Hepatitis C-associated Osteosclerosis (HCAO): Long-Term Follow-Up of a New Case Recovered After Antiviral Treatment

Hepatitis C-associated osteosclerosis (HCAO) is a very rare condition that can be observed in a small number of patients with Hepatitis C Virus (HCV) infection. HCAO is usually characterized by widespread bone sclerosis, associated with severe bone pain, and increased levels of bone turnover markers, especially alkaline phosphatase (ALP). In this report, we present the case of a 55-year-old woman who was affected by HCV and came to our attention for severe and diffuse bone pain. Radiological studies showed bone sclerosis, and bone mineral density (BMD) was markedly increased, as well as serum ALP levels. The patient was initially treated with intravenous pamidronate, which provided only a transient benefit on clinical symptoms. Then antiviral therapy for HCV (interferon-alfa and ribavirin) was started and it was effective in making the viral load undetectable. After a long follow-up period, we observed a persistent remission of bone pain, a reduction in BMD together with a progressive trend toward the normalization of bone turnover markers. In conclusion, HCAO, although rare, should be considered among the potential causes of increased bone mass in patients with HCV infection, and treatment for the underlying infection may be effective in controlling the manifestations of this disease.

Diffuse osteosclerosis as a presentation of recurrent breast cancer: role of endothelin 1

We report a 46-yr-old woman with a history of breast cancer who presented with diffuse myalgias, bone pain, and osteosclerosis. She was found to have recurrent breast cancer producing endothelin-1.

INTRODUCTION

Acquired osteosclerosis can be caused by various disorders. Endothelin -1 is believed to contribute to osteosclerosis caused by breast cancer.

METHODS

Although the bone marrow biopsy did not reveal breast cancer, she developed skin lesions consistent with metastatic breast cancer. She ultimately died from progressive disease. At autopsy immunohistochemistry for endothelin-1 was performed on a section from the L5 vertebral body.

RESULTS

The section from the L5 vertebral body showed small foci of cells consistent with metastatic carcinoma and a prominent sclerotic response. Immunohistochemistry for endothelin-1 was strongly positive.

CONCLUSIONS

Recurrent breast cancer may present with diffuse osteosclerosis. Endothelin-1 may be a paracrine factor responsible for increased bone formation and osteosclerosis.

Congenital lipodystrophy induces severe osteosclerosis

Berardinelli-Seip congenital generalized lipodystrophy is associated with increased bone mass suggesting that fat tissue regulates the skeleton. Because there is little mechanistic information regarding this issue, we generated "fat-free" (FF) mice completely lacking visible visceral, subcutaneous and brown fat. Due to robust osteoblastic activity, trabecular and cortical bone volume is markedly enhanced in these animals. FF mice, like Berardinelli-Seip patients, are diabetic but normalization of glucose tolerance and significant reduction in circulating insulin fails to alter their skeletal phenotype. Importantly, the skeletal phenotype of FF mice is completely rescued by transplantation of adipocyte precursors or white or brown fat depots, indicating that adipocyte derived products regulate bone mass. Confirming such is the case, transplantation of fat derived from adiponectin and leptin double knockout mice, unlike that obtained from their WT counterparts, fails to normalize FF bone. These observations suggest a paucity of leptin and adiponectin may contribute to the increased bone mass of Berardinelli-Seip patients.

Bi-allelic CSF1R Mutations Cause Skeletal Dysplasia of Dysosteosclerosis-Pyle Disease Spectrum and Degenerative Encephalopathy with Brain Malformation

Colony stimulating factor 1 receptor (CSF1R) plays key roles in regulating development and function of the monocyte/macrophage lineage, including microglia and osteoclasts. Mono-allelic mutations of CSF1R are known to cause hereditary diffuse leukoencephalopathy with spheroids (HDLS), an adult-onset progressive neurodegenerative disorder. Here, we report seven affected individuals from three unrelated families who had bi-allelic CSF1R mutations. In addition to early-onset HDLS-like neurological disorders, they had brain malformations and skeletal dysplasia compatible to dysosteosclerosis (DOS) or Pyle disease. We identified five CSF1R mutations that were homozygous or compound heterozygous in these affected individuals. Two of them were deep intronic mutations resulting in abnormal inclusion of intron sequences in the mRNA. Compared with Csf1r-null mice, the skeletal and neural phenotypes of the affected individuals appeared milder and variable, suggesting that at least one of the mutations in each affected individual is hypomorphic. Our results characterized a unique human skeletal phenotype caused by CSF1R deficiency and implied that bi-allelic CSF1R mutations cause a spectrum of neurological and skeletal disorders, probably depending on the residual CSF1R function.

