Paget Disease of Bone

Chronic Diffuse Sclerosing Osteomyelitis of the Mandible: The Use of Bisphosphonates as a Treatment for a Rare and Challenging Condition

Chronic diffuse sclerosing osteomyelitis is a very rare condition, described as a non-suppurative, inflammatory disease of the bone and characterized by a proliferative endosteal reaction, which clinically reveals itself with cyclic pain of the jaw and swelling. We reported two clinical cases, where patients suffered recurrent swelling and pain at the mandible irradiating to the preauricular area, denying any previous trauma or significant medical history. Odontogenic causes were excluded. An initial treatment with antibiotics and NSAIDs temporarily relieved the symptoms without complete resolution, prompting further investigations. After a comprehensive array of diagnostic tools (X-rays, CT scans, scintigraphy, bone biopsy, serum markers), both patients were diagnosed with chronic diffuse sclerosing osteomyelitis of the mandible. Bisphosphonates (clodronate and zolendronate) with different treatment schemes were used to treat the condition, until a full recovery from symptoms was reported. Bisphosphonates could therefore represent an effective option in managing this rare but impactful condition. Further research is warranted to better understand the underlying mechanisms of the disease and to optimize treatment strategies.

The Superiority of Zoledronic Acid Over Risedronate for Paget's Disease: A 16-Year Experience at a Single Institution

Introduction Bisphosphonates are considered to be the treatment of choice for patients with active Paget's disease. The aim of this study was to record and assess the therapeutic effect in response to a single intravenous infusion of 5mg zoledronic acid or oral risedronate. Methods A retrospective observational study was conducted of 89 patients in Greek patients with active Paget's disease from a tertiary hospital in North Greece. Patients were treated with either a single intravenous infusion of 5mg zoledronic acid (1st group, n=46) or 30mg of risedronate per day for 60 days (2nd group, n=43). All patients received 1000mg of calcium and 400-800IU of calciferol daily. The primary outcome measure was to record the therapeutic response defined as the control of patients' symptoms and normalization of the biochemical markers of bone metabolism. The secondary outcome measures included the patient's quality of life which was evaluated by the questionnaire SF-36 and adverse events. Results Forty patients from the zoledronic acid group and 38 patients from the risedronate group, who reported pain at the beginning of the study, showed a significant degree of clinical improvement. All the patients in our study showed a therapeutic response at six months while the remission was persistent at 36 months. There was a statistically significant difference between pre-treatment basal results and values at the sixth and 36th months of treatment (p<0.001) between the two groups. Conclusion The study demonstrated the superiority of zoledronic acid over risedronate in patients with active Paget's disease.

Updates on Paget's Disease of Bone

Paget's disease of the bone is a prevalent bone disease characterized by disorganized bone remodeling; however, it is comparatively uncommon in East Asian countries, including China, Japan, and Korea. The exact cause still remains unknown. In genetically susceptible individuals, environmental triggers such as paramyxoviral infections are likely to cause the disease. Increased osteoclast activity results in increased bone resorption, which attracts osteoblasts and generates new bone matrix. Fast bone resorption and formation lead to the development of disorganized bone tissue. Increasing serum alkaline phosphatase or unique radiographic lesions may serve as the diagnostic indicators. Common symptoms include bone pain, bowing of the long bones, an enlarged skull, and hearing loss. The diagnosis is frequently confirmed by radiographic and nuclear scintigraphy of the bone. Further, bisphosphonates such as zoledronic acid and pamidronate are effective for its treatment. Moreover, biochemical monitoring is superior to the symptoms as a recurrence indicator. This article discusses the updates of Paget's disease of bone with a clinical case.

Bilateral Cemented Custom-Made Total Hip Arthroplasty in Paget's Disease with Femoral Cortical Thickening and Canal Narrowing

In this report, we present a case of a 57-year-old man complaining of pain in both his hips. Clinically, the patient reported lameness and reduction in the range of motion of the hips. Radiographic imaging showed a very narrow medullary femoral canal, confirmed by a computed tomography scan. In consideration of the narrowness of the femoral canal and cortex thickening, and due to the rarity of the clinical case, we opted to use a custom-made prosthesis. We performed total hip arthroplasty, initially on the right side. One year later, we repeated the procedure on the left side. One year after the last surgery, the patient reported well-being and continuous improvement in walking, with no complications. This case report highlights the features and the critical issues related to this kind of surgery in patients affected by Paget's disease of the bone and the importance of custom-made implants in challenging cases.

Catastrophic failure of cup revision hip arthroplasty due to undiagnosed Paget disease of bone: A case report

INTRODUCTION

Paget's disease of bone (PDB) is a localized chronic osteopathy, apparently not genetic in origin, and frequently diagnosed from incidental radiographic images. The disease is characterized by deformation, hypervascularity, and structural weakness of the bone and by changes in joint biomechanics. Most cases of PDB can be easily diagnosed from radiographic findings, but monostotic cases may be problematic and require invasive procedures.

