Frequency of hyperostosis frontalis interna in patients with active acromegaly: is there a possible role of GH excess or hyperprolactinemia in its etiopathogenesis?

PURPOSE

Acromegaly is characterized by bone changes due to excessive growth hormone (GH) secretion. Hyperostosis frontalis interna (HFI) is described as an overgrowth in the inner plate of the frontal bone. An increased incidence of HFI has been reported in patients with acromegaly. Since the etiology of HFI is poorly understood, we have analyzed whether there is a relationship between the hormonal and metabolic status of patients with acromegaly (with or without hyperprolactinemia) and the pathogenesis of HFI.

METHODS

Forty-five patients with acromegaly and two control groups consisting of 25 patients with prolactinoma (group 1) and 47 healthy subjects (group 2) were included in this retrospective study. Baseline hormonal data and cranial imaging were obtained from medical records and analyzed.

RESULTS

Mean frontal bone thickness was 6.75 mm in acromegaly, 4.85 mm in group 1, and 5.1 mm in group 2 of controls (p < 0.001). The frequency of HFI was higher in acromegalic patients than in the controls (22%, 0%, and 2.2%, respectively). There was no difference between the HFI positive and negative acromegalic patients in basal GH, IGF-1, and PRL levels, IGF-1 index, diagnosis lag time, and insulin resistance. There was no difference between groups regarding parietal and occipital bone thickness.

CONCLUSION

Although the frequency of HFI is 22% in patients with acromegaly, neither excess GH nor hyperprolactinemia plays a role in its etiopathogenesis. Various genetic or epigenetic factors may contribute to its etiology.

Uremic Leontiasis Ossea: Theoretical Concepts and Practical Considerations

Leontiasis ossea (LO) in chronic kidney disease patients, also known as Sagliker syndrome, is an exceptionally uncommon uremic complication of long-lasting and severe secondary hyperparathyroidism. The prominent features of uremic LO (ULO) encompass the characteristic clinical trial of massive thickening of maxillary and mandibular bones, widening of interdental spaces, and flattening of nasal bridges and nares. Moreover, during the transformation of craniofacial architecture, significant structural and functional consequences may appear, including upper airway patency, visual and hearing acuity, oral phase of swallowing as well as various neurological and psychiatric disorders. Only few cases of ULO have been reported in the literature until now, making challenging not only the traditional diagnostic procedures but also the optimal therapeutic approach. In this narrative review, we aim to explore the underlying pathophysiological mechanisms, summarize the evidence for adverse outcomes, and highlight the current therapeutic strategies for ULO prevention and treatment, given that precise genetic determinants remain elusive.

Facial Changes in Adult Uremic Patients on Chronic Dialysis: Possible Role of Hyperparathyroidism

Background

Uremic patients on regular dialytic treatment (RDT) are often affected by a complex metabolic syndrome leading to osteodystrophy. Bone changes are primarily due to high bone turn over, often combined with a mineralization defect leading to increased bone fractures and bone deformities. Although rarely considered, the craniofacial skeleton represents one of the peculiar targets of this complex metabolic disease whose more dramatic pattern is a form of leontiasis ossea. This complication, although described, has never been evaluated in depth nor quantitatively assessed. In order to assess facial deformities in uremic conditions and to understand the possible relation with hyperparathyroidism, we undertook a quantitative evaluation of soft facial structures in a cohort of uremic patients undergoing RDT.

Methods

The three-dimensional coordinates of 50 soft-tissue facial landmarks were obtained by an electromagnetic digitizer in 10 male and 10 female patients with chronic renal insufficiency aged 53–81 years, and in 34 healthy individuals of the same age, ethnicity and sex. Uremic patients were enrolled according to hyperparathyroid status (PTH < 300 pg/mL and PTH > 500 pg/mL). From the landmarks, facial distances, angles and volumes were calculated according to a geometrical face model.

Results

Overall, the uremic patients had significantly larger facial volumes than the reference subjects. The effect was particularly evident in the facial middle third (maxilla), leading to an inversion of the mandibular-maxillary ratio. Facial dimensions were increased in all three spatial directions: width (skull base, mandible, nose), length (nose, mandible), and depth (mid face, mandible). The larger maxilla was accompanied by a tendency to more prominent lips (reduced interlabial angle). Some of the facial modifications (nose, lips, mandible) were significantly related to the clinical characteristics of the patients (age, duration of renal insufficiency and PTH levels).

