Fine structure of nuclei and cytoplasm of osteoclasts in Paget's disease of bone

Paget's disease of bone-genetic and environmental factors

Paget's disease of bone is generally diagnosed in individuals aged >50 years, usually manifests in one or several bones and is initiated by osteoclast-induced osteolytic lesions. Subsequently, over a period of many years, osteoblastic activity can result in sclerosis and deformation of bone. The prevalence of Paget's disease is highest in the UK and in countries where a large number of residents have ancestors from the UK. Currently, in many countries, the prevalence of the disorder has decreased. A considerable number of affected patients have a family history of Paget's disease and the disorder has an autosomal dominant pattern of inheritance but with incomplete penetrance. A large number of mutations in SQSTM1 (which encodes sequestosome-1; also known as ubiquitin-binding protein p62) seem to account for the susceptibility to develop Paget's disease in some families; the involvement of other genes is currently under investigation. In addition to a genetic cause, environmental factors have been proposed to have a role in the pathogenesis of Paget's disease. Although most evidence has been presented for measles virus as an aetiologic factor, some studies have not confirmed its involvement. The decreasing incidence of Paget's disease, which could be attributed to measles vaccination along with the measles virus nucleocapsid protein induction of Paget's disease lesions in transgenic mice, supports an aetiologic role of the virus.

Current perspectives on bisphosphonate treatment in Paget's disease of bone

Paget's disease of bone is a chronic metabolic bone disease with focal increase in bone turnover. The exact etiology of the disease is uncertain, although genetic and environmental factors are believed to be important. Bisphosphonate is the main class of medication being used to control disease activity via its antiresorptive effect. This review discusses the controversies concerning the use of bisphosphonates in the treatment of Paget's disease of bone, the efficacy of different bisphosphonates in controlling disease activity, and the possible rare side effects of bisphosphonates. Symptoms are the main indication for treatment in Paget's disease of bone. As treatment benefits in asymptomatic individuals remain controversial and nonevidence based, the decision to treat these patients should be individualized to their risk and benefit profiles. There are several trials conducted to evaluate and compare the efficacy of different regimes of bisphosphonates for treating Paget's disease of bone. Most trials used biochemical markers rather than clinical symptoms or outcomes as parameters for comparison. Zoledronate is an attractive option as it can achieve high rates of biochemical remission and sustain long duration of suppression by a single dose. Atypical femoral fracture and osteonecrosis of the jaw are two rare and severe side effects reported, possibly related to the use of bisphosphonates in patients with osteoporosis and malignancy-induced hypercalcemia. As the regimes of bisphosphonates used for treating Paget's disease of bone are different from those two diseases, the risks of developing these two possible side effects are expected to be very low, although this remains unknown. Vitamin D and calcium supplement should be given to patients at risk of vitamin D insufficiency when given zoledronate, as symptomatic hypocalcemia may develop. For those intolerant of bisphosphonates, subcutaneous calcitonin can be used for a limited period due to its associated risk of malignancy.

Benign fibro-osseous lesions of the craniofacial complex. A review

Benign fibro-osseous lesions of the craniofacial complex are represented by a variety of disease processes that are characterized by pathologic ossifications and calcifications in association with a hypercellular fibroblastic marrow element. The current classification includes neoplasms, developmental dysplastic lesions and inflammatory/reactive processes. The definitive diagnosis can rarely be rendered on the basis of histopathologic features alone; rather, procurement of a final diagnosis is usually dependent upon assessment of microscopic, clinical and imaging features together. Fibrous dysplasia and osteitis deformans constitute two dysplastic lesions in which mutations have been uncovered. Other dysplastic bone diseases of the craniofacial complex include florid osseous dysplasia, focal cemento-osseous dysplasia and periapical cemental dysplasia, all showing a predilection for African descent individuals; although no specific genetic alterations in DNA coding have yet to be uncovered and most studies have been derived from predominant high African descent populations. Ossifying fibromas are neoplastic lesions with four subtypes varying with regard to behavior and propensity for recurrence after surgical excision. The clinicopathologic and molecular features of this unique yet heterogeneous group of diseases are reviewed.

