation Our overall estimated prevalence shows consistency with original international data. This is the first prevalence estimation of hypophosphatemic rickets in Colombia and will be relevant to support public health decisions for rare diseases and to provide a pre-test probability framework in clinical practice. DISMOD II and the model are useful tools to estimate the prevalence of rare and orphan diseases, when probabilistic studies cannot be carried out. There are limited bibliographic resources worldwide reporting prevalence values supported by original studies. Our study can be used as a cost-effective methodology reference in this regard, especially for Latin America. Funding Ultragenyx Pharmaceutical, as a donation.
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Affiliation(s)
- Jancy Andrea Huertas-Quintero
- School of Medicine, Universidad Nacional de Colombia - Hospital Universitario Nacional de Colombia, Bogotá, Colombia,Ministry of Health and Social Protection of Colombia, Bogotá, Colombia,Corresponding author: Dr. J. Andrea Huertas-Quintero, Calle 44 # 59-75, 111321, Departamento de Medicina Interna, Hospital Universitario Nacional de Colombia. Bogotá, Colombia; Ph.: 57300 6167866
| | - Natalia Losada-Trujillo
- School of Medicine, Universidad Nacional de Colombia - Hospital Universitario Nacional de Colombia, Bogotá, Colombia
| | | | - Harvy Mauricio Velasco-Parra
- School of Medicine, Universidad Nacional de Colombia - Hospital Universitario Nacional de Colombia, Bogotá, Colombia,SURA Ayudas Diagnósticas
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Ito N, Kubota T, Kitanaka S, Fujiwara I, Adachi M, Takeuchi Y, Yamagami H, Kimura T, Shinoda T, Minagawa M, Okazaki R, Ozono K, Seino Y, Fukumoto S. Clinical performance of a novel chemiluminescent enzyme immunoassay for FGF23. J Bone Miner Metab 2021; 39:1066-1075. [PMID: 34255195 DOI: 10.1007/s00774-021-01250-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/04/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Measurement of fibroblast growth factor 23 (FGF23) has been reported to be clinically useful for the differential diagnosis of chronic hypophosphatemia. However, assays for research use only are available in Japan. Thus, the objective of this study was to examine the clinical utility of a novel and automated chemiluminescent enzyme immunoassay for the measurement of FGF23. MATERIALS AND METHODS Participants were recruited from July 2015 to January 2017 at six facilities in Japan. Thirty-eight patients with X-linked hypophosphatemic rickets (XLH 15 males, 23 females, age 0-66 years), five patients with tumour-induced osteomalacia (TIO 3 males, 2 females, age 60-73 years), and twenty-two patients with hypophosphatemia (11 males, 11 females, age 1-75 years) caused due to other factors participated in this study. RESULTS With the clinical cut-off value of FGF23 at 30.0 pg/mL indicated in the Diagnostic Guideline of Rickets/Osteomalacia in Japan, the sensitivity and specificity of FGF23-related hypophosphatemic rickets/osteomalacia without vitamin D deficiency (disease group-1) were 100% and 81.8%, respectively, which distinguished it from non-FGF23-related hypophosphatemia (disease group-2). Furthermore, the diagnostic sensitivity of FGF23-related hypophosphatemia with vitamin D deficiency remained at 100%. Among the four patients with FGF23 levels ≥ 30.0 pg/mL in disease group-2, two patients with relatively higher FGF23 values were suspected to have genuine FGF23-related hypophosphatemia, due to the ectopic production of FGF23 in pulmonary and prostate small cell carcinomas. CONCLUSION The novel FGF23 assay tested in this study is useful for the differential diagnosis of hypophosphatemic rickets/osteomalacia in a clinical setting.
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Affiliation(s)
- Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Takuo Kubota
- Department of Pediatrics, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Sachiko Kitanaka
- Department of Pediatrics, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ikuma Fujiwara
- Department of Pediatric Endocrinology and Environmental Medicine, Graduate School of Medicine, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Masanori Adachi
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Kanagawa, 232-8555, Japan
| | - Yasuhiro Takeuchi
- Endocrine Center, Toranomon Hospital, 2-2-2, Toranomon, Minato-ku, Tokyo, 105-8470, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Hitomi Yamagami
- Minaris Medical Co., Ltd., 1-8-10 Harumi, Chuo-ku, Tokyo, 104-6004, Japan
| | - Takehide Kimura
- Minaris Medical Co., Ltd., 1-8-10 Harumi, Chuo-ku, Tokyo, 104-6004, Japan
| | - Tatsuya Shinoda
- Minaris Medical Co., Ltd., 1-8-10 Harumi, Chuo-ku, Tokyo, 104-6004, Japan
| | - Masanori Minagawa
- Division of Endocrinology, Chiba Children's Hospital, 579-1 Hetacho, Midoriku, Chiba, 266-0007, Japan
| | - Ryo Okazaki
- Division of Endocrinology and Metabolism, Third Department of Medicine, Teikyo University Chiba Medical Center, Ichihara, Chiba, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yoshiki Seino
- Department of Pediatrics, Osaka Hospital, Japan Community Healthcare Organization (JCHO), 4-2-78, Fukushima, Fukushima-ku, Osaka, 553-0003, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, 3-18-15, Kuramoto-cho, Tokushima, 770-8503, Japan