Conclusions

This report, the first in the literature, shows that facial structures of uremic patients are enlarged in comparison with matched normal subjects and that increased bone turnover could be responsible – at least in part – for facial bone changes.

Uremic leontiasis ossea

Uremic leontiasis ossea is a rare manifestation of renal osteodystrophy clinically characterized by jaw enlargement, widening of the nares, flattening of the nasal bridge, and increased interdental spacing. Computed tomography (CT) findings are particular characteristic and include serpiginous tunneling within the maxillofacial bones and cortical bone resorption. Nuclear medicine scans are also useful for demonstrating hyperplasia of the parathyroid glands. Ultimately, the diagnosis of uremic leontiasis ossea can be made non-invasively through a combination of clinical parameters and imaging findings, as described in this article.

Total parathyroidectomy with autotransplantation for a rare disease derived from uremic secondary hyperparathyroidism, the uremic leontiasis ossea

SUMMARY

We described six uremic leontiasis ossea (ULO) patients who underwent total parathyroidectomy with autotransplantation. ULO demonstrated more a systemic disease than a simple craniofacial deformation. The surgery seemed an effective treatment to alleviate secondary hyperparathyroidism and to improve patients' quality of life. ULO may have a high postoperative recurrence tendency.

INTRODUCTION

ULO is a rare disease derived from uremic secondary hyperparathyroidism (SHPT). Previous studies mostly focused on the craniofacial deformations. This study aims to investigate the systemic features of the disease and the surgical outcomes.

METHODS

The present study retrospectively assessed six ULO patients who underwent total parathyroidectomy (TPTX) with autotransplantation (AT). Follow-up data were recorded. The follow-up status was considered as "effectiveness" if serum intact parathyroid hormone (iPTH) levels were <150 pg/mL in the first 3 days after surgery, or as "recurrence" if serum iPTH gradually increased >300 pg/mL during follow-up in patients whose status was initially considered as "effectiveness".

RESULTS

Craniofacial deformations, short stature, thoracocyllosis, spine malformations, osteodynia, and muscle weakness were observed in all patients. Abnormal pulmonary functions were observed in five patients. After surgery, one patient died from respiratory failure. Surgery was effective in the remaining five patients with relieved osteodynia and stopped craniofacial deformation. A mean follow-up of 7.6 (4 to 12) months was available. Three patients suffered from recurrence of hyperparathyroidism originating from autografts.

CONCLUSIONS

Our data suggests that ULO is not only a simple disease with craniofacial malformations but is a severe systemic disease leading to increased surgical risks. TPTX with AT seems an effective treatment to relieve SHPT and to improve quality of life. ULO may have a high postoperative recurrence tendency.

Dramatic alteration of the skull in a uremic patient with leontiasis ossea

The craniofacial skeleton represents a peculiar target of hyperparathyroidism in patients with end-stage renal disease who exhibit a dramatic pattern of uremic leontiasis ossea. Scant information regarding this condition is available in the renal literature, as the extreme and typical manifestations of leontiasis ossea have been described in only a small series of patients. We herein report a case of significant amelioration of massive modification of the facial appearance of a 30-year-old uremic Chinese woman with severe skeletal deformities who underwent total parathyroidectomy with a forearm autograft concurrently with effective drug treatment. This report may shed light on how to better understand and treat this metabolic derangement.

The spectrum of orofacial manifestations in renal osteodystrophy: diagnostic challenges of an uncommon presentation

Renal osteodystrophy refers to a spectrum of bone diseases caused by pathologic alterations in the metabolism of calcium, phosphate, and bone in the context of end-stage renal disease and secondary hyperparathyroidism. Radiographic alterations affecting the jaw and facial skeleton are common and among the earliest signs of renal bone disease. Renal osteodystrophy also shares clinical, histologic, and radiologic similarities with several benign fibro-osseous conditions affecting the craniofacial region, and its recognition is critical to prevention, choice of therapy, and overall prognosis. The aim of this article is to review the craniofacial manifestations of renal osteodystrophy, describe the work-up of a patient with macrognathia and facial disfigurement caused by renal bone disease, discuss the challenges in arriving at a definitive diagnosis, and highlight an interdisciplinary approach to evaluation and timely diagnosis in overall management.

Hyperostosis frontalis interna mimicking Mount Fuji sign

We report an interesting case of 'Hyperostosis frontalis interna' in a 73-yr-old female whose MRI pictures mimics the CT appearance of 'Mount Fuji sign' in tension pneumocephalus a neurological emergency.

