Knee pain An uncommon cause

Transcription

1 Knee pain An uncommon cause Dr.Nihal Gunatilake - Consultant Rheumatologist - CSTH Dr.Dinesha Sudusinghe - Registrar Medicine

2 Case history Mrs.J, 57 years P/C B/L knee pain for 2 years H/P/C Apparently healthy. Progressive bilateral knee pain for the last 2 years. Pain increases with activity and towards the end of the day. Pain worst at night. No associated swelling. Neck pain and lower backache for the last 6 months. No small joint pain or stiffness.

3 Case history No heel pain, red eyes or scaly skin rash. Did not have alteration of bowel habits or lower urinary tract symptoms. LOA and LOW without evening pyrexia and drenching night sweats. No pleuritic chest pain, chronic cough or contact history of TB. Denied palpitation, easy fatiguability suggestive of anaemia. Menopause 12 years back. No family history of arthritis or malignancy. PMHx - Not significant. Social Hx - Mother of three children. Activities of daily living maintained (slowed).

4 ?? Diagnosis Middle aged female 1. KJ osteoarthritis Non inflammatory KJ pain - Primary - Secondary LOA and LOW 2.?? Occult malignancy

5 Examination Not pale. No LN, clubbing No goiter/breast lumps

6 Examination Cardiovascular Respiratory - BP-130/90mmHg - No added sounds - PR- 88 bpm - Apex - normal position - No murmur

7 Examination Abdomen - No organomegaly Neurology - Cranial nerves - normal - No motor weakness - No sensory impairment

8 Musculoskeletal examination B/L KJ No deformity No swelling Full range of movements Early osteoarthritis Crepitus + Spine No deformities or muscle spasms Full range of movement without pain

9 What is the diagnosis? 1. KJ osteoarthritis - Primary - Secondary 2.?? Occult malignancy

10 X-ray knee joint - sclerotic lesions

11 X-ray cervical spine - lateral view Sclerosis of cervical vertebrae

12 Sclerotic bone lesions Focal or multifocal sclerotic bone lesions Vascular Hemangioma Infarct Infection Chronic osteomyelitis Neoplasm Primary Osteosarcoma Metastatic Trauma fracture (stress) Endocrine/Metabolic Paget's disease Diffuse Sclerotic Bone Lesions Vascular Infarct (e.g. sickle cell) Neoplasm Metastatic Prostate Breast Drugs Vitamin D Fluoride Endocrine/Metabolic Hyperparathyroidism

13 D/D Metastatic bone disease Paget s disease Osteoblastic lymphoma KJ osteoarthritis - Primary - Secondary

14 Investigations FBC WBC 5.8 x Hb 12.8 g/dl PLT 230 x 103 Normal ESR 15 mm 1st hr S.Ionized Ca mmol/l S.Phosphate 4 mg/dl

15 Investigations LFT ALT 28 U/L AST 38 U/L ALB 58 mg/dl Total protein 70 mg/dl ALP 1726 U/L GGT 38 U/L TBIL 14 µmol/l Isolated elevation of ALP Scr 60 µmol/l USS abdomen No organomegaly No intra abdominal lymphadenopathy

16 Skull x-ray - lateral Cotton wool skull

17 X-ray pelvis - lytic and sclerotic lesions Cortical thickening

18 Diagnosis Metastatic bone disease Paget s disease Osteoblastic lymphoma KJ osteoarthritis - Primary - Secondary

19 Paget s disease Sir James Paget first described chronic inflammation of bone as osteitis deformans in Today it is known as, Paget s disease of bone.

20 Paget's disease Second most common bone disorder (after osteoporosis) in elderly. Common among male. Cause unknown. Chronic, progressive disorder. Localized area of excessive bone resorption and formation. Frequently multifocal. New lesions rarely develop in previously un affected areas after the diagnosis.

21 Paget's disease Predilection for the axial skeleton. (pelvis, femur, lumbar spine, and skull) (descending order of frequency)

22 Pathophysiology Normal Paget s

23 Pathophysiology Three phases 1. Lytic phase 2. Mixed phase 3. Sclerotic phase At any one time, multiple stages of the disease may be demonstrated in different skeletal regions at different rates of progression.