PRESENTATION OF CASE

A 70-year-old woman had re-revision surgery for early catastrophic failure of an isolated cup revision hip arthroplasty because of undiagnosed PDB 21 years after the primary total hip arthroplasty. To identify the pathomechanism of early failure, we performed bone biopsy on the right iliac crest. Histopathological findings showed a mosaic pattern in the bone characteristic of PDB. Prior to the planned re-revision surgery, we treated the PDB with denosumab until the patient's serum level of alkaline phosphatase (ALP) was within the normal limits. Two months after denosumab treatment, we performed re-revision hip arthroplasty using a structural allograft and a Kerboull-type reinforcement device.

DISCUSSION

The delay in correct diagnosis of PDB was associated with the rapid destruction of pelvic bone. The preoperative use of antipagetic medication could decrease the risk of implant loosening and may be warranted to mitigate that risk.

CONCLUSION

In patients with a failed arthroplasty, thoughtful evaluation is warranted for preoperative antipagetic medication in order to reduce PDB activity and potentially decrease the risk of implant loosening. This paper offers some steps for such risk reduction in the workup before revision surgery.

Regulation of Osteoclast Differentiation at Multiple Stages by Protein Kinase D Family Kinases

Balanced osteoclast and osteoblast activity is necessary for skeletal health, whereas unbalanced osteoclast activity causes bone loss in many skeletal conditions. A better understanding of pathways that regulate osteoclast differentiation and activity is necessary for the development of new therapies to better manage bone resorption. The roles of Protein Kinase D (PKD) family of serine/threonine kinases in osteoclasts have not been well characterized. In this study we use immunofluorescence analysis to reveal that PKD2 and PKD3, the isoforms expressed in osteoclasts, are found in the nucleus and cytoplasm, the mitotic spindle and midbody, and in association with the actin belt. We show that PKD inhibitors CRT0066101 and CID755673 inhibit several distinct aspects of osteoclast formation. Treating bone marrow macrophages with lower doses of the PKD inhibitors had little effect on M-CSF + RANKL-dependent induction into committed osteoclast precursors, but inhibited their motility and subsequent differentiation into multinucleated mature osteoclasts, whereas higher doses of the PKD inhibitors induced apoptosis of the preosteoclasts. Treating post-fusion multinucleated osteoclasts with the inhibitors disrupted the osteoclast actin belts and impaired their resorptive activity. In conclusion, these data implicate PKD kinases as positive regulators of osteoclasts, which are essential for multiple distinct processes throughout their formation and function.

A Novel Rhein Derivative Modulates Bone Formation and Resorption and Ameliorates Estrogen-Dependent Bone Loss

Osteoporosis, an osteolytic disease that affects millions of people worldwide, features a bone remodeling imbalance between bone resorption by osteoclasts and bone formation by osteoblasts. Identifying dual target-directed agents that inhibit excessive bone resorption and increase bone formation is considered an efficient strategy for developing new osteoporosis treatments. Rhein, a natural anthraquinone, can be isolated from various Asian herbal medicines. Rhein and its derivatives have been reported to have various beneficial pharmacological effects, especially their bone-targeting ability and anti-osteoclastogenesis activity. Moreover, hydrogen sulfide (H₂ S) was reported to prevent ovariectomy- (OVX-) induced bone loss by enhancing bone formation, and sulfur replacement therapy has been considered a novel and plausible therapeutic option. Based on this information, we synthesized a rhein-derived thioamide (RT) and investigated its effects on bone resorption and bone formation in vitro and in vivo. It has been found that the RT-inhibited receptor activator of the nuclear factor-κB (NF-κB) ligand- (RANKL-) induced osteoclastogenesis and bone resorption in a dose-dependent manner. The expression of osteoclast marker genes was also suppressed by RT treatment. Furthermore, exploration of signal transduction pathways indicated that RT markedly blocked RANKL-induced osteoclastogenesis by attenuating MAPK pathways. However, RT treatment in an osteoblastic cell line, MC3TE-E1, indicated that RT led to an increase in the deposition of minerals and the expression of osteoblast marker genes, as demonstrated by Alizarin Red staining and alkaline phosphatase activity. Importantly, an OVX mouse model showed that RT could attenuate the bone loss in estrogen deficiency-induced osteoporosis in vivo with a smart H₂ S-releasing property and that there was a considerable improvement in the biomechanical properties of bone. Accordingly, our current work highlights the dual regulation of bone remodeling by the rhein-derived molecule RT. This may be a highly promising approach for a new type of anti-osteoporosis agent. © 2018 American Society for Bone and Mineral Research.

Response to Zoledronic Acid in Patients with Active Paget's Disease of Bone: A Retrospective Study

BACKGROUND

Traditionally, bisphosphonates are used to treat active Paget's disease of bone (PDB). Intravenous zoledronic acid (ZA) is the most effective treatment option leading to sustained remission.