Paget's disease of bone in a Chinese patient: A case report and review of the literature

Although it is fairly common in the Western countries, Paget's disease of bone is very rare in Chinese individuals. Through an extensive literature search, only 8 Chinese Paget's disease cases were found in the English language literature and all were reported in local medical journals of Asia that may not be accessible to international readers. To enhance the awareness of the rarity of Paget's disease in Chinese individuals to pathologists worldwide, we present a case of Paget's disease in a 54-year-old Chinese male. We also compare the clinical features of Paget's disease reported in Chinese patients to Paget's disease reported in the Western countries. No familial cases and no malignant transformation are found in the reported cases of Paget's disease in Chinese patients. In addition, more often skull involvement, higher frequency of monostotic cases, and symptomatic cases are observed in this limited number of Paget's disease cases reported in Chinese individuals.

Paget's disease and fibrous dysplasia

Paget's disease and fibrous dysplasia are benign disorders that can involve the temporal bone and skull base. They commonly lead to otolaryngologic symptoms such as impingement of cranial nerves or the orbit or blockage of the external auditory canal or paranasal sinuses, although they can often be a challenge to diagnose because of their insidious presentation. Their benign nature and common presentation within the difficult-to-access confines of the skull base should lead the clinician to exercise caution in their treatment, reserving surgical intervention for either diagnosis or the relief of symptoms. As a better understanding of the etiology of these conditions develops and new pharmacotherapeutic agents are tested, it is likely that physicians will be able to turn to medical rather than surgical techniques to treat these disorders.

Paget disease of bone: mapping of two loci at 5q35-qter and 5q31

Paget disease of bone is characterized by focal increases of the bone-remodeling process. It is the second most common metabolic bone disease after osteoporosis. Genetic factors play a major role in the etiology of Paget disease of bone, and two loci have been mapped for the disorder: PDB1 and PDB2. The gene(s) causing the typical form of the disorder remains to be characterized. To decipher the molecular basis of Paget disease of bone, we performed genetic linkage analysis in 24 large French Canadian families (479 individuals) in which the disorder was segregating as an autosomal dominant trait. After exclusion of PDB2, a genomewide scan was performed on the three most informative family nuclei. LOD scores >1.0 were observed at seven locations. The 24 families were then used to detect strong evidence for linkage to chromosome 5q35-qter. Under heterogeneity, a maximum LOD score of 8.58 was obtained at D5S2073, at straight theta= .1. The same characteristic haplotype was carried by all patients in eight families, suggesting a founder effect. A recombination event in a key family confined the disease region within a 6-cM interval between D5S469 and the telomere. The 16 other families, with very low conditional probability of linkage to 5q35-qter, were further used, to map a second locus at 5q31. Under heterogeneity, a maximum LOD score of 3.70 was detected at D5S500 with straight theta=.00. Recombination events refined the 5q31 region within 12.2 cM, between D5S642 and D5S1972. These observations demonstrate the mapping of two novel loci for Paget disease of bone and provide further evidence for genetic heterogeneity of this highly prevalent disorder. It is proposed that the 5q35-qter and 5q31 loci be named "PDB3" and "PDB4," respectively.

Paget's disease of bone: a disease of the osteoclast

Paget's disease is a chronic focal disease of the skeleton that affects up to 2-3% of the population over the age of 60 years. There is a genetic predisposition for Paget's disease, with one predisposition locus identified on chromosome 18q-21-22. Osteoclasts and osteoclast precursors from Paget's patients are abnormal and appear hyperresponsive to 1,25(OH)2D3 and RANK ligand and contain paramyxoviral transcripts (Fig. 1). The basis for the abnormalities detected in Paget's disease and the role that the paramyxoviruses may play in this disease are still unclear.

Genetic linkage of Paget disease of the bone to chromosome 18q

Paget disease is a common bone disease characterized by abnormal osteoclasts that are large, multinucleated, and overactive and that contain paramyxovirus-like nuclear inclusions. There is evidence for a major genetic component to Paget disease, with up to 40% of patients having affected first-degree relatives; however, the locus (loci) and gene(s) involved are unknown. Another bone disorder, familial expansile osteolysis (FEO), although extremely rare, also is characterized by similar osteoclast abnormalities but has an earlier age at onset and a more aggressive clinical progression. The causative gene for FEO has been localized to a region of human chromosome 18q. On the basis of the presence of similar clinical findings and of viral-like nuclear inclusions in osteoclasts, we hypothesized that FEO and Paget disease are allelic versions of the same locus. Therefore, a large kindred with a high incidence of Paget disease was examined to determine if Paget disease was linked to genetic markers in the same region of chromosome 18 as that for FEO. Our analysis yielded a two-point LOD score of 3.40, with the genetic marker D18S42, a marker tightly linked to the FEO locus. This demonstrates that the gene(s) responsible for FEO and that for Paget disease are either closely linked or the same locus.