[Osteosclerosis associated with hepatitis C]

We describe the first Finnish case of hepatitis C associated osteosclerosis. In which the patient's bone symptoms and bone density were resolved with hepatitis C treatment. Suspecting the possibility of osteosclerosis underlying bone pains in a hepatitis C patient is well-founded, although osteoporotic fractures are a more common problem.

[Evaluation of five years of treatment of Erdheim-Chester disease with anakinra: case report and overview of literature]

Erdheim-Chester disease is a histiocytic neoplasm of diseases from the group of non-Langerhans-cell histiocytoses, formed by infiltrates of foamy histiocytes. These pathological histiocytes produce pro-inflammatory cytokines. Therefore Erdheim-Chester disease is called inflammatory histiocytary neoplasm. The disease is accompanied by clinical symptoms of systemic inflammatory response, i.e. B symptoms. Imaging examinations detect typical osteosclerotic changes affecting diaphyses and metaphyses of the lower long bones and fibrotic changes which affect the aorta wall and the vessels leading from it. Also characteristic are perirenal fibrotic changes spreading in the retroperitoneum. They can cause serious complications - hydronephrosis with all its consequences. The therapy for this disease was not satisfactory in the previous years. Conventional chemotherapy or glucocorticoids do not bring any substantial and long-term improvement. Considering cytostatic drugs, only 2-chlorodeoxyadenosine (cladribine) is effective, though not in all patients. We have only reached complete remission through 2-chlorodeoxyadenosine in one of our two patients, which now lasts more than 5 years, while cladribine in the same patient did effect the reduction of infiltrates into the CNS, but it did not achieve abatement of the disease activity in other locations as shown by PET/CT with the application of the radio-pharmaceutical fluorodeoxyglucose (FDG). Another effective medicine for patients with Erdheim-Chester disease is interferon α. However its long-term administration is associated with multiple adverse effects and so we did not test it in the described patient. The introduction of anakinra, the interleukin-1 receptor blocker, to therapy brought a new hope for these patients. We are describing the patient who has been treated with anakinra for more than 5 years. The patient applies 1 ampoule of 100 mg subcutaneously per day. This treatment completely removed systemic B symptoms, relieved bone pains and attained normalization of all findings that signalled systemic inflammatory response. The treatment effect is regularly checked by CT imaging of the abdomen and by FDG-PET/CT examinations. The retroperitoneal fibrotic changes gradually regressed during the 5 years of anakinra treatment, as documented by the pictures in the text. Low-dose CT imaging which was part of the PET/CT examination, identified many osteosclerotic lesions in the skeleton, mainly in the legs, with an increased accumulation of 18F-fluorodeoxyglucose (FDG). Osteosclerotic lesions remain well visible at repeated examinations. Still during the course of the 5-year period the FDG accumulation in them decreased, as shown by the pictures in the text. Anakinra treatment has a character of maintenance therapy. The BRAFV600E mutation was not proven in the described patient, therefore we did not test vemurafenib treatment.

CONCLUSION

anakinra effected regression of fibrotic changes in the retroperitoneum and disappearance of B symptoms as well as decrease in FDG accumulation at FDG-PET/CT examination.Key words: anakinra - Erdheim-Chester disease - cladribine - retroperitoneal fibrosis - vemurafenib.

POEMS Syndrome: A Rare Disease With A Challenging Diagnosis

A complex conglomerate of symptoms, signs, and abnormalities are present with POEMS syndrome, making the diagnosis, management and follow-up a challenge. Recognizing the disease early on may be difficult. Many patients are initially misdiagnosed as having others disorders, for example: multiple myeloma. There is no standard treatment for patients diagnosed with POEMS syndrome.

[Diagnosis of Erdheim-Chester disease following a traumatic fracture]

We describe the case of a woman with the diagnosis of Erdheim-Chester disease following an upper limb traumatic fracture. A 65-year-old woman presents to the emergency department for left shoulder and right ankle pain, she admits recent multiple falls. Imaging shows a left trochiter fracture and osteosclerotic lesions in the upper and lower limbs. Bone biopsy confirms the suspicion of Erdheim-Chester disease. Erdheim-Chester disease is a rare systemic non- Langerhans cell histiocytosis of the middle-aged adult. The most common characteristic is bilateral and symmetric osteosclerotic lesions in long bones. Pathological examination provides the definitive diagnosis. Imaging and clinical biology assess the extent of the disease. Treatment must be decided on a case-to-case basis taking into account patient's symptoms.