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Crotti C, Bartoli F, Coletto LA, Manara M, Marini E, Daolio PA, Parafioriti A, Armiraglio E, Zucchi F, Sinigaglia L, Caporali R, Varenna M. Tumor induced osteomalacia: A single center experience on 17 patients. Bone 2021; 152:116077. [PMID: 34175499 DOI: 10.1016/j.bone.2021.116077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/21/2021] [Accepted: 06/16/2021] [Indexed: 01/02/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome due to a phosphaturic tumor, which overproduces Fibroblast Growth Factor 23 (FGF-23), causing hyperphosphaturia, hypophosphatemia, low 1,25(OH)2D and osteomalacia. Tumor localization is critical, diagnostic delay ranges from 2.5 to 28 years and to date surgical removal is considered effective treatment. We retrospectively evaluated patients with definite diagnosis of TIO referred to a tertiary Rheumatology Center between September 2000 and May 2020, investigating clinical management and disease outcome. We included 17 patients: 10 (58.8%) were females, mean age at diagnosis was 55.3 ± 13.9 years (mean ± standard deviation), with a diagnostic delay from symptoms onset to tumor detection of 6.6 ± 6.25 years. Biochemical data were: serum phosphorus 1.3 ± 0.4 mg/dL (Reference Range: 2.5-4.6), serum 1,25(OH)2D 31.8 ± 22.9 ng/mL (RR: 25-86), intact FGF-23, 358.9 ± 677 pg/mL (RR: 25-45); 24 h-Urine Phosphorus was increased in only 2 patients, while tubular reabsorption of phosphate (TRP) was decreased in all patients confirming a renal phosphate wasting. In 2013 68Ga- DOTA-based PET/CT was introduced in routinely practice and diagnostic delay was consistently reduced (from 8.6 ± 7.9 to 4.3 ± 2.4 years). Thirteen patients underwent surgery, one patient underwent radiofrequency ablation; 3 patients, not eligible for surgery, were treated only with supplements of phosphorus and calcitriol. One was started on Burosumab after several unsuccessful surgical attempts. After surgery or ablation, 8 patients had complete remission, 3 TIO persistence, and 3 had overtime relapse. Relapses were observed only in patients who previously underwent closed biopsy. To our knowledge, this is the widest European cohort of TIO patients in the last two decades. We confirm a usual diagnostic delay and recommend a stepwise diagnostic approach. Tumor biopsy is not recommended due to the potential cell spilling. Surgery is generally considered a definitive treatment, even though other approaches have been successful in curing TIO. Active surveillance on possible recurrence is always needed. Burosumab appears a promising therapy.
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Affiliation(s)
- C Crotti
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - F Bartoli
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - L A Coletto
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - M Manara
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - E Marini
- Oncologic Orthopedic Surgery, Gaetano Pini Institute, Milan, Italy
| | - P A Daolio
- Oncologic Orthopedic Surgery, Gaetano Pini Institute, Milan, Italy
| | | | - E Armiraglio
- UOC Pathology, Gaetano Pini Institute, Milan, Italy
| | - F Zucchi
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - L Sinigaglia
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - R Caporali
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - M Varenna
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy.
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Brandi ML, Clunie GPR, Houillier P, Jan de Beur SM, Minisola S, Oheim R, Seefried L. Challenges in the management of tumor-induced osteomalacia (TIO). Bone 2021; 152:116064. [PMID: 34147708 DOI: 10.1016/j.bone.2021.116064] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 12/16/2022]
Abstract
Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is a rare acquired paraneoplastic disease, which is challenging to diagnose and treat. TIO is characterized by hypophosphatemia resulting from excess levels of tumor-secreted fibroblast growth factor 23 (FGF23), one of the key physiological regulators of phosphate metabolism. Elevated FGF23 results in renal phosphate wasting and compromised vitamin D activation, ultimately resulting in osteomalacia. Patients typically present with progressive and non-specific symptoms, including bone pain, multiple pathological fractures, and progressive muscle weakness. Diagnosis is often delayed or missed due to the non-specific nature of complaints and lack of disease awareness. Additionally, the disease-causing tumour is often difficult to detect and localize because they are often small, lack localizing symptoms and signs, and dwell in widely variable anatomical locations. Measuring serum/urine phosphate should be an inherent diagnostic component when assessing otherwise unexplained osteomalacia, fractures and weakness. In cases of hypophosphatemia with inappropriate (sustained) phosphaturia and inappropriately normal or frankly low 1,25-dihydroxy vitamin D, differentiation of the potential causes of renal phosphate wasting should include measurement of FGF23, and TIO should be considered. While patients experience severe disability without treatment, complete excision of the tumour is typically curative and results in a dramatic reversal of symptoms. Two additional key current unmet needs in optimizing TIO management are: (1 and 2) the considerable delay in diagnosis and consequent delay between the onset of symptoms and surgical resection; and (2) alternative management. These may be addressed by raising awareness of TIO, and taking into consideration the accessibility and variability of different healthcare infrastructures. By recognizing the challenges associated with the diagnosis and treatment of TIO and by applying a stepwise approach with clear clinical practice guidelines, patient care and outcomes will be improved in the future.
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Affiliation(s)
- Maria Luisa Brandi
- FirmoLab, FIRMO Foundation, Stabilimento Chimici Farmaceutico Militare di Firenze, Via Reginaldo Giuliani 201, 50141 Florence, Italy.
| | - Gavin P R Clunie
- Cambridge University Hospitals, Box 204, Hills Road, Cambridge CB2 0QQ, UK.
| | - Pascal Houillier
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Hopital Européen Georges Pompidou, 20 Rue Leblanc, 75015 Paris, France.
| | - Suzanne M Jan de Beur
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA.
| | | | - Ralf Oheim
- University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany.
| | - Lothar Seefried
- Julius-Maximilians University, Brettreichstr. 11, 97074 Würzburg, Germany.
