DOCSLIB.ORG

Bone Pathology for the Surgical Pathologist Disclosure Outline

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Bone Pathology for the Surgical Pathologist Disclosure Outline 5/25/19 Disclosure UCSF Current Issues in Pathology 2019 Company Relationship type Presage Biosciences Consultant Bone Pathology for the Surgical Pathologist Andrew Horvai MD PhD Clinical Professor, Pathology UCSF, San Francisco, CA Outline Diseases of bone • Approach to bone pathology Developmental • 1% Inflammatory Decalcification 4% • Osteomyelitis Metabolic • Avascular necrosis 17% Trauma Metastatic • Infected arthroplasty 76% 1% Neoplasm Primary <1% 1 5/25/19 Approach to bone diagnosis Approach to bone diagnosis Pathology Clinical Clinical Imaging Clinical Pathology Pathology Imaging Fracture Metastatic carcinoma Imaging Osteoporosis Myeloma, lymphoma Anatomy Composition osteon epiphysis Physis – Osteoid: (growth plate) • Collagen (mostly type I) metaphysis • Other proteins – Mineral periosteum • Carbonated calcium hydroxylapatite diaphysis trabeculae • Ca10(PO4)6(OH)2 Haversian canal bone Volkmann canal osteoid cortex medulla http://classes.midlandstech.edu 2 5/25/19 Decalcification Sample case • Bone = Protein + Carbonated Calcium hydroxylapatite [Ca10(PO4)6(OH)2] A 16 year old girl with travel to Costa Rica • Calcium crystals in tissue are hard to cut several weeks ago sustained an insect bite on • Acid decalcifiers destroy nucleic acids Product Constituents UCSF use the right leg. This evolved into a presumed Easy-Cut Formic Acid + HCl Non-neoplastic bone (toes etc.), septic arthritis which was managed with cortical bone antibiotics in Costa Rica. She returned to the US Formical2000 Formic Acid + EDTA Bone biopsy, intramedullary bone tumor with persistent right leg pain and sustained a Decal-Stat EDTA + HCl Bone marrow fracture of the left femur 3 days ago. Imaging IED Formic Acid + HCl + exchange Histology resin revealed a pathologic fracture which was Immunocal Formic acid Not used at UCSF biopsied. EDTA Pure EDTA Not used at UCSF Bone Radiology: Opacity Lytic Sclerotic B 3 5/25/19 Histology: what is “normal”? Radiology: Border lamellar J J J L Marginated Circumscribed Permeative Marrow: fat and hematopoetic cells only Remodeling <20% of surface Blue nuclei in lacunae Evenly spaced cement lines Always abnormal: woven bone Always abnormal: excess cement lines Lamellar Woven Paget disease • Neoplasms • Osteoblastoma • Osteosarcoma • Inflammatory • Neoplasms • Osteomyelitis • Low-grade osteosarcoma • Metabolic/Developmental • Inflammatory • Osteogenesis Imperfecta • Osteopetrosis • Paget disease • Necrosis 4 5/25/19 Always abnormal: Marrow replaced Always abnormal: Excess remodeling Hyperparathyroidism Chondrosarcoma • Neoplasms • • Chondrosarcoma Inflammatory • Metastasis • Paget disease • Hematolymphoid • Chronic osteomyelitis • Inflammatory • Metabolic/Developmental • Osteomyelitis • Hyperparathyroidism • Metabolic/Developmental • Renal osteodystrophy • Fibrous dysplasia • Xanthomatosis Always* abnormal: Empty lacunae Sample case: biopsy Empty lacunae Empty lacunae • Inflammatory • Bone infarct Marrow replaced • Osteomyelitis • Trauma • *Normal: interstitial lamellae • *Artifact: over-decalcification 5 5/25/19 Acute osteomyelitis Sequestrum • Clinical: Wide distribution of age and location, often Involucrum no pain, or fever; hematogenous or direct. • Radiology: Lytic, moth eaten and permeative – Children: does not cross physis (dual vascular supply) – Infants and adults: can cross physis • Histology: 1. Neutrophils 2. dead bone (sequestrum) or unequivocal destruction of bone and/or cartilage (scalloping) – Optional: New, woven bone (involucrum), bacteria, fungi, chronic inflammation Acute osteomyelitis: sequestrum Acute osteomyelitis Lacunae not empty but destruction of bone and cartilage by neutrophils 6 5/25/19 Acute osteomyelitis: involucrum Acute osteomyelitis Nonbacterial S. aureus Other gram - Other gram + Polymicrobial Chronic osteomyelitis Chronic osteomyelitis • Clinical: All ages, painless, often no fever – Progression/reactivation of acute, TB/fungus – Some variants culture negative (CRMO, CNO, SAPHO) • Radiology: Lytic -> sclerotic, permeative • Histology: – Very nonspecific, no gold standard – Plasma cells predominate – Sequestrum may persist for months – Involucrum becomes sclerotic (dense, without medullary spaces) – Medullary space may be fibrotic, cellular • DDx: Rosai Dorfman (xanthoma + plasma), myeloma, lymphoma, Langerhans, old bone infarct, nonspecific changes 7 5/25/19 Chronic osteomyelitis Chronic osteomyelitis Chronic osteomyelitis Chronic osteomyelitis 8 5/25/19 Empty lacunae Avascular necrosis • Clinical: Pain with activity then at rest, any age • Osteonecrosis – Drugs: Glucocorticoids, alcohol, bisphosphonates (?) – Osteomyelitis – Systemic: Hyperbarism, sickle cell, Gaucher – Childhood: Osteochondroses (Legg-Calve-Perthe, Osgood – Trauma Schlatter, etc.) – Avascular necrosis (sterile) • Radiology: • Physiologic: interstitial lamellae – Geographic or wedge shaped lucency – Subchondral collapse • Artifact: excess decalcification • Histology – Central: empty lacunae, fat necrosis – Peripheral: Ingrowth of granulation tissue, creeping substitution, calcified rim – Cortex and cartilage usually viable Bone infarct Bone infarct (avascular necrosis) 9 5/25/19 Bone infarct: central Bone infarct Bone infarct: peripheral Bone infarct: creeping substition 10 5/25/19 Bone infarct: peripheral calcification Empty lacunae • Osteonecrosis – Acute osteomyelitis – Trauma – Avascular necrosis (sterile) • Physiologic: interstitial lamellae • Artifact: excess decalcification Necrosis in interstitial lamellae: not “always” abnormal Empty lacunae • Osteonecrosis – Acute osteomyelitis – Trauma – Avascular necrosis (sterile) • Physiologic: interstitial lamellae • Artifact: excess decalcification 11 5/25/19 Do not overdiagnose over-decalcification as osteonecrosis Do not overdiagnose over-decalcification as osteonecrosis Decalcification Osteonecrosis Decalcification Osteonecrosis Sample case Infected arthroplasty Early Late • A 61 year old man with a prior left hip arthroplasty noted Time <3 months > 24 months increased pain over 2 months Organisms S. Aureus Coag – Staph E. Coli P. Acnes • Loosening of the hardware is noted clinically and Route Direct Hematogenous radiographically Clinical Fever Loosening ↑ WBC Instability • A specimen arrives in the Pain Pain frozen section lab “rule out infection” • A “delayed” form (3-24 months) has overlapping features between Early and Late. 12 5/25/19 Hardware loosening Septic loosening • Aseptic loosening • Septic loosening • Gold standard: Positive culture from (85%) (15%) multiple sites – Wear induced particle • Late infection debris • Intraoperative: Neutrophils in capsule, – Stress shielding synovium or granulation tissue (atrophy) – Hardware failure Criterion Sensitivity Specificity Feldman 5 neutrophils/hpf in > 5 hpf* 25% 98% Removal Athanasou 10 neutrophils / 10 hpf 70% 64% Antibiotic cement spacer *hpf: 400X high power field. Immediate replacement 6 weeks IV antibiotics Bori G et al. J Bone Joint Surg 2007 89:1232 PMNs in capsule or granulation tissue :YES PMNs in fibrin : NO 13 5/25/19 PMNs in vessels : NO Common re-do arthroplasty findings Barium (black flakes) Foam cells Common re-do arthroplasty findings Take home messages Wear debris reaction (polyethylene, Methyl methacrylate, Silastin) • Bone lesions require radiographic and clinical information for accurate diagnosis • Woven bone, excess cement lines, marrow replacement, excess turnover and empty lacunae are (almost) always abnormal • Do not mistake over decalcification for osteonecrosis • Do not count neutrophils in fibrin for septic loosening 14.