Paget's disease and osteoclast biology

Paget's disease is the most exaggerated example of bone remodeling in which abnormal osteoclastic bone resorption remains coupled to new bone formation. There are abnormalities in the stages of osteoclast development, and studies in Paget's disease have suggested a major role for IL-6 in human osteoclast activity. The pathophysiologic basis for these abnormalities is not clearly defined, except that the primary cellular abnormality resides in the osteoclast. Many important questions about the pathophysiology of Paget's disease still remain to be answered, including: (1) What is the identity of the virus in pagetic osteoclasts?; (2) Are Paget's patients in different geographical locales harboring a similar virus in their osteoclasts, or can different paramyxoviruses induce Paget's disease?; (3) How is the virus maintained and propagated for many years, so that it can be expressed in the osteoclast, a cell with a finite lifespan?; and (4) Since Paget's disease has a very high familial tendency, with up to 40% of patients having an affected relative, what is the genetic locus associated with Paget's disease, and does this genotype result in an increased propensity for hematopoietic cells such as the osteoclast to harbor paramyxoviruses? The application of the techniques of molecular and cell biology to Paget's disease should provide answers to some of these questions and give important insights into the normal bone remodeling process.

The effect on chick osteoclasts of infection with paramyxoviruses

The detection of virus in osteoclasts from Pagetic patients is now well known, but it has yet to be shown convincingly that the presence of virus in Pagetic osteoclasts influences their behaviour. In this study, osteoclasts from embryonic chick tibiae were infected with canine distemper virus or measles virus and compared with mock-infected controls. Infection was confirmed using virus-specific fluorescent antibodies. It was found that virus infection did not alter osteoclast morphology or tartrate-resistant acid phosphatase (TRAP) activity. Both infected and mock-infected osteoclasts produced resorption pits on bovine bone slices; these could be divided into two distinct size classes with a computer-based measuring system. Virus infection significantly increased the proportion of the larger size class of resorption pit. These results suggest that virus infection can increase bone resorption by osteoclasts, lending further support to the hypothesis that viruses play a role in Paget's disease of bone.

Viral behavior of paracrystalline inclusions in osteoclasts of Paget's disease of bone

Fresh tissues from six patients with Paget's disease of bone were examined ultrastructurally to investigate whether the characteristic paracrystalline inclusions in pagetic osteoclasts revealed viral behavior. These inclusions appeared as microfilamentous aggregates in both nuclei and cytoplasm of the osteoclasts in all six cases. The filamentous elements of the inclusions with a diameter of 11-15 nm showed tubular structures with a central electron-lucent zone measuring 5-7 nm in diameter. Viral budding-like structures containing these inclusions were found at the peripheral cytoplasm or cell processes in the ruffled border of some pagetic osteoclasts in two cases. The inclusions in the budding-like structures were often arrayed in a parallel fashion on the cytoplasmic side of the cell membranes of extruded cytoplasm or cell processes. Virion-like particles were also found in the extracellular spaces of the ruffled border. Marked nuclear degeneration was often seen in pagetic osteoclasts of three cases, although other nuclei in the same osteoclasts appeared normal. The degenerated nuclei showed nuclear ring formation where destroyed nuclear membranes were seen and disappearance of nuclear matrices was noted. Since the modifications were always associated with the accumulation of abundant inclusions, they were probably caused by the inclusions. These findings suggested that the inclusions showed viral behavior in pagetic osteoclasts, and that the nuclear modifications were caused by virus infection.

Canine bone marrow cell cultures infected with canine distemper virus: an in vitro model of Paget's disease

We have previously shown that the canine paramyxovirus, canine distemper virus (CDV), is a possible aetiologic agent in Paget's disease of bone and in the canine bone disorder, metaphyseal osteopathy. More recently, we have examined the effects of CDV on the formation of multinucleated, tartrate resistant acid phosphatase positive, calcitonin receptor positive, osteoclast-like cells in cultures of canine bone marrow mononuclear cells, and shown that both in vitro and in vivo infection with CDV produced a dose dependent increase in the number and size of osteoclast-like cells. We have now extended these results to show that CDV infection induces interleukin-6 and c-Fos mRNA in these cells, similar to our recent findings in pagetic bone cells. These results further support the hypothesis that CDV might be involved in the aetiopathogenesis of Paget's disease and metaphyseal osteopathy and suggest that canine marrow culture systems will prove useful as an in vitro model to examine the disease processes in more detail.