Synchronous Paget disease of bone and hyperparathyroidism: report of a case with extensive craniofacial involvement

Paget disease of bone (PDB) and hyperparathyroidism (HPT) are metabolic osseous disorders which affect ≥2% of the population. As these diseases may share clinical, radiographic, biochemical, and histopathologic features, knowledge of their phenotypic overlap may provide diagnostic utility and improve clinical outcome. Scant information is available in the dental literature regarding patients concurrently affected with both pathologies. We present an unusual case report of a 63-year-old woman coaffected with primary HPT, attributed to a functional oxyphilic parathyroid adenoma, and PDB. Bone scintigraphy revealed pagetoid lesions of the skull, humeral head, spine, sacrum, and hemipelvis. Salient craniofacial features noted were bony involvement of the calvarium and midface, resulting in extensive maxillary overgrowth, hearing loss, telecanthus and consequent visual impairment, nasal deformity, and leontiasis ossea. The patient underwent a partial parathyroidectomy and bisphosphonate administration was to be initiated upon extraction of the remaining dentition.

Leontiasis ossea and post traumatic cervical cord contusion in polyostotic fibrous dysplasia

Leontiasis ossea (leonine facies) or cervical canal stenosis are rare complications of polyostotic fibrous dysplasia (PFD). This case report documents dramatic leontiasis ossea in PFD as well as post traumatic cervical cord contusion due to hyperextension injury in a patient with generalized PFD involving the cranio-facial bones, axial skeleton and entire spine with secondary cervical canal stenosis. Cervical cord contusion has not been reported earlier in PFD.

Hyperostosis frontalis interna associated with hypogonadism in an elderly man

Hyperostosis frontalis interna (HFI), symmetric thickening of the inner table of the frontal bone, is relatively common in women but very rare in men. We report the case of an elderly male patient with HFI. This patient was accompanied by primary hypogonadism, which may be related to the underlying pathogenesis of HFI.

[Cranial hyperostosis as a metastasic adenocarcinoma presentation form]

Hyperostosis is a volume-unit osseous increase of very diverse etiology. We present the case of a 68-year woman with a cranial hyperostosis debuting with frontal protrusion, headache and neurologic symptoms. Image proves demonstrated a hyperostosis in the calotte and meningeal enhancement, without intracerebral lesions nor malignant cells in the cerebrospinal fluid. Analytic data were unspecific. Cranial biopsy showed huge neoplastic infiltration in bone and meninges. Primary site remained unknown after a CAT and a mammography.

Hyperostosis frontalis interna: archaeological evidence of possible microevolution of human sex steroids?

Hyperostosis frontalis interna is a restricted bilateral thickening of the frontal endocranial surface, which is frequently found in postmenopausal females today. Surprisingly, this condition had a higher male prevalence in its rare archaeological records. This is again highlighted by the oldest known male European hyperostosis frontalis interna case in an adult Celtic from 100 BC presented here. This unique specimen supports earlier suggestions of the possible microevolution of human endocrine regulation, e.g. by sex steroids, and its pathoanatomical impact.

Leontiasis ossea in a patient with hyperparathyroidism secondary to chronic renal failure

Osteitis fibrosa describes the bone changes seen in renal osteodystrophy secondary to longstanding hyperparathyroidism. We report a 19-year-old man with longstanding chronic renal failure with a severe form of osteitis fibrosa affecting the jaws and other maxillofacial bones causing bizarre facial and dental deformity in a patient-uraemic leontiasis ossea.

[82-year old patient with hyperostosis frontalis, prognathism, makroglossia and cutis gyrata. Acromegaly]

We present a 82 year old female patient with typical acral enlargement. There were no signs of visceromegaly. Magnetic resonance imaging of the pituitary region showed a macroadenoma. Oral glucose tolerance test revealed missing suppression of the Human Growth Hormone (HGH), which could be achieved with a long acting somatostatin analog. A HGH suppressive therapy with a long acting dopamine agonist (Cabergolin) was induced. The patient died one year later following cardiovascular complications.