Load more

Recommended publications
  • Pathologic Fracture Does Not Influence Prognosis in Stage IIB Osteosarcoma: a Case–Control Study Dongqing Zuo†, Longpo Zheng†, Wei Sun, Yingqi Hua* and Zhengdong Cai*
    Zuo et al. World Journal of Surgical Oncology 2013, 11:148 http://www.wjso.com/content/11/1/148 WORLD JOURNAL OF SURGICAL ONCOLOGY RESEARCH Open Access Pathologic fracture does not influence prognosis in stage IIB osteosarcoma: a case–control study Dongqing Zuo†, Longpo Zheng†, Wei Sun, Yingqi Hua* and Zhengdong Cai* Abstract Objective: This study tested the implication of pathologic fractures on the prognosis in stage IIb osteosarcoma. Methods: A single center retrospective evaluation of clinical management and oncologic outcome was conducted with 15 pathological fracture patients (M:F = 10:5; age: mean 23.2, range 12–42) and 50 non-fracture patients between April 2002 and December 2010. These stage IIB osteosarcoma patients were matched for age, tumor site (femur, tibia, and humerus), and osteosarcoma subtype (i.e., control patients with osteosarcoma in the same sites as the fracture patients). All osteosarcoma patients with pathological fractures underwent brace or cast immobilization, adjuvant chemotherapy, and limb salvage surgery or amputation. Musculoskeletal Tumor Society (MSTS) functional scores were assessed. The mean follow-up time was 34.7 months (range, 8–47 months). Results: Following limb salvage surgery, no statistical differences were observed in major complications (fracture = 20.0%, control = 12.0%, P = 0.43) or local recurrence complications (fracture = 26.7%, control = 14.0%, P = 0.25). Overall 3-year survival rates of the fracture and control groups (66.7% and 75.3%, respectively) were not statistically different (P = 0.5190). Three-year disease-free survival rates of the fracture and control groups were 53.3% and 66.5%, respectively (P = 0.25).
    [Show full text]
  • Evaluating and Treating the Reproductive System
    18_Reproductive.qxd 8/23/2005 11:44 AM Page 519 CHAPTER 18 Evaluating and Treating the Reproductive System HEATHER L. BOWLES, DVM, D ipl ABVP-A vian , Certified in Veterinary Acupuncture (C hi Institute ) Reproductive Embryology, Anatomy and Physiology FORMATION OF THE AVIAN GONADS AND REPRODUCTIVE ANATOMY The avian gonads arise from more than one embryonic source. The medulla or core arises from the meso- nephric ducts. The outer cortex arises from a thickening of peritoneum along the root of the dorsal mesentery within the primitive gonadal ridge. Mesodermal germ cells that arise from yolk-sac endoderm migrate into this gonadal ridge, forming the ovary. The cells are initially distributed equally to both sides. In the hen, these germ cells are then preferentially distributed to the left side, and migrate from the right to the left side as well.58 Some avian species do in fact have 2 ovaries, including the brown kiwi and several raptor species. Sexual differ- entiation begins by day 5 in passerines and domestic fowl and by day 11 in raptor species. Differentiation of the ovary is characterized by development of the cortex, while the medulla develops into the testis.30,58 As the embryo develops, the germ cells undergo three phases of oogenesis. During the first phase, the oogonia actively divide for a defined time period and then stop at the first prophase of the first maturation division. During the second phase, the germ cells grow in size to become primary oocytes. This occurs approximately at the time of hatch in domestic fowl. During the third phase, oocytes complete the first maturation division to 18_Reproductive.qxd 8/23/2005 11:44 AM Page 520 520 Clinical Avian Medicine - Volume II become secondary oocytes.
    [Show full text]
  • Metastatic Osseous Pain Control: Bone Ablation and Cementoplasty
    328 Metastatic Osseous Pain Control: Bone Ablation and Cementoplasty Alexis Kelekis, MD, PhD, EBIR, FSIR1 Francois H. Cornelis, MD, PhD2 Sean Tutton, MD, FSIR3 Dimitrios Filippiadis, PhD, MSc, EBIR1 1 Division of Diagnostic and Interventional Radiology, 2nd Department of Address for correspondence Alexis Kelekis, MD, PhD, EBIR, FSIR, Radiology, University General Hospital “ATTIKON,” Athens, Greece Division of Diagnostic and Interventional Radiology, 2nd Department 2 Department of Radiology, Université Pierre et Marie Curie, Sorbonne of Radiology, University General Hospital “ATTIKON,” 1 Rimini street, Université, Tenon Hospital, Paris, France 12462 Athens, Greece (e-mail: [email protected]). 3 Division of Vascular and Interventional Radiology, Department of Radiology and Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin Semin Intervent Radiol 2017;34:328–336 Abstract Nociceptive and/or neuropathic pain can be present in all phases of cancer (early and metastatic) and are not adequately treated in 56 to 82.3% of patients. In these patients, radiotherapy achieves overall pain responses (complete and partial responses com- bined) up to 60 and 61%. On the other hand, nowadays, ablation is included in clinical guidelines for bone metastases and the technique is governed by level I evidence. Depending on the location of the lesion in the peripheral skeleton, either the Mirels Keywords scoring or the Harrington (alternatively the Levy) grading system can be used for ► ablation prophylactic fixation recommendation. As minimally invasive treatment options may ► cementoplasty be considered in patients with poor clinical status or limited life expectancy, the aim of ► pain this review is to detail the techniques proposed so far in the literature and to report the ► bone metastasis results in terms of safety and efficacy of ablation and cementoplasty (with or without ► interventional fixation) for bone metastases.