Generation of multinucleated osteoclast-like cells from canine bone marrow: effects of canine distemper virus

Recent evidence has implicated canine distemper virus (CDV) as a possible aetiologic agent in Paget's disease of bone and the canine bone disorder, metaphyseal osteopathy. We have therefore examined the effects of CDV on the formation of multinucleated osteoclast-like cells in cultures of canine bone marrow mononuclear cells. Marrow cells from a distemper-infected dog and from five uninfected dogs were cultured in the presence of 1 alpha, 25-(OH)2 vitamin D3 and the number of tartrate resistant acid phosphatase positive multinucleated cells (MNCs) was determined. The presence of calcitonin (CT) receptors was confirmed by autoradiography with 125I-labeled human CT. Cultures from the distemper-infected dog contained a higher level of MNCs than those from the normal dogs. The in vitro addition of CDV to the cultures from all the dogs produced a dose-dependent increase in the number of MNCs, and an increase in size of these cells in the cultures from the infected dog. Cells infected with CDV were hyperresponsive to 1 alpha,25-(OH)2 vitamin D3. The presence of the virus in the relevant samples was confirmed using molecular techniques. In situ hybridization studies also revealed a significant increase in the level of infection following in vitro addition of the virus to the culture from the distemper-infected dog, suggesting that further infection had taken place. Resorption pits were formed on bone slices, although the number of pits was not significantly altered by viral infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Interleukin-6, IL-6 receptor, and IL-6 nuclear factor gene expression in Paget's disease

The cytokine interleukin-6 (IL-6) is considered an important regulator of bone cell function and may play a central role in bone disease states characterized by increased bone remodeling, such as Paget's disease. Indeed, recent in vitro data suggest that IL-6 may be an autocrine/paracrine factor for pagetic osteoclasts. However, its expression and role in vivo are not known. Using in situ hybridization we investigated the spatial localization of expression of IL-6, IL-6 receptor (IL-6R), and the transcription factor (NF-IL-6) in pagetic bone. Our results show that osteoblasts in the normal remodeling bone of osteoarthritis (controls) and in Paget's disease express IL-6, IL-6R, and NF-IL-6 genes with higher levels of IL-6 and IL-6R mRNA in pagetic bone. Osteoclasts in both osteoarthritic and pagetic bone express IL-6R mRNA and NF-IL-6, but only pagetic osteoclasts expressed IL-6, suggesting that in Paget's disease IL-6 can act as an autocrine factor on osteoclasts. These results provide evidence for a major role of the IL-6 regulatory pathway in the phenotype of the pagetic osteoclasts and lead us to suggest a model linking possible paramyxovirus infection and IL-6 regulation in the pagetic osteoclast.

Paget's disease of bone: current concepts in pathogenesis and treatment

Recent advances have been made in understanding the aetiology, diagnosis and treatment of Paget's disease of bone (osteitis deformans). The role of viruses in the pathogenesis of the disease has been extensively investigated, although no causative link has yet been demonstrated between infective agents and Paget's disease. Recent advances in the diagnosis of the disease have been made with increasing usage of radionucleotide imaging to determine the extent and distribution of the lesions. Treatment options have been extended with the emergence of the biphosphonates as potential main line therapeutic agents.

Absence of paramyxovirus RNA in cultures of pagetic bone cells and in pagetic bone

It has been proposed that Paget's disease of bone is caused by the infection of bone cells with one or several paramyxoviruses. In this study we used the polymerase chain reaction (PCR), which allows the detection of very low levels of a target nucleic acid sequence, to study cultures of pagetic bone cells and samples of pagetic bone. Oligonucleotide primers were designed to flank a sequence of the nucleocapsid genome of measles virus and canine distemper virus (CDV). Within this fragment there were contrasting restriction endonuclease sites specific to measles or CDV that allowed identification of the original template. We were unable to detect paramyxovirus RNA in four strains of human bone cells outgrown from pagetic bone and one strain derived from an uninvolved site of a patient with Paget's disease. Furthermore, paramyxovirus sequences were not detected in cDNA prepared from six samples of pagetic bone biopsies. The work presented here further questions the role of measles and CDV in the abnormal remodeling observed in Paget's disease.

Dogs, distemper and Paget's disease

The cause of Paget's disease is still unknown, despite many years of intensive study. During this time, evidence has sporadically emerged to suggest that the disease may result from a slow viral infection by one or more of the Paramyxoviruses. More recently, epidemiologic and molecular studies have suggested that the canine paramyxovirus, canine distemper virus, is the virus responsible for the disease. If true, then along with rabies, this would be a further example of a canine virus causing human disease. Studies in the natural host have now supported these findings. Further investigations have proposed that the bony abnormalities seen in Paget's disease are due to the effects of the virus on osteoclastic interleukin-6 and c-FOS production, possibly via the transcription factor NF-kappa B.