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Uday S, Shaw NJ, Mughal MZ, Randell T, Högler W, Santos R, Padidela R. Monitoring response to conventional treatment in children with XLH: Value of ALP and Rickets Severity Score (RSS) in a real world setting. Bone 2021; 151:116025. [PMID: 34052463 DOI: 10.1016/j.bone.2021.116025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 04/22/2021] [Accepted: 05/25/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION X-linked hypophosphataemia (XLH) is conventionally managed with oral phosphate and active vitamin D analogues. OBJECTIVES To evaluate long term treatment response by assessing biochemical disease activity [serum alkaline phosphatase (ALP)], radiological rickets severity score (RSS), growth and morbidity in patients with XLH on conventional therapy and assess the correlation between serum ALP and RSS. METHODS XLH patients from 3 UK tertiary centres with ≥3 radiographs one year apart were included. Data was collected retrospectively. The RSS was assessed from routine hand and knee radiographs and ALP z scores were calculated using age-specific reference data. RESULTS Thirty-eight (male = 12) patients met the inclusion criteria. The mean ± SD knee, wrist and total RSS at baseline (median age 1.2 years) were 2.0 ± 1.2, 1.9 ± 1.2 and 3.6 ± 1.3 respectively; and at the most recent clinic visit (median age 9.0 years, range 3.3-18.9) were 1.6 ± 1.0, 1.0 ± 1.0 and 2.5 ± 1.5 respectively. The mean ± SD serum ALP z scores at baseline and the most recent visit were 4.2 ± 2.3 and 4.0 ± 3.3. Median height SDS at baseline and most recent visit were -1.2 and -2.1 (p = 0.05). Dental abscess, craniosynostosis, limb deformity requiring orthopaedic intervention and nephrocalcinosis were present in 31.5%, 7.9%, 31.6% and 42.1% of the cohort respectively. There was no statistically significant (p > 0.05) correlation between ALP z scores and knee (r = 0.07) or total (r = 0.12) RSS. CONCLUSIONS Conventional therapy was not effective in significantly improving biochemical and radiological features of disease. The lack of association between serum ALP and rickets severity on radiographs limits the value of ALP as the sole indicator of rickets activity in patients receiving conventional therapy.
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Affiliation(s)
- S Uday
- IMSR, University of Birmingham, Birmingham, UK; Birmingham Women's and Children's Hospital, Birmingham, UK.
| | - N J Shaw
- IMSR, University of Birmingham, Birmingham, UK; Birmingham Women's and Children's Hospital, Birmingham, UK
| | - M Z Mughal
- Royal Manchester Children's Hospital, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - T Randell
- Nottingham Children's Hospital, Nottingham, UK
| | - W Högler
- IMSR, University of Birmingham, Birmingham, UK; Johannes Kepler University, Linz, Austria
| | - R Santos
- Evelina London Children's Hospital, London, UK
| | - R Padidela
- Royal Manchester Children's Hospital, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Hatano M, Kitajima I, Yamamoto S, Nakamura M, Isawa K, Hirota Y, Hoshino J, Sawa N, Ubara Y. Case report: Osteomalacia due to bisphosphonate treatment in a patient on hemodialysis. BMC Nephrol 2021; 22:298. [PMID: 34479496 PMCID: PMC8414854 DOI: 10.1186/s12882-021-02509-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 08/20/2021] [Indexed: 01/23/2023] Open
Abstract
Background No publications have reported on osteomalacia in patients receiving intermittent cyclical therapy with etidronate (a bisphosphonate) and undergoing long-term hemodialysis (HD). Case presentation We report on a 46-year-old Japanese man admitted to our hospital for further examination of left forearm pain. Maintenance HD was started at age 24 years, and the man had been on HD since then. At age 38 years, surgical parathyroidectomy was performed for secondary hyperparathyroidism; iliac crest bone biopsy performed at the same time showed osteitis fibrosa. The active vitamin D3 preparation calcitriol was started, and intermittent cyclical etidronate therapy was introduced 2 years later for osteoporosis. At age 45 years, the patient stopped taking calcitriol because of hypercalcemia but continued with etidronate. At age 46 years, a pseudofracture with a Looser zone occurred in the left ulna, and left femur bone biopsy revealed osteomalacia. Etidronate was discontinued, and calcitriol was restarted; open reduction and internal fixation with an angular stability plate were performed. Union of the bone was achieved 10 months after the operation. At age 49 years, a lumber bone biopsy confirmed improved bone morphometry. Conclusions We believe that intermittent cyclical etidronate therapy without administration of active vitamin D3 during long-term HD might have induced osteomalacia, resulting in the ulna insufficiency fracture. Therefore, we propose that administration of active vitamin D3 is essential to prevent osteomalacia in patients on long-term HD who are receiving bisphosphonates and have potential vitamin D3 deficiency.
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Affiliation(s)
- Masaki Hatano
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan.
| | - Izuru Kitajima
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Seizo Yamamoto
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Masaki Nakamura
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Kazuya Isawa
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Yutaka Hirota
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Junichi Hoshino
- Department of Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan.,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Naoki Sawa
- Department of Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan.,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Yoshifumi Ubara
- Department of Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan. .,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan.