OBJECTIVE

The primary objective of this study was to analyze the effect of intravenous ZA in patients with active PDB in a tertiary care center of India.

MATERIALS AND METHODS

Retrospective data of 13 patients with active PDB who received a single dose of 4 mg intravenous ZA at our institute from January 2011 to June 2017 were reviewed. Response to therapy was monitored clinically, biochemically by serum alkaline phosphatase (ALP), and scintigraphically by 99m-Technetium methylene diphosphonate bone scan.

RESULTS

All of our patients reported relief of bone pain. The mean duration of follow-up in our study was 35.2 ± 16.8 months. Serum ALP levels reduced significantly from 1190.9 ± 666.1 IU/L (n = 13) at baseline to 200.5 ± 68.4 IU/L (n = 13) at 6 months (P < 0.001). ALP level at 1 year was 174 ± 33.6 IU/L (n = 12), which remained stable till 36 months at 176.5 ± 50 IU/L (n = 8). This indicates that remission achieved by 6 months post ZA is sustained for at least 3 years. Scintigraphic ratio reduced from 9.6 [interquartile range (IQR) 5.25-18.2] at baseline to 2.7 (IQR 1.20-4.05) at follow-up (P < 0.001). Similarly, scintigraphic index of involvement reduced from 9.9 (IQR 5.6-28.5) at baseline to 3 (IQR 2-4) at follow-up (P = 0.018).

CONCLUSION

A 4 mg single dose of intravenous ZA results in clinical, biochemical, and scintigraphic response that is sustained for at least 3 years.

Clinical and Microstructural Findings in Paget Disease of the Entire Mandible

Paget disease of bone (PDB) is a chronic progressive bone disorder characterized by localized increased bone turnover and focal areas of woven bone formation. Although skull involvement is common, PDB very rarely affects the mandible. This report describes the clinical and histologic findings in a 75-year-old patient with PDB involving the mandible. Microstructural analyses showed an altered quality of the bone microstructure and calcium depletion of the affected bone. Differential diagnosis of PDB affecting the mandible is discussed.

Renal Cell Carcinoma Metastasized to Pagetic Bone

Paget's disease of the bone, historically known as osteitis deformans, is an uncommon disease typically affecting individuals of European descent. Patients with Paget's disease of the bone are at increased risk for primary bone neoplasms, particularly osteosarcoma. Many cases of metastatic disease to pagetic bone have been reported. However, renal cell carcinoma metastasized to pagetic bone is extremely rare. A 94-year-old male presented to the emergency department complaining of abdominal pain. A computed tomography scan of the abdomen demonstrated a large mass in the right kidney compatible with renal cell carcinoma. The patient was also noted to have Paget's disease of the pelvic bones and sacrum. Within the pagetic bone of the sacrum, there was an enhancing mass compatible with renal cell carcinoma. A subsequent biopsy of the renal lesion confirmed renal cell carcinoma. Paget's disease of the bone places the patient at an increased risk for bone neoplasms. The most commonly reported sites for malignant transformation are the femur, pelvis, and humerus. In cases of malignant transformation, osteosarcoma is the most common diagnosis. Breast, lung, and prostate carcinomas are the most common to metastasize to pagetic bone. Renal cell carcinoma associated with Paget's disease of the bone is very rare, with only one prior reported case. Malignancy in Paget's disease of the bone is uncommon with metastatic disease to pagetic bone being extremely rare. We report a patient diagnosed with concomitant renal cell carcinoma and metastatic disease within Paget's disease of the sacrum. Further research is needed to assess the true incidence of renal cell carcinoma associated with pagetic bone.

Case report of early aseptic loosening of total hip arthroplasty in monostotic paget disease, a diagnostic challenge

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Paget disease of bone can lead with severe bone destruction.

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Altered bone metabolism in patients with arthroplasties has a difficult diagnosis.

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We propose laboratory studies when severe boen destruction is seen in radiological images from hip implants.

Paget’s disease of bone is a localised chronic osteopathy which produces bone deformities, bone hypervascularity, structural weakness and altered joint biomechanics. Although radiological diagnosis of Paget's disease of bone is usually straightforward, monostotic cases may potentially raise specific problems which require invasive and expensive procedures such as bone biopsies. The pelvis and upper femur are frequently affected, resulting in disabling hip disease that may require total hip arthroplasty. We report a case of Paget disease of bone in an 84-year-old woman, which was initially identified as avascular necrosis of the hip, reason for which she underwent total hip arthroplasty. During follow up, the patient complained about hip pain and in a few months she was not able to walk because of an early loosening with bone destruction. Radiological and laboratory exams were carried out with normal results except for alkaline phosphatase (AP). After treatment with biphosphonates hip pain relieved but hip reconstruction was not possible. In this paper we present an early aseptic loosening of hip arthroplasty due to monostotic Paget’s disease of bone, a rare ethiology of loosening which poses particular diagnostic difficulties prompting an excessive use of excisional biopsies.