PCR detection of cytokines in normal human and pagetic osteoblast-like cells

We investigated the expression of cytokine transcripts in osteoblast-like cells derived from explants of pagetic and normal bone. A reverse transcription-linked PCR was used that allowed the simultaneous analysis of a range of cytokines. Normal osteoblast-like cells were found to contain the transcripts for IL-1 beta, IL-6, and TGF-beta 1. For the first time we detected in bone cells the two other mammalian isoforms of TGF-beta, beta 2, and beta 3. Furthermore, we have also identified mRNA for IL-3 and the novel chemotactic factor, IL-8. Using this sensitive technique it was not possible to detect mRNA for IL-1 alpha, IL-2, IL-4, IL-5, IL-7, TNF-alpha, or interferon-gamma. The human osteosarcoma cell line Saos-2 also showed a similar pattern of expression of these cytokines to primary osteoblast-like cells, with the exception that TNF-alpha was also identified. Cells isolated from pagetic bone showed essentially the same profile of cytokine expression as normal bone except that TNF-alpha was also detected in two of four samples. The cytokine profile of successive populations of cells harvested from one explant culture at 9, 22, and 57 days showed a consistent pattern of cytokine expression, demonstrating the phenotypic stability of the osteoblast-like cells in long-term cultures.

Canine distemper virus transcripts detected in the bone cells of dogs with metaphyseal osteopathy

Using the technique of in situ hybridisation, we have recently extended our observations that canine distemper virus (CDV) is present in the bone cells of patients with Paget's disease, and have shown that CDV is also detectable in the bone cells of dogs that are naturally infected with the virus. Since hybridisation was localised to bone cells within the metaphyses of the affected dogs, we investigated the possibility that CDV might be involved in the canine metaphyseal bone disorder, metaphyseal osteopathy. Bone samples from three cases of metaphyseal osteopathy were examined for the presence of the CDV nucleocapsid (CDV-N) gene and the measles virus nucleocapsid (MV-N) gene, using 35S-labelled sense and antisense riboprobes. As with our previous findings in Paget's disease of bone, only the antisense probe was found to hybridize to the osteoblasts and osteoclasts within the affected metaphyses. No hybridisation was seen with the CDV-N sense and MV-N probes in any of the samples tested. Bone samples were also taken from one of the cases to check for the presence of the CDV-N gene using the polymerase chain reaction (PCR). Our findings with in situ hybridisation were confirmed by PCR and subsequent Southern blotting and probing with a 32P-labelled cDNA probe. The detection of CDV RNA within the bone cells of dogs with metaphyseal osteopathy suggests that this virus may be a cause of the disease and provides further, indirect evidence that CDV might be responsible for the bony abnormalities seen in Paget's disease of bone.

Canine distemper virus transcripts sequenced from pagetic bone

Paget's disease is a chronic disease of the skeleton which is believed to be caused by a persistent virus of the paramyxovirus family. There is still conflict as to the precise identity of the virus(es) involved in causing this disease. Our previous results using in situ hybridisation have implicated distemper as a possible cause of this disease. In order to confirm these results, we have reverse transcribed RNA from pagetic bone and have specifically amplified for distemper and measles sequences using the polymerase chain reaction (PCR) technique. We have found that 8/13 of the patients examined had distemper and 1/10 cases had measles nucleic acids sequestered within their bone cells. One individual was found to have both viruses sequestered in his bone cells. Dideoxy sequencing of the distemper virus PCR products revealed 2% base pair changes in the nucleic acid sequences relative to the Onderstpoort strain of canine distemper. We can conclude that in Paget's disease, canine distemper and possible other paramyxoviruses reside in bone cells and that the persistent nature of the virus may be due to mutations in the viral genome.