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Whyte MP, May JD, McAlister WH, Burgener K, Cortez SR, Kreienkamp R, Castro O, Verzola R, Zavala AS, McPherson CC, Gottesman GS, Ericson KL, Coburn SP, Arbelaez AM. Vitamin B 6 deficiency with normal plasma levels of pyridoxal 5'-phosphate in perinatal hypophosphatasia. Bone 2021; 150:116007. [PMID: 34000433 DOI: 10.1016/j.bone.2021.116007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/29/2021] [Accepted: 05/10/2021] [Indexed: 01/29/2023]
Abstract
Pyridoxal 5'-phosphate (PLP), the principal circulating form of vitamin B6 (B6), is elevated in the plasma of individuals with hypophosphatasia (HPP). HPP is the inborn-error-of-metabolism caused by loss-of-function mutation(s) of ALPL, the gene that encodes the "tissue-nonspecific" isoenzyme of alkaline phosphatase (TNSALP). PLP accumulates extracellularly in HPP because it is a natural substrate of this cell-surface phosphomonoester phosphohydrolase. Even individuals mildly affected by HPP manifest this biochemical hallmark, which is used for diagnosis. Herein, an exclusively breast-fed newborn boy with life-threatening perinatal HPP had uniquely normal instead of markedly elevated plasma PLP levels before beginning asfotase alfa (AA) TNSALP-replacement therapy. These abnormal PLP levels were explained by B6 deficiency, confirmed by his low plasma level of 4-pyridoxic acid (PA), the B6 degradation product. His mother, a presumed carrier of one of his two ALPL missense mutations, had serum ALP activity of 50 U/L (Nl 40-130) while her plasma PLP level was 9 μg/L (Nl 5-50) and PA was 3 μg/L (Nl 3-30). Her dietary history and breast milk pyridoxal (PL) level indicated she too was B6 deficient. With B6 supplementation using a breast milk fortifier, the patient's plasma PA level corrected, while his PLP level remained in the normal range but now in keeping with AA treatment. Our experience reveals that elevated levels of PLP in the circulation in HPP require some degree of B6 sufficiency, and that anticipated increases in HPP can be negated by hypovitaminosis B6.
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Affiliation(s)
- Michael P Whyte
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA; Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St Louis, St. Louis, MO 63110, USA.
| | - Jennifer D May
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - William H McAlister
- Mallinckrodt Institute of Radiology, Washington University School of Medicine at St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| | - Katherine Burgener
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Samuel R Cortez
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Raymond Kreienkamp
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Olivia Castro
- Nutritional Services, Department of Pediatrics, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Rachel Verzola
- Nutritional Services, Department of Pediatrics, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Ana Solis Zavala
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Christopher C McPherson
- Department of Pharmacy, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Gary S Gottesman
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St Louis, St. Louis, MO 63110, USA.
| | - Karen L Ericson
- Department of Chemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
| | - Stephen P Coburn
- Department of Chemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
| | - Ana Maria Arbelaez
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
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Abstract
BACKGROUND Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare mosaic disorder of Gαs activation. Fibroblast Growth Factor 23 (FGF23)-mediated hypophosphatemia is a feature of FD/MAS that has been associated with poor skeletal outcomes. Standard therapy includes oral phosphorus and vitamin D analogs; however, treatment is limited by potential adverse renal and gastrointestinal effects. Burosumab is a monoclonal antibody to FGF23 approved to treat patients with X-linked hypophosphatemia and tumor-induced osteomalacia. There is currently no safety or efficacy data to support burosumab use in patients with FD/MAS. CASE DESCRIPTION A 7-year-old boy with severe FD/MAS presented with persistent hypophosphatemia and skeletal complications despite conventional treatment with oral phosphate and calcitriol. He was started on burosumab and achieved sustained normalization of serum phosphorus and marked improvement in alkaline phosphatase levels. This was accompanied by an encouraging clinical response, including decreased bone pain, improved muscle strength, and improved ambulation. No adverse effects of burosumab therapy were observed. CONCLUSIONS This is the first reported case of burosumab treatment in a patient with FD/MAS. The encouraging biochemical and clinical response in this patient highlights the need for future studies to explore the safety and efficacy of burosumab in the FD/MAS pediatric population.
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Affiliation(s)
- Anne Gladding
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Vivian Szymczuk
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA; National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, USA
| | - Bethany A Auble
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alison M Boyce
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
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Abstract
Some, but not all, intravenous iron formulations have been recognized to induce renal phosphate wasting syndrome. Most commonly this has been reported following treatment of iron deficiency anemia (IDA) with ferric carboxymaltose (FCM). A search of PubMed identified relevant randomized controlled trials (RCTs), and case studies evaluating hypophosphatemia (HPP) resulting from intravenous iron treatment. While more recent larger comparative RCTs have confirmed that the majority of patients receiving FCM, especially those with normal renal function, may experience severe HPP, complete documentation is hampered by inconsistent reporting of serum phosphate in such trials. Similarly, while case series and RCTs have documented the persistence of HPP for several weeks or even months, the lack of studies lasting beyond 5–6 weeks has constrained full understanding of the duration of effect. Clinical trials have established that the mechanism involves the bone/metabolic axis with the elevation of intact fibroblast growth factor 23 playing the central role. Reports continue to accumulate of the clinical consequences of severe HPP which are, most commonly, bone abnormalities following repetitive dosing. Case reports and studies, however, have also shown that symptomatic hypophosphatemia can occur after a single FCM dose. The frequency of such events remains unknown, in part due to lack of awareness of hypophosphatemia coupled with the fact that the most common acute symptoms of HPP (fatigue and weakness) are the same for IDA and for many of the chronic diseases that cause IDA. Changes to US and European prescribing information for FCM should raise awareness of the potential for HPP and need to monitor patients at risk for it.
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Affiliation(s)
- John A Glaspy
- Division of Hematology-Oncology, Department of Medicine, UCLA School of Medicine, Los Angeles, CA, 90095, USA.