Diffuse osteosclerosis in a patient with prostate cancer

A 61-year-old man was referred to our outpatient clinic because of severe bilateral upper leg pain for 1 year. On admission, the patient had anemia and a high serum alkaline phosphatase level. Lumbar and femoral neck T-scores were +10.5 and +9.6, respectively. His radius 33 % T-score was -2.8. Plain radiographs of the patient's pelvis, spine, and long bones revealed osteosclerosis. The patient had previously undergone a prostate biopsy, which showed prostate adenocarcinoma (Gleason score 3 + 4). The patient's total and free prostate-specific antigen were very high. According to previous records, the patient did not have anemia, and his serum alkaline phosphatase (ALP) level was normal. An abdominal radiograph taken 2 years earlier revealed a normal spine and pelvic bone. Bone scintigraphy yielded nontypical findings for prostate cancer metastasis. Computed tomography of the patient's thorax and abdomen showed heterogeneous sclerotic areas in all bones consistent with prostate cancer metastasis. A bone marrow biopsy disclosed disseminated carcinomatosis of bone marrow in association with prostate cancer. Clinicians should be aware of the possibility of prostate malignancy as a cause of high bone mineral density (BMD), even in the absence of typical localized findings on plain radiographs.

A possible association of idiopathic osteosclerosis with excessive occlusal forces

OBJECTIVES

The aim of the study was to determine the relationship between idiopathic osteosclerotic lesions and occlusal forces using the T-Scan II computerized occlusal analysis device, and to test the sensitivity of the system in occlusal analysis.

METHOD AND MATERIALS

The study was conducted with 21 volunteers with idiopathic osteosclerosis (IO; 14 women, 7 men) aged between 17 and 62 years (mean 29.95). For every patient, seven or eight recordings were made with the T-Scan II occlusal analysis device in maximum intercuspation, and the last two (excluding any with technical problems) were chosen for evaluation. For each lesion-related area, the distribution of high occlusal forces from two different movies was analyzed.

RESULTS

In 18 patients (85.71%), lesions were observed in an area of high occlusal force, and in 13 patients (61.9%), the lesions were located at the first area subjected to high occlusal forces. The percentage distribution of high forces at a lesion related area ranged from 0% to 88%. On average, the high forces at an osteosclerotic lesion area accounted for 20% of the maximum total force. No statistical differences were observed between the measurements of the two selected recordings (P > .05).

CONCLUSION

The findings of this study suggest a possible relationship between IO and occlusal forces and primary contacts. T-Scan II was found to be a successful diagnostic device for detecting primary contacts and excessive occlusal forces.

[Computed tomographic criteria for the diagnosis of variable manifestations of Paget's disease in the cerebral cranium and facial bones]

OBJECTIVE

to optimize the diagnosis of different stages of Paget's disease, by determining the extent of bone structural lesions in the cerebral and visceral cranium on the basis of computed tomography data.

MATERIAL AND METHODS

Computed tomographic data were assessed by keeping in mind the structure, density, outlines, shadow shapes of the described tumor-like disease and the state of involved bone structures. Twelve patients with histologically verified Paget's disease were examined.

RESULTS

The findings allowed the high informative value of computed tomography in diagnosing different stages of Paget's disease to be estimated in bone structural lesions in the cerebral and visceral cranium and skull base. Also, the obtained computed tomography data permitted the tracing of the extent of the lesion in the area under study.

Efficacy of lenalidomide plus dexamethasone for POEMS syndrome relapsed after autologous peripheral stem-cell transplantation

POEMS syndrome is a rare paraneoplastic condition associated to an underlying plasmacellular dyscrasia. The pathogenesis of POEMS is poorly understood, but overproduction of VEGF, probably secreted by clonal plasma cells, is thought to be responsible for the signs and symptoms of the syndrome, and it seems to be useful for the monitoring of the response to therapy. At present, an effective therapeutic option for the patients is represented by autologous peripheral blood stem-cell transplantation (aPBSCT), although relapses have been described, and there is an important morbidity associated with this procedure. Before the implementation of aPBSCT, the clinical course of POEMS syndrome was characterized by progressive polyneuropathy potentially leading to death for respiratory failure. Given the high serum and plasma levels of VEGF observed in POEMS patients, the use of anti-angiogenetic drugs such as thalidomide and lenalidomide and other drugs with anti-VEGF and anti-TNF effect such as bortezomib have been considered to treat this syndrome. There are evidences of lenalidomide benefit in both front-line and previously treated patients, but scanty data are available about its use for relapse after aPBSCT. Here, we report the successful use of lenalidomide in a patient who relapsed after aPBSCT.