Maxillary brown tumor and uremic leontiasis ossea in a patient with chronic renal insufficiency

Findings of renal osteodystrophy in cranial bones are not uncommon and include osteomalacia, osteosclerosis, erosion of the cortical bone, brown tumors and resorption of the lamina dura. However, massive thickening of the cranial vault and facial bones, called uremic leontiasis ossea, have been reported very rare. In the present article, we describe the case of an uncooperative female patient with a brown tumor, involving the left maxillary sinus and massive thickening of the cranial vault and facial bones, secondary to severe secondary hyperparathyroidism during 8 years of regular hemodialysis treatment.

Hyperostosis frontalis interna: case report and review of literature

Hyperostosis frontalis interna (HFI) has been reported in high frequency among post-menopausal elderly women. Although it was widely discussed in the past, this entity is rarely mentioned in the current pathology literature. We report a postmortem case of a 56 yr-old post-menopausal woman with irregular thickening of the internal surface of the frontal bone. Histology revealed an organized trabecular pattern with overall thickening of the cancellous bone. The periosteum and cortical bone were unaffected. The finding was considered to be unrelated to her death. HFI should be recognized as a benign entity and distinguished from other disorders that involve the frontal skull bone, such as Paget's disease, acromegaly, and malignancy. The etiology of HFI is unknown, but current hypotheses implicate hormonal stimulation.

Are hyperostosis frontalis interna and leptin linked? a hypothetical approach about hormonal influence on human microevolution

It is striking that evidence for hyperostosis frontalis interna - a phenomenon of exclusive bilateral thickening of frontal endocranial surface - in archaeological samples is very rare in contrast to its modern prevalence. Because microevolutionary changes have been shown for various human characteristics any alteration of hormonal levels is very likely. Selection pressure was definitively higher in earlier times. This favoured prolonged alertness in order to access sufficient food, shorter feeling of satiety, lower level of fat metabolism, lower metabolic rates and, therefore, lower level of leptin - a 167 amino acid peptide mainly involved in human total body fat regulation. Its effects on bone metabolism are still debated. Nevertheless, we postulate the following hypothesis: In humans a decrease of selective pressure favoured an increased metabolic rate. This, being related to the higher level of leptin caused an increase of localized bony overgrowth like hyperostosis frontalis interna.

[Japanese cases of hyperostosis frontalis interna]

Although hyperostosis frontalis interna is common in the western countries, it has been rarely reported in the literature in Japan. We had a chance to observe 5 cases diagnosed as hyperostosis frontalis interna. They were found among 10,902 patients who came to our hospital from August 1, 1993 to September 30, 1995. All the patients in these five cases are females aged 67 to 85 (mean = 74.2 years). Four of the 5 cases had been treated as hypertension, 2 as diabetes mellitus, and 1 as hyperlipoidemia. Two cases were accompanied by unruptured aneurysms. The pathology of one case accompanied by chronic subdural hematoma revealed no apparent development of Haversian systems of bone. It seems that the prevalence of this disease in Japan would increase from now on due to the fact that the life style and the diet among Japanese people has been getting westernized.

Uremic leontiasis ossea: "bighead" disease in humans? Radiologic, clinical, and pathologic features

PURPOSE

To describe the clinical, radiologic, and pathologic findings in patients with uremic leontiasis ossea (ULO).

MATERIALS AND METHODS

Five patients with renal osteodystrophy developed marked hyperostosis of the facial and cranial bones. Radiologic studies included plain radiography of the skull (n = 5), computed tomography with three-dimensional reconstruction (n = 4), magnetic resonance imaging (n = 3), and fluorine-18 sodium fluoride positron emission tomography (PET) (n = 1). Specimens from bone biopsies (three patients) were examined.

RESULTS

Skull and facial alterations were remarkably similar. Numerous nodules of varying attenuation and signal intensity in the widened diploic space suggested brown tumors in different stages of evolution. Biochemical data and PET findings enabled confirmation of markedly increased bone turnover. Bone specimens demonstrated severe osteitis fibrosa. After parathyroidectomy, facial changes in all patients stabilized or improved mildly.

CONCLUSION

A similar entity in animals, "bighead" disease, which results from nutritional and uremic secondary hyperparathyroidism, may provide a useful animal model for ULO in humans. Mild forms of this entity may be more common than the scarcity of previous reports suggests.

Facial leontiasis ossea: a rare presentation of hyperparathyroidism secondary to chronic renal insufficiency

The term renal osteodystrophy is often used in a generic sense to include skeletal disorders of patients with chronic renal failure due to secondary hyperparathyroidism. The prevalence of this condition among patients on hemodialysis is considerably high. However, extreme forms such as facial leontiasis ossea are very rare, only 2 well-characterized cases having been reported thus far in the literature. In the present article we report the case of a female patient who developed hyperparathyroidism secondary to end-stage renal disease which was manifested as facial leontiasis ossea and culminated in dysphagia and respiratory difficulties caused by excess bone tissue growth.