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Bacchetta J, Rothenbuhler A, Gueorguieva I, Kamenicky P, Salles JP, Briot K, Linglart A. X-linked hypophosphatemia and burosumab: Practical clinical points from the French experience. Joint Bone Spine 2021; 88:105208. [PMID: 34102329 DOI: 10.1016/j.jbspin.2021.105208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
Hereditary hypophosphatemia with increased FGF23 levels are rare inherited metabolic diseases characterized by low serum phosphate because of impaired renal tubular phosphate reabsorption. The most common form is X-linked hypophosphatemia (XLH), secondary to a mutation in the PHEX gene. In children, XLH is often manifested by rickets, delayed development of gait, lower limb deformities, growth retardation, craniosynostosis, and spontaneous dental abscesses. In adults, patients present diffuse musculoskeletal pain (bone and joints), early osteoarthritis, entesopathies, pseudo-fractures, muscular weakness, and severe dental damage. Conventional medical management is based on the combined administration of oral phosphate supplementation with active vitamin D analogs. Treatment with the recently approved anti-FGF23 burosumab is an alternative, especially in severe forms. Burosumab restores phosphate reabsorption in the proximal tubule and stimulates the endogenous synthesis of calcitriol. In Europe, burosumab has been approved for the treatment of XLH with radiographic evidence of bone disease in pediatric patients from one year of age and in adults. This manuscript will discuss the specific management of burosumab in children and adolescents in daily practice.
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Affiliation(s)
- Justine Bacchetta
- Reference Center for Rare Renal Diseases, Department of Pediatric Nephrology, Rheumatology and Dermatology, Nephrogones, Filière ORKiD, HFME, Lyon University Hospital, Lyon, France; Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, Filière OSCAR, HFME, Lyon University Hospital, Lyon, France
| | - Anya Rothenbuhler
- AP-HP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France; AP-HP, Endocrinology and Diabetes for Children, Bicêtre Paris-Sud Hospital, Le Kremlin-Bicêtre, France
| | - Iva Gueorguieva
- Pediatric Department, Endocrinology Unit, Children's Center, Lille University Hospital, Jeanne-de-Flandre Hospital, Lille, France
| | - Peter Kamenicky
- AP-HP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France; AP-HP, Department of Endocrinology and Reproductive Diseases, Bicêtre Paris-Sud Hospital, Paris, France
| | - Jean-Pierre Salles
- Unit of Endocrinology, Bone Diseases, Genetics and Gynecology, Children's Hospital, Toulouse University Hospital, 31059 Toulouse cedex 09, France; Toulouse-Purpan Pathophysiology Center, CPTP, INSERM UMR 1043, Paul-Sabatier University, Toulouse, France
| | - Karine Briot
- AP-HP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France; AP-HP, Department of Rheumatology, Cochin Hospital, Paris, France
| | - Agnès Linglart
- AP-HP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France; AP-HP, Endocrinology and Diabetes for Children, Bicêtre Paris-Sud Hospital, Le Kremlin-Bicêtre, France.
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Makhlouf Y, Boussaid S, Ajlani H, Jemmali S, Rekik S, Sehli H, Eleuch M. A Rare Case of Hypophosphataemic Osteomalacia in von Recklinghausen Neurofibromatosis. Eur J Case Rep Intern Med 2021; 8:002618. [PMID: 34123954 DOI: 10.12890/2021_002618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 11/05/2022] Open
Abstract
Background Neurofibromatosis type 1 (NF1), also known as von Recklinghausen disease, is a one of the more common hereditary autosomal disorders. However, osteomalacia in neurofibromatosis type 1 is very rare tumour-induced osteomalacia; fibroblast growth factor-23 is usually implicated. Patients and methods We report the case of a patient with a history of von Recklinghausen neurofibromatosis who presented with hypophosphataemic osteomalacia. Results The patient was treated with high-dose calcitriol and oral phosphate with clinical improvement. Conclusion Even though it is a rare entity, we must consider the diagnosis of hypophosphataemic osteomalacia in patients with neurofibromatosis in order to deliver appropriate treatment. LEARNING POINTS Osteomalacia during von Recklinghausen disease is a rare presentation of an uncommon condition and has a poorly understood mechanism.The treatment of oncogenic osteomalacia includes tumour removal which, however, is not always possible.Administration of calcitriol alone is not sufficient and phosphorus intake is mandatory to improve symptoms.
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Affiliation(s)
| | | | - Houda Ajlani
- Department of Rheumatology, Rabta Hospital, Tunisia
| | | | - Sonia Rekik
- Department of Rheumatology, Rabta Hospital, Tunisia
| | - Hela Sehli
- Department of Rheumatology, Rabta Hospital, Tunisia
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Nakagawa D, Oe K, Fukui T, Kuroda R, Niikura T. Bilateral Tibial Proximal Fractures Caused by Secondary Osteomalacia due to Autoimmune Polyendocrine Syndrome Type 2: A Case Report. J Orthop Case Rep 2021; 11:14-17. [PMID: 34327157 PMCID: PMC8310636 DOI: 10.13107/jocr.2021.v11.i04.2132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Hypophosphatemic osteomalacia can be overlooked or confused with other musculoskeletal disorders due to the variety of associated clinical, laboratory, and radiographic findings. If osteomalacia is diagnosed early and the fractures are not displaced, they often heal with nutritional supplements, but, if they progress to displaced fractures, they may require surgical intervention. Case Report We present a case of secondary osteomalacia due to autoimmune polyendocrine syndrome Type 2 due to this condition, the patient developed bilateral tibial proximal fractures and her varus deformity had progressed. No clear indication of the timing for surgery for adults with osteomalacia has been reported. However, medical treatment improves the symptoms of osteomalacia and it is reported that in children, appropriate level of the serum phosphate (P) should be attained and maintained for the successful bone healing after osteotomy. Therefore, we prioritized pharmacological treatment and prescribed surgery after confirming that the value of serum phosphate P had been improved to recommended levels (2.5-3.5 mg/dl). We performed high tibial osteotomy for the right side and gradual correction by an external fixation for the left tibia, because of more severe deformation, and converted to an internal fixation to shorten the treatment period. During conversion, we performed the operation with a locking plate by the minimal invasive plate osteosynthesis method (MIPO). Conclusion We conclude that the use of different deformity correction methods, depending on the degree of deformity, and the pharmacological treatment of osteomalacia may lead to favorable results.
