Knee pain An uncommon cause Dr.Nihal Gunatilake - Consultant Rheumatologist - CSTH Dr.Dinesha Sudusinghe - Registrar Medicine
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.
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).
?? Diagnosis Middle aged female 1. KJ osteoarthritis Non inflammatory KJ pain - Primary - Secondary LOA and LOW 2.?? Occult malignancy
Examination Not pale. No LN, clubbing No goiter/breast lumps
Examination Cardiovascular Respiratory - BP-130/90mmHg - No added sounds - PR- 88 bpm - Apex - normal position - No murmur
Examination Abdomen - No organomegaly Neurology - Cranial nerves - normal - No motor weakness - No sensory impairment
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
What is the diagnosis? 1. KJ osteoarthritis - Primary - Secondary 2.?? Occult malignancy
X-ray knee joint - sclerotic lesions
X-ray cervical spine - lateral view Sclerosis of cervical vertebrae
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
D/D Metastatic bone disease Paget s disease Osteoblastic lymphoma KJ osteoarthritis - Primary - Secondary
Investigations FBC WBC 5.8 x Hb 12.8 g/dl PLT 230 x 103 Normal ESR 15 mm 1st hr S.Ionized Ca2+ 1.13 mmol/l S.Phosphate 4 mg/dl
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
Skull x-ray - lateral Cotton wool skull
X-ray pelvis - lytic and sclerotic lesions Cortical thickening
Diagnosis Metastatic bone disease Paget s disease Osteoblastic lymphoma KJ osteoarthritis - Primary - Secondary
Paget s disease Sir James Paget first described chronic inflammation of bone as osteitis deformans in 1877. Today it is known as, Paget s disease of bone.
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.
Paget's disease Predilection for the axial skeleton. (pelvis, femur, lumbar spine, and skull) (descending order of frequency)
Pathophysiology Normal Paget s
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.
Histology
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
Examination Facial disfiguration Skull enlargement Bowing of long bones
Diagnosis Serological investigations - Total alkaline phosphatase (ALP) - Bone specific ALP Radiograph - characteristic appearance Bone scan - to assess the extent of the disease
Radiological investigations - Lytic phase Osteoporosis circumscripta V shaped blade of grass lesion
Sclerotic phase
Advanced paget s disease sclerotic and lytic lesions Cotton wool skull
Paget s disease of vertebra - picture frame vertebral body Cortical thickening
Bone scan - polyostotic disease
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
Treatment Indications Metabolically active disease Bone pain Fracture Bony deformities and weight-bearing bone involvement. Compression of spinal cord or nerve roots
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.
Treatment Non - pharmacological Gait abnormality - canes and walkers Pharmacological Bisphosphonate NSAID/Opioid - pain management Surgery Bone deformities, fractures or secondary osteoarthritis
Bisphosphonates Antiresorptive agent - osteoclast apoptosis Inhibit bone turnover Improve bone pain C/I if GFR < 35 ml/min - can substitute with calcitonin
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%
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 1996 53% in 6 months Miller 2004 80% in 6 months Reid 2005
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.
Surgical treatment Corrective osteotomy for deformity Hip replacement
Our patient.. Alandronate 70 mg EOD Awaiting Zolendronic acid
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.
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.
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. 2014 Dec;99(12):4408-22. Guideline Stresses Bisphosphonate Infusion for Paget...www.medscape.org/viewarticle/837040 Ralston SH, Layfield R. Pathogenesis of Paget disease of bone. Calcif Tissue Int 2012;91:97-113. Stuart H. Ralston, M.D. Paget's disease of bone. N Engl J Med 2013; 368:644-650. 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, 2012:335-43. 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;26:2261-2270 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
Acknowledgement Dr. Nihal Gunatilake - Consultant Rheumatologist Dr. Apsara Epa - Consultant Radiologist Patient
Thank you..