Bisphosphonate-related osteonecrosis of the jaw in patients with oral bisphosphonate exposure: clinical course and outcomes

PURPOSE

To characterize the spectrum and outcomes of bisphosphonate-related osteonecrosis of the jaw (BRONJ) occurring with oral bisphosphonate therapy.

MATERIALS AND METHODS

We assembled a retrospective cohort of patients who had developed oral BRONJ according to the 2009 American Association of Oral and Maxillofacial Surgeons criteria and received care within Kaiser Permanente, Northern California, during 2004 to 2011. Patients with intravenous bisphosphonate exposure were excluded. The demographic factors, comorbidities, pharmacologic exposure, maxillofacial findings, and outcomes were ascertained from the clinical and radiologic records.

RESULTS

We identified 30 cases of oral BRONJ (median age 77 years, 87% women). All had received oral bisphosphonate for osteoporosis/osteopenia (median duration 4.4 years, interquartile range 1.9 to 6.6). More than one half (57%) had comorbidities or relevant drug exposure, including rheumatoid arthritis, diabetes, glucocorticoid therapy, and disease-modifying antirheumatic medications. Extractions preceded BRONJ in 17 patients and trauma in 3; 10 developed BRONJ spontaneously. Overall, 83% had healed within 3 to 52 months, although the relative rate of healing varied by antecedent factor and/or the presence of comorbid conditions/exposures. Nearly all patients with trauma-related and spontaneous BRONJ healed within 1 year (median 7.0 and 7.5 months, respectively) compared with those developing BRONJ after extraction, in whom the median time to healing was 18 months (P < .0001). Patients with relevant comorbidities had a lower probability of healing (P = .0002) and a longer median time to healing (20 months) than patients without comorbidities (7.5 months).

CONCLUSIONS

We found that postextraction patients and those with comorbid conditions/exposures showed refractory BRONJ with prolonged healing times. Practitioners should be aware that the BRONJ clinical course and outcome varies depending on the antecedent factor and comorbidity status.

Skeletal fluorosis from brewed tea

BACKGROUND

High fluoride ion (F(-)) levels are found in many surface and well waters. Drinking F(-)-contaminated water typically explains endemic skeletal fluorosis (SF). In some regions of Asia, however, poor quality "brick tea" also causes this disorder. The plant source of brick, black, green, orange pekoe, and oolong tea, Camellia sinensis, can contain substantial amounts of F(-). Exposure to 20 mg F(-) per day for 20 yr of adult life is expected to cause symptomatic SF. High F(-) levels stimulate osteoblasts and enhance bone apposition but substitute for OH(-) groups in hydroxyapatite crystals and thereby result in skeletal fragility and perhaps lead to secondary hyperparathyroidism. Beginning in 2005, we showed that daily consumption of 1-2 gallons of instant tea made from this plant can lead to SF.

AIM

We describe a 48-yr-old American woman who developed SF from brewed tea.

PATIENT AND METHODS

Our patient had elevated bone mineral density revealed by dual-energy x-ray absorptiometry (spine Z-score, +9.9), severe chronic bone and joint pain, and kyphosis after consuming 1-2 gallons of brewed orange pekoe tea daily for more than three decades. F(-) levels were high in her serum, urine, and clippings of fingernails and toenails, as well as in our reproduction of her beverage. Renal function was normal. She had vitamin D deficiency. Elevated serum PTH levels were unresponsive to adequate vitamin D supplementation. Pain resolved over several months when she stopped drinking tea and continued ergocalciferol.

CONCLUSION

Our patient shows that SF can result from chronic consumption of large volumes of brewed tea.

Socket sclerosis: a rare complication obstructing orthodontic tooth movement

Socket sclerosis is usually asymptomatic and does not require any treatment. The only potential complication arises during orthodontic treatment, wherein a sclerosed socket of the premolars may be an obstacle in closing spaces by movement of teeth through the extraction space. This article demonstrates the problems encountered during the orthodontic treatment of a 20-year-old woman with socket sclerosis and the treatment strategy employed to overcome the same.

[Bone and joint diseases in children. Abnormal bone mineral density in children]

In recent years, the problem of osteoporosis is increasingly raised in children as well as adults both as a primary disorder and as secondary results to various diseases, medications, and lifestyle issues. On the other hand, molecular mechanisms of pathogenesis have been elucidated in several sclerosing disorders contributing to our understanding of basic biology of bone metabolism. In this chapter, we reviewed the recent progress on the method to evaluate BMD in growing period and etiologies of abnormal BMD in children.