Paramyxovirus-like nuclear inclusions identical to those of Paget's disease of bone detected in giant cells of primary oxalosis

Nuclear inclusions, identical to those characteristic of Paget's disease of bone, were observed in giant cells in four of eight cases of primary oxalosis. The giant cells containing nuclear inclusions were directly involved in phagocytosis of large oxalate crystals in the context of typical foreign body granulomas in the bone marrow. Cytochemically, all of them exhibited strong tartrate-resistant acid phosphatase activity, and a proportion of them also tartrate-resistant acid ATPase. The inclusions consisted of typical arrays of filamentous material as described in Paget's disease, admixed with variable proportions of electron-dense material closely reminiscent of nucleolar pars fibrillaris and fibrillary centres. These data indicate: (a) the occurrence of Paget-like inclusions in a bone disease unrelated to Paget's disease, not causally related to viral infection, and resulting from an inborn metabolic derangement; and (b) the occurrence of Paget-like inclusions in foreign body giant cells as opposed to osteoclasts. We suggest that the occurrence of paramyxovirus-like nuclear inclusions in either osteoclasts or giant cells may represent an epiphenomenon of cell fusion and giant cell formation whenever appropriate stimuli act on latently infected precursor cells. Furthermore, our data suggest that nucleoli may represent the specific site of virus-like inclusion formation.

Detection of canine distemper virus in bone cells in the metaphyses of distemper-infected dogs

In the light of recent evidence implicating canine distemper virus (CDV) as a possible etiologic agent in Paget's disease of bone, we thought that it would be of interest to examine distemper-infected bone in the natural host. Samples from the long bones, spleen, and bladder of four distemper-infected and three uninfected dogs were examined for the presence of CDV nucleocapsid and phosphoprotein genes and the measles virus (MV) nucleocapsid gene using the technique of in situ hybridization with radioactively labeled riboprobes. Two of the four distemper-infected dogs showed strongly positive hybridization with both of the CDV probes. The signal was present in marrow cells, in osteoblasts, in osteocytes, and particularly in osteoclasts. No hybridization was seen over the cartilage cells of the growth plate, and there was a clear line of demarcation at the point of invasion of osteoclasts and vascularization. The spleen and bladder samples from infected dogs also showed positive hybridization. There was no hybridization with the MV probe in any of the distemper-infected tissue. Samples from the uninfected dogs showed no evidence of hybridization with either the CDV or MV probes. These results show that CDV can infect bone cells of the natural host and provide further support for the theory that CDV may play a role in human Paget's disease of bone.

Interleukin 6. A potential autocrine/paracrine factor in Paget's disease of bone

Pagetic osteoclasts are greatly increased in number and size and have increased numbers of nuclei per cell compared to normal osteoclasts. The mechanisms responsible for enhanced osteoclast formation in Paget's disease are unknown. We have used our recently described model system for pagetic osteoclast formation to evaluate culture media conditioned by these atypical multinucleated cells (MNC) to determine if pagetic osteoclasts produce an autocrine or paracrine factor that enhances osteoclast formation. Conditioned media from long-term bone marrow cultures from patients with Paget's disease stimulated osteoclast-like MNC formation in normal marrow cultures. At least part of this activity could be ascribed to interleukin 6 (IL-6). In contrast, conditioned media from normal marrow cultures contained lower levels of IL-6 and did not stimulate formation of osteoclast-like MNC. 7 of 8 bone marrow plasma samples taken from involved bones and 18 of 27 peripheral blood serum samples from Paget's patients had high levels of IL-6. Normal marrow plasma and peripheral blood serum had no or very low levels of IL-6. These results suggest that IL-6 produced by marrow and/or bone cells in patients with Paget's disease may be an autocrine/paracrine factor for pagetic osteoclasts.

[Current aspects of Paget's bone disease]

The clinical and laboratory signs, as well as the imaging and course of Paget's disease of bone, are now well known. This chronic and usually benign disease is characterized by excessive remodelling of bone tissue, associated with an increase, sometimes considerable, of osteoclast resorption and osteoblast formation activities. Studies conducted during the last two decades were aimed at determining more precisely some aspects of the disease, notably: its epidemiological aspect and in particular its geographical distribution; its aetiological aspect using data obtained from electron microscopy, immunocytology and hydridization in situ, which has led to the hypothesis of a viral origin, and finally its therapeutic aspect with the recent introduction of truly effective treatments such as calcitonin and biphosphonates.

Canine distemper virus localised in bone cells of patients with Paget's disease

The technique of in situ hybridisation was applied using radioactively labelled riboprobes to examine for the presence of canine distemper (CDV) and measles (MV) RNA in Paget's disease of bone. The results indicate that in 41% of Paget's patients, CDV RNA could be detected in osteoclasts, osteoblasts, and osteocytes, but not in controls. In contrast, RNA to the measles virus was not detected. We suggest that CDV may in some cases play a role in the aetiology of Paget's disease.