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Affiliation(s)
- Daisuke Nakagawa
- Department of Orthopedic Surgery, Kobe University Graduate, School of Medicine, Chuo-ku, Kobe, Japan
| | - Keisuke Oe
- Department of Orthopedic Surgery, Kobe University Graduate, School of Medicine, Chuo-ku, Kobe, Japan
| | - Tomoaki Fukui
- Department of Orthopedic Surgery, Kobe University Graduate, School of Medicine, Chuo-ku, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopedic Surgery, Kobe University Graduate, School of Medicine, Chuo-ku, Kobe, Japan
| | - Takahiro Niikura
- Department of Orthopedic Surgery, Kobe University Graduate, School of Medicine, Chuo-ku, Kobe, Japan
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Khezami K, Bennour MA. Osteomalacia: a forgotten diagnosis of multiple bone fractures. Pan Afr Med J 2021; 38:369. [PMID: 34367448 PMCID: PMC8308846 DOI: 10.11604/pamj.2021.38.369.28987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/01/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Karim Khezami
- Faculty of Medicine of Tunis, University Tunis El Manar, Department of Orthopedic Surgery, Habib Bougatfa Hospital, Bizerte, Tunisia
| | - Mohamed Amine Bennour
- Faculty of Medicine of Tunis, University Tunis El Manar, Department of Orthopedic Surgery, Habib Bougatfa Hospital, Bizerte, Tunisia
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Cook FJ, Seagrove-Guffey M, Mumm S, Veis DJ, McAlister WH, Bijanki VN, Wenkert D, Whyte MP. Non-endemic skeletal fluorosis: Causes and associated secondary hyperparathyroidism (case report and literature review). Bone 2021; 145:115839. [PMID: 33418099 PMCID: PMC8142331 DOI: 10.1016/j.bone.2021.115839] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/10/2020] [Accepted: 12/31/2020] [Indexed: 12/25/2022]
Abstract
Skeletal fluorosis (SF) is endemic primarily in regions with fluoride (F)-contaminated well water, but can reflect other types of chronic F exposure. Calcium (Ca) and vitamin D (D) deficiency can exacerbate SF. A 51-year-old man with years of musculoskeletal pain and opiate use was hypocalcemic with secondary hyperparathyroidism upon manifesting recurrent long bone fractures. He smoked cigarettes, drank large amounts of cola beverage, and consumed little dietary Ca. Then, after 5 months of Ca and D3 supplementation, serum 25(OH)D was 21 ng/mL (Nl, 30-100), corrected serum Ca had normalized from 7.8 to 9.4 mg/dL (Nl, 8.5-10.1), alkaline phosphatase (ALP) had decreased from 1080 to 539 U/L (Nl, 46-116), yet parathyroid hormone (PTH) had increased from 133 to 327 pg/mL (Nl, 8.7-77.1). Radiographs revealed generalized osteosclerosis and a cystic lesion in a proximal femur. DXA BMD Z-scores were +7.4 and +0.4 at the lumbar spine and "1/3" radius, respectively. Bone scintigraphy showed increased uptake in two ribs, periarticular areas, and proximal left femur at the site of a subsequent atraumatic fracture. Elevated serum collagen type I C-telopeptide 2513 pg/mL (Nl, 87-345) and osteocalcin >300 ng/mL (Nl, 9-38) indicated rapid bone turnover. Negative studies included hepatitis C Ab, prostate-specific antigen, serum and urine electrophoresis, and Ion Torrent mutation analysis for dense or high-turnover skeletal diseases. After discovering markedly elevated F concentrations in his plasma [4.84 mg/L (Nl, 0.02-0.08)] and spot urine [42.6 mg/L (Nl, 0.2-3.2)], a two-year history emerged of "huffing" computer cleaner containing difluoroethane. Non-decalcified histology of a subsequent right femur fracture showed increased osteoblasts and osteoclasts and excessive osteoid. A 24-hour urine collection contained 27 mg/L F (Nl, 0.2-3.2) and <2 mg/dL Ca. Then, 19 months after "huffing" cessation and improved Ca and D3 intake, yet with persisting bone pain, serum PTH was normal (52 pg/mL) and serum ALP and urine F had decreased to 248 U/L and 3.3 mg/L, respectively. Our experience combined with 15 publications in PubMed concerning unusual causes of non-endemic SF where the F source became known (19 cases in all) revealed: 11 instances from high consumption of black tea and/or F-containing toothpaste, 1 due to geophagia of F-rich soil, and 7 due to "recreational" inhalation of F-containing vapors. Circulating PTH measured in 14 was substantially elevated in 2 (including ours) and mildly increased in 2. The severity of SF in the cases reviewed seemed to reflect cumulative F exposure, renal function, and Ca and D status. Several factors appeared to influence our patient's skeletal disease: i) direct anabolic effects of toxic amounts of F on his skeleton, ii) secondary hyperparathyroidism from degradation-resistant fluorapatite bone crystals and low dietary Ca, and iii) impaired mineralization of excessive osteoid due to hypocalcemia.