Prevalence of radiological findings among cases of severe secondary hyperparathyroidism

CONTEXT AND OBJECTIVE

Patients with end stage renal disease (ESRD) and secondary hyperparathyroidism (HPT2) are prone to develop heterotopic calcifications and severe bone disease. Determination of the sites most commonly affected would decrease costs and patients' exposure to X-ray radiation. The aim here was to determine which skeletal sites produce most radiographic findings, in order to evaluate hemodialysis patients with HPT2, and to describe the most prevalent radiographic findings.

DESIGN AND SETTING

This study was cross-sectional, conducted in one center, the Hospital Universitário Clementino Fraga Filho (HUCFF), in Rio de Janeiro, Brazil.

METHODS

Whole-body radiographs were obtained from 73 chronic hemodialysis patients with indications for parathyroidectomy due to severe HPT2. The regions studied were the skull, hands, wrists, clavicles, thoracic and lumbar column, long bones and pelvis. All the radiographs were analyzed by the same two radiologists, with great experience in bone disease interpretation.

RESULTS

The most common abnormality was subperiosteal bone resorption, mostly at the phalanges and distal clavicles (94% of patients, each). 'Rugger jersey spine' sign was found in 27%. Pathological fractures and deformities were seen in 27% and 33%, respectively. Calcifications were presented in 80%, mostly at the forearm fistula (42%), abdominal aorta and lower limb arteries (35% each). Brown tumors were present in 37% of the patients, mostly on the face and lower limbs (9% each).

CONCLUSION

The greatest prevalence of bone findings were found on radiographs of the hands, wrists, lateral view of the thoracic and lumbar columns and femurs. The most prevalent findings were bone resorption and ectopic calcifications.

Osteosclerotic "plasmocytoma" with polyneuropathy, hypertrichosis and diabetes

The combination of osteosclerosis, polyneuropathy, monoclonal immunoglobulin, hypertrichosis, serositis and a number of other symptoms is described. It seems probable that this is a special type of myeloma. Similar cases have been described in Japan and out findings are compared with the Japanese picture. The age of the patients is unusually low. The M-component in the plasma is small. There is very little Bence Jones protein in the urine and osteolytic lesions in the skull do not seem to have occurred. The polyneuropathy may improve during treatment with cytostatic drugs.

Osteosclerotic myeloma with polyneuropathy

Five cases of histologically verified plasma cell myeloma in sclerotic skeletal foci and polyneuropathy are reported. Thirty similar cases were collected from the literature. They illustrate a special form of plasma cell neoplasia. The characteristic features are osteosclerosis, polyneuropathy resembling polyradiculitis, approximately normal hemoglobin concentration, bone marrow smears and ESR, low concentration of M-protein, and absence of Bence-Jones' proteinuria. Slow progesssion of the disease is a possible additional feature. It is hypothesized that autoimmune mechanisms are involved in the pathogenesis. This hypothesis is based on the observation of circulating immune complexes, positive Waaler's reaction and relative increase in the number of circulating B-lymphocytes.

A half-century of community water fluoridation in the United States: review and commentary

The nearly 50-year history of community water fluoridation is reviewed with the major emphasis on the benefits and safety of fluoridation. Other aspects of water fluoridation also described include the apparent reduction in measurable fluoridation benefits because of the abundance of other fluoride sources, the diffusion of fluoridation effects into fluoride-deficient communities, preeruptive and posteruptive effects, technical and cost aspects, sociopolitical and legal issues that affect the successful fluoridation of communities, and alternatives to community water fluoridation. The majority of studies have evaluated the effectiveness of water fluoridation on the permanent teeth of children, while there are fewer studies on deciduous teeth and in adults; the relationship between fluoride ingestion and bone health needs further clarification; the sociopolitical issues of fluoridation need to be better understood.

Hypocalcemia as a presentation for multifocal osteosarcoma

We report the case of a 16-year-old male with multifocal osteosarcoma presented with symptomatic hypocalcemia. The patient presented signs of hypocalcemia accompanied by generalized bone pain and a femoral mass. Further evaluation revealed secondary hyperparathyroidism, highly elevated alkaline phosphatase levels, and generalized sclerotic and lytic lesions. Biopsy confirmed osteosarcomatosis. Despite aggressive chemotherapy, he died from progressive disease 2 months after diagnosis. The course of disease in this patient suggests that hypocalcemia reflects a poor prognosis.