Atypical multinucleated cells form in long-term marrow cultures from patients with Paget's disease

Although Paget's disease is the most flagrant example of a primary osteoclast disorder, little is known of osteoclast biology in this disease. In this report we have studied the formation of cells with the osteoclast phenotype in long-term cultures of marrow mononuclear cells derived from patients with Paget's disease, and compared these with similar cells formed in long-term marrow cultures from normal individuals, and with osteoclasts present in pagetic bone. Osteoclasts formed in pagetic marrow cultures resembled osteoclasts present in pagetic bone, but were distinctly different from osteoclasts formed in normal marrow cultures. Osteoclast formation was 10-20-fold greater in pagetic marrow cultures than in normal cultures. The multinucleated cells formed in cultures of pagetic marrow were much larger in size, were hyperresponsive to 1,25(OH)2 vitamin D, had more nuclei per cell, had increased levels of tartrate-resistant acid phosphatase activity and had ultrastructural features which were not seen in multinucleated cells formed from normal marrow mononuclear cells. These pagetic marrow-derived multinucleated cells formed large resorption lacunae on calcified matrices and cross-reacted with monoclonal antibodies which preferentially bind to osteoclasts. The multinucleated cells formed from marrow obtained from uninvolved sites in Paget's patients also displayed these abnormal features.

Sarcomatous degeneration in Paget's bone disease

The authors report 12 cases (8 men and 4 women) of sarcomatous degeneration in Paget's bone disease, with an average age of 72.3 years. Sarcomatous degeneration occurred often in polyostotic Paget's disease, and osteitis deformans was seen in 4 cases. Femur and pelvis were the most affected bones. Pain was a constant feature, whereas tumefaction and fracture were less common. Osteolytic lesions were more frequent than condensed or mixed lesions and radiological signs of malignancy were usually found. Seven cases were histologically classified as osteogenic sarcoma and 3 cases as fibrosarcoma. Electron microscopy was performed on 2 osteogenic sarcomas and in 1 case revealed microcylindrical inclusions in Pagetic osteoclasts and in multinucleated giant tumor cells, but none in mononucleated tumor cells. The average survival time for the patients in this study was only 4.5 months.

Frequency and diagnostic value of the virus-like filamentous intranuclear inclusions in giant cell tumor of bone, not associated with Paget's disease. A study of 43 cases

This paper deals with the paramyxovirus-like intranuclear inclusions observed in giant cells tumours of bone (GCTB). Twenty-one (49%) of 43 cases of GCTB (1977-1985), either fresh and/or cultured, show these ultrastructural inclusions. Fifty samples of various bone lesions in which giant cell lesions occurred, including aneurysmal cysts, hyperparathyroidism, osteoblastoma, human and rat osteopetrosis, GCT of tendon sheaths, and non skeletal granuloma were used as controls. These, together with 20 samples of normal bone (osteoclasts) did not contain intranuclear or intracytoplasmic viral inclusions.

A survey of respiratory syncytial virus and parainfluenza virus type 3 neutralising and immunoprecipitating antibodies in relation to Paget disease

The aetiology of Paget disease of bone has not been established but certain features have suggested involvement of a parainfluenzalike virus. To seek further evidence of the possible role of paramyxoviruses in Paget disease we have surveyed the presence of neutralising and immunoprecipitating antibodies to both respiratory syncytial virus and parainfluenza virus type 3 in the sera of patients attending a bone disease clinic. These two viruses were implicated by the sporadic observation of viral antigen in individual nuclei of osteoclasts in Paget disease bone lesions. A total of 315 samples were obtained from 177 patients attending the clinic during 1 year. Thirty-six of the patients had confirmed Paget disease and the remainder other conditions. All sera possessed neutralising activity to both viruses. The mean titres for each virus were similar in patients with Paget disease and those with other conditions whether matched or not. In the case of respiratory syncytial virus the neutralising titres were distributed closer to the mean in the Paget group and showed little variation in repeat samples taken over periods of up to 1 year in contrast to the greater variability of the control group. The antigenic specificity of 20 age- and sex-matched sera from each group was examined by immunoprecipitation. No significant differences were observed between Paget and non-Paget patients. These results do not provide confirmation of involvement of either virus in Paget disease, but the serological data suggest that persistent infection with respiratory syncytial virus can occur.

Ultrastructural study of intranuclear tubulo-filaments in a giant cell tumour of bone in a patient with Paget's disease

The intranuclear tubulo-filaments appearing in giant cells were studied ultrastructurally in a giant cell tumour of bone arising in a patient with Paget's disease. Serial sections have shown the presence of invaginating nuclear membrane around these apparent intranuclear tubulo-filaments, thus segregating these structures from the nuclear substance proper. Further sectioning showed clear continuity between these tubulo-filaments and the rest of the cytoplasmic contents. It is found that these apparent intranuclear tubules represent pseudo-inclusions rather than true intranuclear inclusions.