    [Show full text]
  • Henry Ford Hospital Medical Journal Osteomalacia
    Henry Ford Hospital Medical Journal Volume 31 Number 4 Article 11 12-1983 Osteomalacia Boy Frame Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Frame, Boy (1983) "Osteomalacia," Henry Ford Hospital Medical Journal : Vol. 31 : No. 4 , 213-216. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol31/iss4/11 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp Med J Vol 31, No 4,1983 Osteomalacia Boy Frame, MD" fd. Note - This overview was originally presented at the Recent advances in laboratory methods and techniques International Symposium on Clinical Disorders of Bone related to bone and mineral metabolism have provided a and Mineral Metabolism, May 9-13, 1983. The following detailed study of factors important in bone formation. list indicates the presentations given in this session at the Osteomalacia results from a disturbance in mineraliza­ Symposium and the contents ofthe corresponding chap­ tion of bone matrix. Theoretically, bone matrix may fail ter in the Proceedings of the Symposium published by to mineralize because of abnormalities in collagen and Excerpta Medica. The numbers in parentheses refer to matrix proteins, or because of an alteration in mineral pages in this volume. Complete information about the metabolism at the mineralization front. The result is an contents ofthe Proceedings can be found at the back of accumulation of increased quantities of unmineralized this issue.
    [Show full text]
  • Imaging of Osteomyelitis: the Key Is in the Combination
    Special RepoRt Special RepoRt Imaging of osteomyelitis: the key is in the combination An accurate diagnosis of osteomyelitis requires the combination of anatomical and functional imaging techniques. Conventional radiography is the first imaging modality to begin with, as it provides an overview of both the anatomy and the pathologic conditions of the bone. Sonography is most useful in the diagnosis of fluid collections, periosteal involvement and soft tissue abnormalities, and may provide guidance for diagnostic or therapeutic interventions. MRI highlights sites with tissue edema and increased regional perfusion, and provides accurate information of the extent of the infectious process and the tissues involved. To detect osteomyelitis before anatomical changes are present, functional imaging could have some advantages over anatomical imaging. Fluorine-18 fluorodeoxyglucose-PET has the highest diagnostic accuracy for confirming or excluding the diagnosis of chronic osteomyelitis. For both SPECT and PET, specificity improves considerably when the scintigraphic images are fused with computed tomography. Close cooperation between clinicians and imagers remains the key to early and adequate diagnosis when osteomyelitis is suspected or evaluated. †1 KEYWORDS: computed tomography n hybrid systems n imaging n MRI n nuclear Carlos Pineda , medicine n osteomyelitis n ultrasonography Angelica Pena2, Rolando Espinosa2 & Cristina Osteomyelitis is inflammation of the bone that osteomyelitis. The ideal imaging technique Hernández-Díaz1 is usually due to infection. There are different should have a high sensitivity and specificity; 1Musculoskeletal Ultrasound Department, Instituto Nacional de classification systems to categorize osteomyeli- numerous studies have been published con- Rehabilitacion, Avenida tis. Traditionally, it has been labeled as acute, cerning the accuracy of the various modali- Mexico‑Xochimilco No.