POEMS syndrome: relapse after successful autologous peripheral blood stem cell transplantation

We report a patient with POEMS syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, Skin changes) treated with high dose chemotherapy and auto-Peripheral Blood Stem Cell Transplantation (auto-PBSCT) who had a very good response with complete clinical remission. Seven years later, she relapsed and a new sclerotic bone lesion was found. To our knowledge, this is the first POEMS syndrome relapse after successful auto-PBSCT.

Two cases of SAPHO syndrome accompanied by classic features of Behcet's disease and review of the literature

We describe two patients with SAPHO (synovitis-acne-pustulosis-hyperostosis-ostitis) syndrome who presented some of the classic features of Behcet's disease. The first case is a man diagnosed as SAPHO at 74 years old. His major complaint is pain and swelling of the bilateral sterno-clavicular region for more than 14 years. Another conspicuous complication was bilateral glaucoma and episodes of iritis were recognized during the follow-up period. The second case is a 65-year-old woman, who first consulted us with right knee pain. As she had a past history of palmoplantar pustulosis and anterior chest pain, her sterile knee arthritis was diagnosed as SAPHO. She also had been suffering from recurrent oral aphthous ulceration since 6 months before visiting our hospital. Considering the clinical courses of our two cases and a review of five previously reported cases, these conditions may imply that classic features of Behcet's disease are minor complications of SAPHO syndrome. Human leukocyte antigen typing and frequent association of sacroiliitis in our cases and in the review of the literature for SAPHO syndrome with some of the classic features of Behcet's disease may indicate this condition to be a closely related disease with seronegative spondylo-arthritis.

Hyperostosis with hyperphosphatemia and tumoral calcinosis: a case report

The combination of hyperostosis and hyperphosphatemia is very rare. In this case report, we present a boy with a combination of diffuse hyperostosis and hyperphosphatemia. We evaluated most possible known causes of hyperphosphatemia and hyperostosis. He had normal renal function and serum parathormone level. Concerning some few similar cases, most of them from Middle Eastern countries, we present this combination (diffuse hyperostosis and hyperphosphatemia) as a new syndrome to be discussed in pediatric textbooks.

A sheep model of intracapsular condylar fracture

PURPOSE

An animal model of a condylar head fracture similar to a type B intracapsular fracture in humans was created. The effect of this model on mandibular function and morphological changes of temporomandibular joint (TMJ) structure was evaluated.

MATERIALS AND METHODS

Ten sheep were divided into 3 groups, sacrificed at 1 week (2 sheep), 4 weeks (4 sheep), and 12 weeks (4 sheep) after surgery. The right side of the TMJ was considered the surgical group; the left side, the control group. The anterior and posterior attachments of the discs were cut, and an oblique vertical osteotomy was made from the lateral pole of the condyle to the medial side of the condylar neck. The condyle fragment was pushed together with the disc anteriorly, inferiorly, and medially. The lateral side of the condylar stump was sutured to the capsule to limit movement. Preoperative and postoperative body weight, maximum mouth opening, lateral excursions, and x-ray and computed tomography (CT) findings in the 3 surgical groups and the control group were recorded. The SPSS software program was used for all statistical analyses.

RESULTS

There were no significant differences in weight loss and left lateral movement among the 3 surgical groups, but maximum mouth opening and the right lateral movement decreased significantly in the 4-week and 12-week surgical groups. X-rays demonstrated severe bone erosion and new bony outgrowth in the lateral side of the condylar stump and a narrowed, indistinct joint space in these 2 groups. Three-dimensional reconstruction of CT images showed changed contours of the condylar stump, condylar fragment and articular eminence in all 3 surgical groups.

CONCLUSIONS

This study demonstrates progressive changes toward ankylosis and pathological changes in sheep TMJ over time consistent with what has been found in humans.

Alport syndrome. Report of a case with severe maxillofacial manifestations

Alport syndrome (AS) represents a genetic cause of renal failure that affects about 1 in 5,000 Americans. In cases of AS, the problem resides on the X chromosome. Specific mutations to the gene cause defects in one of several subunits of Type IV collagen. Accumulation of collagen types V and VI, with subsequent abnormalities in the permeability and sclerosis of the kidney, leads to renal failure. Renal failure causes severe bone disease since the kidney processes vitamin D, which is necessary for calcium absorption from the intestine. Therefore, in a patient with chronic renal disease, vitamin D is not produced, resulting in a decrease in intestinal absorption of calcium and subsequent lower serum calcium levels. Furthermore, the decreased phosphate excretion by the kidney leads to elevation of plasma phosphate, which increases the amounts of parathyroid hormone required to move calcium from bone (secondary hyperparathyroidism) to maintain plasma calcium at a constant level and preserve an appropriate calcium-phosphorous ratio. We have described AS, reviewed the pathogenesis and presented an interesting extreme case with numerous craniofacial manifestations.