24 Histology

25 Clinical features Majority are asymptomatic. Patient may present with non-specific symptoms or symptoms suggestive of another disease, Bone pain Osteoarthritis Deformity Fracture Deafness Diagnosis is often based on incidental findings Elevated total or bone specific ALP Radiological findings

26 Examination Facial disfiguration Skull enlargement Bowing of long bones

27 Diagnosis Serological investigations - Total alkaline phosphatase (ALP) - Bone specific ALP Radiograph - characteristic appearance Bone scan - to assess the extent of the disease

28 Radiological investigations - Lytic phase Osteoporosis circumscripta V shaped blade of grass lesion

29 Sclerotic phase

30 Advanced paget s disease sclerotic and lytic lesions Cotton wool skull

31 Paget s disease of vertebra - picture frame vertebral body Cortical thickening

32 Bone scan - polyostotic disease

33 Complications Acceletated bone remodeling Osteosarcoma Bone enlargement Impaired bone micro architecture Hypervascularity Bony overgrowth around nerves Fractures Micro-fractures High output cardiac failure Nerve impingement syndrome Bowing deformity of weight bearing bones Gait change and mechanical stress Secondary osteoarthritis Back pain and joint pain

34 Treatment Indications Metabolically active disease Bone pain Fracture Bony deformities and weight-bearing bone involvement. Compression of spinal cord or nerve roots

35 Treatment Preparation for orthopedic surgery. (If joint replacement anticipated at involved site within 6 months) Hypercalcaemia or hypercalciuria - recurrent renal calculi. Serum ALP levels greater than twice the upper limit of the reference range.

36 Treatment Non - pharmacological Gait abnormality - canes and walkers Pharmacological Bisphosphonate NSAID/Opioid - pain management Surgery Bone deformities, fractures or secondary osteoarthritis

37 Bisphosphonates Antiresorptive agent - osteoclast apoptosis Inhibit bone turnover Improve bone pain C/I if GFR < 35 ml/min - can substitute with calcitonin

38 Compare the effects of two management strategies on fracture, quality of life, bodily pain, and other common complications of PDB, including the requirement for orthopedic surgery and hearing loss. Symptomatic Intensive Any fracture 7.4% 7.0% Pagetic bone pain 30.8% 26.4% Any bone pain 73.7% 69.7% Quality of life -1.2% -1.3%

39 Bisphosphonates Drug Dose Fall in ALP Reference Alendronate 40mg/day, orally, for 6 months 73-79% in 6 months Siris 1996 Risedronate Pamidronate Zolendronic 30mg/day, orally, for 2 months 60mg/day, intravenously, for 3days 5mg, intravenously, single dose 69% in 6 months Reid % in 6 months Miller % in 6 months Reid 2005

40 Follow up Serum total or bone specific ALP - fall within 7-10 days of starting treatment and nadir after 3-4 months. ALP every 1-2 years in zolendronic acid treated group Periodic x-rays of osteolytic lesions. Retreatment indicated if patient has not responded after 6 months of treatment or clinical or biochemical relapse.

41 Surgical treatment Corrective osteotomy for deformity Hip replacement

42 Our patient.. Alandronate 70 mg EOD Awaiting Zolendronic acid

43 Future. ZiPP (Zoledronate in Prevention of Paget s disease) Randomized trial of genetic testing and targeted zolendronic acid therapy to prevent SQSTM1 mediated Paget s disease.

44 Take home message Morbidity from Paget s disease can be extensive. Most of the patients are asymptomatic at presentation. Important to suspect and initiate treatment early to prevent complications. Treatment does not cure the disease, but it can control. Prognosis is good, if treatment administered before major changes have occurred.

45 References Singer FR, Bone HG, Hosking DJ, Lyles KW, Murad MH, Reid IR, Siris ES, Endocrine Society. Paget's disease of bone: an endocrine society clinical practice guideline. J Clin Endocrinol Metab Dec;99(12): Guideline Stresses Bisphosphonate Infusion for Paget... Ralston SH, Layfield R. Pathogenesis of Paget disease of bone. Calcif Tissue Int 2012;91: Stuart H. Ralston, M.D. Paget's disease of bone. N Engl J Med 2013; 368: Siris ES, Roodman GD. Paget's disease of bone. In: Rosen C, ed. Primer on the metabolic bone diseases and disorders of mineral metabolism. Hoboken, NJ: Wiley, 2012: Reid IR, Lyles K, Su G, et al. A single infusion of zoledronic acid produces sustained remissions in Paget disease -- data to 6.5 years. J Bone Miner Res 2011;26: Langston AL, Campbell MK, Fraser WD, MacLennan GS, Selby PL, Ralston SH. Randomized trial of intensive bisphosphonate treatment versus symptomatic management in Paget's disease of bone. J Bone Miner Res 2010;25:20-31

46 Acknowledgement Dr. Nihal Gunatilake - Consultant Rheumatologist Dr. Apsara Epa - Consultant Radiologist Patient

47 Thank you..