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Affiliation(s)
- Fiona J Cook
- Division of Endocrinology, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
| | - Maighan Seagrove-Guffey
- Division of Endocrinology, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
| | - Steven Mumm
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Deborah J Veis
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA; Department of Pathology and Immunology, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - William H McAlister
- Mallinckrodt Institute of Radiology, Washington University School of Medicine at St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| | - Vinieth N Bijanki
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Deborah Wenkert
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA; Wenkert & Young, LLC, Thousand Oaks, CA, 91362, USA.
| | - Michael P Whyte
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
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Al-Sharafi BA, Al-Yousfi NA, Bamashmus SA. A bedridden young lady with hypophosphatemic rickets treated with denosumab: a case report. J Med Case Rep 2021; 15:48. [PMID: 33549117 DOI: 10.1186/s13256-020-02654-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background Hypophosphatemic rickets is associated with delayed walking, bone deformities, growth failure and physical dysfunction that can limit daily activities. Treatment consists of phosphate salts and calcitriol. We report a case that received denosumab with marked improvement in her condition. Case presentation A 24-year-old Yemeni female with hypophosphatemic rickets presented to an endocrinologist with severe weakness and severe pain in the extremities, she had been bedridden for the last 4 years. Bone density showed severe osteoporosis (T score of hip was − 5.0 and Z score of hip was − 5.0, T score of the spine was − 6.0 and Z score of the spine was − 6.1) so the patient was started on denosumab in addition to calcitriol and after 7months she was feeling stronger and felt she could stand assisted and was walking with assistance within 9 months and after 1.5 years of treatment she was walking unassisted. Conclusion Denosumab is an effective treatment for osteoporosis, we used it in our patient in addition to calcitriol because she had severe osteoporosis due to long standing hypophosphatemic rickets that had not been treated properly, the patient improved markedly and regained the ability to walk again after being bedridden for 4 years. It may be a drug to consider in such cases although further studies need to be done to confirm this.
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López-Romero LC, Broseta JJ, Guillén Olmos E, Devesa-Such RJ, Hernández-Jaras J. X-linked hypophosphatemic rickets: Diagnosis in adult and paucisymptomatic form. Reumatol Clin (Engl Ed) 2021; 17:116-117. [PMID: 31707095 DOI: 10.1016/j.reuma.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/15/2019] [Accepted: 07/31/2019] [Indexed: 06/10/2023]
Abstract
X-linked hypophosphataemic rickets (XLH) is the main form of hereditary rickets caused by mutation of the PHEX gene and occurs mainly in childhood. Clinically, it causes growth retardation and bone deformities; however, there are atypical forms of presentation that make diagnosis difficult. We present a case of XLH of late diagnosis and paucisymptomatic form with multiple fractures and greatly affecting quality of life, under treatment with traditional therapy for this disease.
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Affiliation(s)
- Luis Carlos López-Romero
- Servicio de Nefrología, Área Clínica del Riñón y Vías Urinarias, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - Jose Jesús Broseta
- Servei de Nefrología i Trasplantament Renal, Institut Clínic de Nefrología i Urología, Hospital Clínic de Barcelona, Barcelona, España
| | - Elena Guillén Olmos
- Servei de Nefrología i Trasplantament Renal, Institut Clínic de Nefrología i Urología, Hospital Clínic de Barcelona, Barcelona, España
| | - Ramón Jesús Devesa-Such
- Servicio de Nefrología, Área Clínica del Riñón y Vías Urinarias, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Julio Hernández-Jaras
- Servicio de Nefrología, Área Clínica del Riñón y Vías Urinarias, Hospital Universitari i Politècnic La Fe, Valencia, España
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Hadjab I, Farlay D, Crozier P, Douillard T, Boivin G, Chevalier J, Meille S, Follet H. Intrinsic properties of osteomalacia bone evaluated by nanoindentation and FTIRM analysis. J Biomech 2021; 117:110247. [PMID: 33493712 DOI: 10.1016/j.jbiomech.2021.110247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/29/2020] [Accepted: 01/03/2021] [Indexed: 11/17/2022]
Abstract
Osteomalacia is a pathological bone condition consisting in a deficient primary mineralization of the matrix, leading to an accumulation of osteoid tissue and reduced bone mechanical strength. The amounts, properties and organization of bone constituents at tissue level, are known to influence its mechanical properties. It is then important to investigate the relationship between mechanical behavior and tissue composition at this scale in order to provide a better understanding of bone fragility mechanisms associates with this pathology. Our purpose was to analyze the links between ultra-structural properties and the mechanical behavior of this pathological bone tissue (osteomalacia) at tissue level (mineral and osteoid separately, or global). Four bone biopsies were taken from patients with osteomalacia, and subsequently embedded, sectioned, and polished. Then nanoindentation tests were performed to determine local elastic modulus E, contact hardness Hc and true hardness H for both mineralized and organic bone phases and for the global bone. The creep of the bone was also studied using a special indentation procedure in order to assess visco-elasto-plastic (creep) bone behavior. This allowed a detailed study of the rheological models adapted to the bone and to calculate the parameters associated to a Burgers model. Ultra-structural parameters were measured by Fourier Transform InfraRed Microspectroscopy (FTIRM) on the same position as the indents. The use of rheological models confirmed a significant contribution from the organic phase on the viscous character of bone tissue. The elastic E and the elasto-plastic Hc deformation were correlated to both collagen maturity and Mineral/Matrix. The pure plastic deformation H was only correlated to the mineral phase. Our data show that mineral phase greatly affects mechanical variables (moduli and viscosities) and that organic phase (as illustrated in osteoid tissue) may play an important role in the creep behavior of bone. In conclusion, this study brings mechanical and physicochemical values for osteoid and mineral phases.