Osteosclerosis due to endemic fluorosis

Endemic water borne fluorosis is a public health problem in Isparta, a city located in southern Turkey. In order to investigate the association between osteosclerosis and fluorosis, we retrospectively screened the results of lumbar spine and femur neck bone mineral density (BMD) of 1500 patients who were examined before, for any reason in between 2001-2003. Sixty nine patients (67 females and 2 males, mean age 52.6+/-10.2) with vertebra T-scores>or=+2 were found only except a patient with osteoid osteoma in the femur neck (femur T-score+6.64). Thirty-four of the patients could be reexamined with lateral vertebra BMD and investigated for fluorosis and the other etiologic causes of osteosclerosis. Of 34 patients, 14 had either mottled tooth enamel or urine fluoride level greater than 1.5 mg/l. Other etiologic causes were hypothyroidism (2), hypoparathyroidism (1), history of lumbar fracture (1), use of retinoids (1), vitamin D (7), oral calcium preparations (9), and bisphosphanates (3). Lateral lumbar vertebral T-score was greater than+2 in 12 patients (35.3%). Femur T-score was greater than+2 in 7 patients (20.6%). Fourteen patients (41.2%) had lateral vertebral or femur T-score>or=+2. Five (35.7%) of these patients had signs of fluorosis, as discussed before. Mean body mass index of individuals with fluorosis was 36.4+/-7.9 and this result was significantly higher than other osteosclerotic subjects (31.6+/-4.4). In conclusion we believe that approximately one third of the osteosclerosis in our region was due to endemic skeletal fluorosis and obesity may enhance this osteosclerotic type bone changes in endemic fluorosis.

Pathogenesis of myelofibrosis with myeloid metaplasia: Insight from mouse models

Myelofibrosis with myeloid metaplasia or idiopathic myelofibrosis is a myeloproliferative disease. It is known to be a stem-cell disorder that leads to a secondary and reactive stromal reaction in the bone marrow microenvironment that is responsible for impaired haematopoiesis. Although progress has been made in the elucidation of the pathogenesis of idiopathic myelofibrosis, lack of suitable models has limited our understanding of the pathology. The aim of this chapter is to address recent inferred new insights in mouse models into the pathogenesis of osteomyelofibrosis. These insights outline the role of transforming growth factor-beta1 and osteoprotegerin in the promotion of myelofibrosis and osteosclerosis, respectively, paying special regard to the role of abnormal megakaryocyte proliferation and maturation.

Impairment of renal function in Schnitzler's syndrome

The list of multisystem diseases involving both kidney and skin is long and includes immunologic disorders like systemic lupus erythematodes, a broad variety of vasculitides, metabolic disorders like diabetes mellitus, and infectious diseases. The present work describes the first case of renal failure due to Schnitzler's syndrome, a rare entity characterized by the association of generalized chronic urticaria, monoclonal IgM gammopathy, and osteosclerotic lesions. The described patient experiences improvement of renal function after treatment with the chimeric anti-CD20 antibody rituximab, indicating that the impairment of renal function might be mediated by B-lymphocytes. Renal insufficiency is known to be a potential complication of hypocomplementemic urticarial vasculitis. The present case reveals that it can occur in normocomplementemic urticarial vasculitides as well. Schnitzler's syndrome is a rare but probably underdiagnosed syndrome. It should be considered in the differential diagnosis of rash and coincidental renal failure of unknown origin. Immunofixation of immunoglobulins constitutes the crucial diagnostic step, since monoclonal gammopathy is a constant clinical sign in this entity.

Osteoporosis and osteosclerosis in sickle cell/beta-thalassemia: the role of the RANKL/osteoprotegerin axis

Bone mineral density (BMD) was evaluated in 52 patients with HbS/beta-thalassemia. Seventeen (32%) patients had osteopenia/osteoporosis and 30 (57%) had osteosclerosis. Bone resorption was diminished in patients with osteosclerosis and increased in those with osteopenia/osteoporosis. The sRANKL/osteoprotegerin ratio was elevated in the osteosclerotic group. Osteoporosis patients had mild renal impairment and their BMD correlated with osteoprotegerin, and bone resorption markers. Osteosclerosis patients had multiple infarctions in the studied bones that led to reduced osteoclast activity and increased BMD. In conclusion, HbS/beta-thalassemia patients may develop osteopenia/osteoporosis mainly due to marrow expansion or osteosclerosis because of ischemia after a vaso-occlusive crisis. The RANKL/ osteoprotegerin axis participates in these phenomena.