Hyperostosis frontalis interna, acromegaly and hyperprolactinaemia

The association between hyperostosis frontalis interna (HFI), acromegaly and hyperprolactinaemia was investigated. Thirty six acromegalic patients, of whom 19 had hyperprolactinaemia, were compared with 36 randomly-selected, age-sex matched controls. There was a higher prevalence of HFI in the skull X-rays of the acromegalic cohort (P = 0.0002) when compared to the control group. This difference was apparent in both men (P = 0.01) and women (P = 0.01). Acromegalic patients with hyperprolactinaemia also expressed HFI in a higher proportion of individuals than the control group (P = 0.0001). Intra- and interobserver variability was assessed and concordance with 100% and 97% in the moderate and severe HFI sub-groups. The following sub-group analysis was undertaken: acromegalics and those acromegalics with hyperprolactinaemia were compared with the controls and a highly significant distinction was confirmed (P = 0.0007 and P = 0.00001 respectively). A relationship between HFI severity and the patient's age was noted in both male and female acromegalics. Also, the severity of HFI appeared related to disease duration in female acromegalics. The cause of HFI remains unknown but appears to be strongly associated with acromegaly, particularly in the presence of co-existent hyperprolactinaemia. The association may have symptomatic significance and the presence of HFI should be confirmed or refuted in all patients with acromegaly.

[Unilateral hyperostosis frontalis interna coexistent with cerebral angioma]

The authors describe a rare case of coexistence of cerebral angioma with hyperostosis frontalis interna in a female patient aged 28 years, suffering from mental disturbances. The coexistence of these two diseases in one person caused considerable diagnostic and therapeutic difficulties. The described case points out that both these conditions may occur concomitantly. Another point of interest is the presence of hyperostosis frontalis interna in a young woman.

Androgens, bone mineral content and hyperostosis frontalis interna in pre-menopausal women

Greater than normal bone mineral content, bone width of the radius measured by photon absorptiometry and bone mineral content to bone width ratio found in women with hyperostosis frontalis interna pointed on a generalized alteration of the skeletal system. An increase in serum dehydroepiandosterone, its sulphate and testosterone levels and a significant correlation between serum free dehydroepiandosterone and bone mineral content in subjects without any sign of hirsutism or obesity suggested an involvement of androgens in pathogenesis of this metabolic bone disorder.

New bone formation in acromegaly: pathogenetic implications for diffuse idiopathic skeletal hyperostosis

Radiographs of spinal and heel entheseal areas and the skull were examined for new bone formation in 30 acromegalic patients. Forty-seven percent satisfied accepted criteria for Diffuse Idiopathic Skeletal Hyperostosis (DISH), 67% had marked heel enthesopathic change and 87% had Hyperostosis Frontalis Interna (HFI). Such hyperostotic changes were indistinguishable from those seen in DISH and the extent and degree of such changes increased with duration of acromegaly. It is proposed that a common metabolic factor, e.g., hyperinsulinaemia, may be responsible for the hyperostotic changes seen in both DISH and acromegaly.

Leontiasis ossea, flail chest and pancytopenia in a patient with renal osteodystrophy

Images

[Leontiasis ossea: a symptom...!]

The keyword "leontiasis ossea" has no diagnostic significance. It is only a description of a symptom of bone disease with a broad variability such as Paget's disease, fibrous dysplasia, hyperparathyroïdism and condensing osteopathies. (Pyle's disease, or cranio-diaphyseal dysplasia.) The first case presented shows advanced Paget's disease with radiographic signs of maxillary bone pathology. A tooth extraction in this patient was complicated by a severe healing problem. Sequestration occurred after two years. Healing was only obtained after removal of the sequestrum. The authors believe that the healing problem was directly related to Paget's disease of maxillary bone. The second case represents a patient with hyperparathyroïdism, showing an unusual facial swelling as only physical symptom of the disease. The problem of interpretation of biopsymaterial and the occurrence of osteosclerotic appearence on X-ray are discussed. The authors suggest that a complete examination (X-ray of the skeleton, blood and urine parameters, and functionel tests) should be performed to put forward a right diagnosis in the patient, presenting leontiasis ossea.