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Affiliation(s)
- I Hadjab
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM, LYOS UMR1033, F69008 Lyon, France; Now, in École Polytechnique de Montréal, Canada
| | - D Farlay
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM, LYOS UMR1033, F69008 Lyon, France.
| | - P Crozier
- Univ Lyon, INSA-LYON, MATEIS, UMR CNRS 5510, F69621 Villeurbanne, France
| | - T Douillard
- Univ Lyon, INSA-LYON, MATEIS, UMR CNRS 5510, F69621 Villeurbanne, France.
| | - G Boivin
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM, LYOS UMR1033, F69008 Lyon, France.
| | - J Chevalier
- Univ Lyon, INSA-LYON, MATEIS, UMR CNRS 5510, F69621 Villeurbanne, France.
| | - S Meille
- Univ Lyon, INSA-LYON, MATEIS, UMR CNRS 5510, F69621 Villeurbanne, France.
| | - H Follet
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM, LYOS UMR1033, F69008 Lyon, France.
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Kumar K, Bhayana H, Vaiphei K, Chouhan D, Kanojia RK, Bhadada S. Coexistence of Osteomalacia in Osteoporotic Hip Fractures in More Than 50 Years Age Group. Indian J Orthop 2021; 55:614-620. [PMID: 33995864 PMCID: PMC8081808 DOI: 10.1007/s43465-020-00323-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/28/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Osteomalacia is a hitherto common orthopaedic condition and is commonly coexists with osteoporosis. However, the identification of osteomalacia always slips under the radar and more emphasis is given to diagnosis and management of osteoporosis. Identification of osteomalacia is equally relevant as management of the osteoporotic fractures is different with or without osteomalacia. METHODS This was a prospective study design that included patients 50 years or above of either sex presented with proximal femur fractures. Osteoporosis was identified by DEXA scan of hip and lumbar spine. Metabolic tests including serum calcium, phosphorus, ALP and vitamin D levels were done. Histopathological diagnosis of osteomalacia was performed on bony tissues that were taken during surgery from a site adjacent to the fracture and histological examination was performed on non-decalcified paraffin sections using special stains. RESULTS A total of 45 patients was included in study. Mean age was 68.7 years (53-85 years). Abnormal values of serum calcium, phosphorus, ALP, vitamin D were noted in 44.4%, 22.2%, 53.3% and 48.9% patients, respectively. On histopathology, 73.17% patients showed osteomalacia. No significant correlation was found between serum biochemical markers and histopathology except with serum Vitamin D (p value - 0.004). CONCLUSION The majority of patients with osteoporotic hip fractures had coexisting osteomalacia. Abnormal biochemical values were not significantly associated with osteomalacia. Hence, histopathology remains the gold standard for the diagnosis of osteomalacia. Further research is needed to identify a biomarker that may enable the clinician to diagnosis and treat osteomalacia well in time.
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Affiliation(s)
- Karmesh Kumar
- Department of Orthopaedics, PGIMER, Chandigarh, 160012 India
| | | | - Kim Vaiphei
- Department of Histopathology, PGIMER, Chandigarh, 160012 India
| | | | | | - Sanjay Bhadada
- Department of Endocrinology, PGIMER, Chandigarh, 160012 India
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Takedani K, Notsu M, Koike S, Yamauchi M, Mori T, Sohara E, Yamauchi A, Yoshikane K, Ito T, Kanasaki K. Osteomalacia caused by atypical renal tubular acidosis with vitamin D deficiency: a case report. CEN Case Rep 2021; 10:294-300. [PMID: 33398781 DOI: 10.1007/s13730-020-00561-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 11/26/2020] [Indexed: 10/22/2022] Open
Abstract
Osteomalacia is a systemic metabolic bone disease. Hypophosphatemia is one of the most important causes of impaired mineralization. Here, we describe a case of osteomalacia associated with atypical renal tubular acidosis. A 43-year-old woman was admitted to our hospital due to sustained unrelieved bilateral flank pain. She had a history of fragile fracture with vitamin D deficiency and had been treated with active vitamin D. On admission, she presented with hypophosphatemia, hypocalcemia, high bone-specific alkaline phosphatase level, bone pain, and low bone mineral density. Multiple areas of uptake were also confirmed by bone scintigraphy, and she was diagnosed with osteomalacia. An increased dose of alfacalcidol was initiated for her vitamin D deficiency; her symptoms remained unstable and unrelieved. Her blood gas examination revealed metabolic acidosis without an increase in the anion gap (HCO3- 11.8 mEq/L, anion gap 3.2 mEq/L). Tubular dysfunction, tubular damage, kidney stones, and inadequate urinary acidification were all observed, suggesting the presence of renal tubular acidosis from a combination of both distal and proximal origin. She also had overt proteinuria, decreased renal function, and hypothalamic hypogonadism. In addition to alfacalcidol, sodium bicarbonate and oral phosphorus supplementation were initiated. After this prescription, her pain dramatically improved in association with the restoration of acid-base balance and electrolytes; renal dysfunction and proteinuria were unaltered. This case indicated that careful assessments of tubular function and acid-base balance are essential for the management of osteomalacia in addition to the evaluation of the calcium/phosphate balance and vitamin D status.
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Affiliation(s)
- Kai Takedani
- Department of Internal Medicine 1, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Masakazu Notsu
- Department of Internal Medicine 1, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan.
| | - Sayo Koike
- Department of Internal Medicine 1, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Mika Yamauchi
- Department of Internal Medicine 1, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Takayasu Mori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
| | - Eisei Sohara
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
| | - Asuka Yamauchi
- Division of Nephrology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Kaori Yoshikane
- Division of Nephrology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Takafumi Ito
- Division of Nephrology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Keizo Kanasaki
- Department of Internal Medicine 1, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan.
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