Complications associated with segmentation of the maxilla: a retrospective radiographic follow up of 82 patients

The aim of the present study was to retrospectively examine the clinical and radiographic incidence and frequency of injuries to teeth and their surrounding tissues adjacent to interdental osteotomies in conjunction with segmentation of the maxilla. Vertical interdental osteotomies have been performed in combination with Le Fort I osteotomy for correction of various dento-facial deformities. All our orthognathic patients are followed prospectively in a standardized manner. Eighty-two consecutive patients who underwent dento-facial correction by segmented maxillary osteotomy alone or in combination with simultaneous mandibular surgery between 1992 and 1998 were included in the study. They were followed for up to 30 months postoperatively. A total of 158 interdental osteotomies were performed, involving a total of 316 teeth. Only a small number of complications such as osteolytic processes, marginal bone destruction, root resorption or mechanical injuries to the teeth were seen.

Reactive sclerosis: hyperintense appearance on T2-weighted magnetic resonance imaging

Osteosclerosis is defined as increased density of bone on X-ray imaging studies. It is known that osteosclerosis appears hypointense on both T1- and T2-weighted magnetic resonance imaging sequences. In this review, we present our experience in various sclerotic skeletal pathologies that appear hyperintense on T2-weighted magnetic resonance imaging. We emphasize the possible pathophysiological mechanisms that may cause this appearance, such as bone marrow edema and/or composition of newly formed bone.

Osteosclerosis in advanced chronic idiopathic myelofibrosis is associated with endothelial overexpression of osteoprotegerin

Advanced chronic idiopathic myelofibrosis (IMF) with osteosclerosis and increase and thickening of bone trabeculae is typically contrasted by the absence or sparse presence of osteoclasts. Because osteoclast formation can be inhibited by osteoprotegerin (OPG) we investigated OPG expression in IMF with severe fibrosis and osteosclerosis, which expressed significantly higher (up to 71-fold) OPG mRNA levels when compared with prefibrotic cellular IMF and control cases. The receptor activator of nuclear factor kappaB ligand (RANKL), a positive regulator of osteoclast differentiation and putative antagonist of OPG was overexpressed by up to 34-fold exclusively in advanced IMF. Case-specific calculation of the RANKL/OPG ratio in advanced IMF showed a wide range without significant differences when compared with the prefibrotic IMF and non-neoplastic haematopoiesis. Immunohistochemical detection of OPG protein revealed strong labelling of endothelial cells within proliferating vessels in fibrotic IMF and heterogeneously labelled megakaryocytes, and fibroblasts. Osteosclerosis and impaired osteoclast function in IMF appears to be associated with upregulated endothelial OPG expression but concomitant reduction of the antagonist RANKL could not be demonstrated. We conclude that osteosclerosis in IMF is associated with increased endothelial OPG expression without concomitant RANKL downregulation.

Osteosclerosis in idiopathic myelofibrosis is related to the overproduction of osteoprotegerin (OPG)

OBJECTIVE

The aim of this study is to investigate the mechanism of osteosclerosis in IMF in relation to OPG derangement.

METHODS

Plasma OPG level was assayed by OPG ELISA in 19 patients with IMF, 15 patients with other myeloproliferative disorders (MPDs), and 12 normal volunteers as controls and correlated with the degree of osteosclerosis. Furthermore, the level of OPG mRNA, in the cultured bone marrow stromal (BMS) cells of patients with IMF and anemia patients used as controls, in the presence or absence of TGF-beta1, was studied by real-time RT-PCR.

RESULTS

The present study showed that blood OPG level was significantly elevated in patients with IMF as compared to patients with other MPDs (p < 0.01) or normal volunteer controls (p < 0.05), and there was no significant difference in the level between patients with MPDs and controls. In addition, there was a positive correlation (r=0.67, p=0.04) between plasma OPG levels and the degree of osteosclerosis. There was no difference in the OPG mRNA in patients with IMF as compared with controls even on TGF-beta1 stimulation.

CONCLUSION

These results suggest that osteosclerosis in IMF may be related to overproduction of OPG and enhanced level of OPG is not due to the effect of TGF-beta1 on the BMS cells. It could be due to the effect of TGF-beta1 or other growth factors on cells other than BMS cells such as the osteoblasts.