Viral aetiology of Paget's disease of bone: a review

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Ultrastructural features of the osteoclasts from Paget's disease of bone in relation to a viral aetiology

The ultrastructure of the osteocytes, osteoblasts, osteoclasts, haemopoietic and other connective tissue cells was examined in 27 biopsies from 22 patients with Paget's disease of bone. Electron microscopy showed characteristic nuclear and cytoplasmic inclusions in the osteoclasts of all of the 25 biopsies exhibiting histological evidence of Paget's disease. Such inclusions were absent from all the other types examined. The intranuclear inclusions consisted of stacked rows or complex whorls of tubular filaments with an individual filament diameter of 12-15 nm, often arranged in a paracrystalline array. The frequency of occurrence of inclusions in the osteoclasts and their individual nuclei measured quantitatively in 18 of the biopsies was related to the histological severity of the disease process. The similarity of the observed inclusions to those of paramyxovirus inclusion bodies (particularly measles) support the hypothesis that Paget's disease is a slow virus infection.

Comparison of the ultrastructure of a malignant tumor of the mandible containing giant cells with Paget's disease of bone

Distinction between lesions of the jaws containing giant cells can be difficult. This study reports the results of the study of the ultrastructure of 30 patients with Paget's disease in comparison with a patient diagnosed as having malignant giant cell tumor of the mandible. The ultrastructure of the malignant giant cell tumor of the mandible was found to contain nuclear inclusions morphologically identical with the 12-15 nm tubules characteristic of the nuclei of osteoclasts in Paget's disease of bone. No clinical or laboratory signs of Paget's disease was found in this patient. A search of the literature failed to produce reports of identical nuclear inclusions in soft tissue giant cell tumors, osteosarcomas, reparative granulomas containing giant cells or in osteitis fibrosa cystica. Such nuclear inclusions have been reported in benign giant cell tumors of bone, one another in malignant giant cell tumor and cases of polymyositis. These observations raise the question of a possible virus associated with the tumor since there are recent reports of immunological evidence for the presence of a virus in Paget's disease, and viruses have been suspected in polymyositis.

Immunohistological demonstration of respiratory syncytial virus antigens in Paget disease of bone

Respiratory syncytial virus antisera have been found to produce a positive immunohistologic response in osteoclasts in bone sections or in cells cultured from Paget disease lesions in 12 out of 12 patients tested. These experiments were carefully controlled by several means. Use of experimentally infected cells served as positive controls. Adsorption of antisera on human bone powder and KB cells did not remove the specific immunologic stain, but adsorption of the antisera by the virus did. Negative results were also obtained in osteoclasts of patients with primary or secondary hyperparathyroidism. In addition, negative results in specimens of Paget disease were found with antisera to measles; parainfluenza 1, 2, and 3; influenza A, B and C; rubella; and herpes simplex. These results are consistent with the hypothesis that the nuclear and cytoplasmic inclusions in the osteoclasts of Paget disease are a result of viral activity.

Towards a viral etiology for Paget's disease of bone

The etiology of Paget's disease of bone has long remained obscure. The recent discovery in electron microscopy of specific inclusions in the cytoplasm and nuclei of osteoclasts in tissue from patients with Paget's bone disease has been the starting point of investigations into a possible viral origin. The inclusions, made up of microcylinders, described by several authors as being found only in osteoclasts in Paget's bone disease, present a close morphological analogy with nucleocapsids of paramyxovirus of the measles group. Immunocytological methods have provided a complementary approach to the problem. It has been demonstrated that the osteoclasts in Paget's bone disease contain antigenic material which reacts positively with sera containing measles antibodies. Both the morphological and the immunocytological evidence is strongly in favour of a viral etiology for Paget's bone disease.

Cell cultures from bone affected by Paget's disease

Cells obtained from Paget's bone specimens were maintained in culture for up to 8 1/2 months. The cells had several characteristics of bone cells including the presence of alkaline phosphatase, acid phosphatase, or succinic dehydrogenase as demonstrated histochemically. Electron microscopy revealed nuclear inclusions similar to those found in the osterclasts of Paget's disease in 4 or 11 cultures. Immunohistology utilizing specific antisera demonstrated the presence of respiratory syncytial virus antigen(s) in 7 or 7 patients. Negative results were obtained with antisera to a variety of paramyxoviruses.