    [Show full text]
  • A Comparison of Imaging Modalities for the Diagnosis of Osteomyelitis
    A comparison of imaging modalities for the diagnosis of osteomyelitis Brandon J. Smith1, Grant S. Buchanan2, Franklin D. Shuler2 Author Affiliations: 1. Joan C Edwards School of Medicine, Marshall University, Huntington, West Virginia 2. Marshall University The authors have no financial disclosures to declare and no conflicts of interest to report. Corresponding Author: Brandon J. Smith Marshall University Joan C. Edwards School of Medicine Huntington, West Virginia Email: [email protected] Abstract Osteomyelitis is an increasingly common pathology that often poses a diagnostic challenge to clinicians. Accurate and timely diagnosis is critical to preventing complications that can result in the loss of life or limb. In addition to history, physical exam, and laboratory studies, diagnostic imaging plays an essential role in the diagnostic process. This narrative review article discusses various imaging modalities employed to diagnose osteomyelitis: plain films, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, bone scintigraphy, and positron emission tomography (PET). Articles were obtained from PubMed and screened for relevance to the topic of diagnostic imaging for osteomyelitis. The authors conclude that plain films are an appropriate first step, as they may reveal osteolytic changes and can help rule out alternative pathology. MRI is often the most appropriate second study, as it is highly sensitive and can detect bone marrow changes within days of an infection. Other studies such as CT, ultrasound, and bone scintigraphy may be useful in patients who cannot undergo MRI. CT is useful for identifying necrotic bone in chronic infections. Ultrasound may be useful in children or those with sickle-cell disease. Bone scintigraphy is particularly useful for vertebral osteomyelitis.
    [Show full text]
  • (Xgeva®) Related Osteonecrosis of the Jaw: a Retrospective Study
    Journal of Clinical Medicine Article A Comparison of the Clinical and Radiological Extent of Denosumab (Xgeva®) Related Osteonecrosis of the Jaw: A Retrospective Study Zineb Assili 1, Gilles Dolivet 2, Julia Salleron 3 , Claire Griffaton-Tallandier 4, Claire Egloff-Juras 1 and Bérengère Phulpin 1,2,* 1 Faculty of Odontology, Lorraine University, 7 Avenue de la Forêt de Haye, 54505 Vandoeuvre les Nancy, France; [email protected] (Z.A.); [email protected] (C.E.-J.) 2 Department of Head and Neck and Dental Surgery, Institut de Cancérologie de Lorraine, 54519 Vadoeuvre-lès-Nancy, France; [email protected] 3 Cellule Data-Biostatistiques, Institut de Cancérologie de Lorraine, 54519 Vandoeuvre-lès-Nancy, France; [email protected] 4 Cabinet de Radiologie RX125, 125 Rue Saint-Dizier, 54000 Nancy, France; [email protected] * Correspondence: [email protected]; Tel.: +33-3-83-59-84-46 Abstract: Medication-related osteonecrosis of the jaw (MRONJ) is a severe side effect of antiresorptive medication. The aim of this study was to evaluate the incidence of denosumab-related osteonecrosis of the jaw and to compare the clinical and radiological extent of osteonecrosis. A retrospective study of patients who received Xgeva® at the Institut de Cancérologie de Lorraine (ICL) was performed. Patients for whom clinical and radiological (CBCT) data were available were divided into two groups: Citation: Assili, Z.; Dolivet, G.; “exposed” for patients with bone exposure and “fistula” when only a fistula through which the bone Salleron, J.; Griffaton-Tallandier, C.; could be probed was observed. The difference between clinical and radiological extent was assessed.
    [Show full text]
  • Secondary Hyperparathyroidism Mimicking Osteomyelitis
    Henry Ford Health System Henry Ford Health System Scholarly Commons Case Reports Medical Education Research Forum 2019 5-2019 Secondary Hyperparathyroidism Mimicking Osteomyelitis Mohamad Hadied Henry Ford Health System Tammy Hsia Henry Ford Health System Anne Chen Henry Ford Health System Follow this and additional works at: https://scholarlycommons.henryford.com/merf2019caserpt Recommended Citation Hadied, Mohamad; Hsia, Tammy; and Chen, Anne, "Secondary Hyperparathyroidism Mimicking Osteomyelitis" (2019). Case Reports. 84. https://scholarlycommons.henryford.com/merf2019caserpt/84 This Poster is brought to you for free and open access by the Medical Education Research Forum 2019 at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Case Reports by an authorized administrator of Henry Ford Health System Scholarly Commons. Secondary Hyperparathyroidism Mimicking Osteomyelitis Tammy Hsia, Mohamad Hadied MD, Anne Chen MD Henry Ford Hospital, Detroit, Michigan Background Case Report Discussion • The advent of dialysis​ technology has improved outcomes for patients • This case highlights renal osteodystrophy from secondary with end stage renal disease. hyperparathyroidism, a common sequelae of chronic kidney disease. • End stage renal disease leads to endocrine disturbances such as • Secondary hyperparathyroidism can manifest with numerous clinical secondary hyperparathyroidism. signs and symptoms including widespread osseous resorptive • Literature is sparse on exact incidence and burden of secondary changes that can mimic osteomyelitis. hyperparathyroidism among populations with end stage renal disease. • In this case, severe knee pain, elevated inflammatory markers and • This case reports examines a case of secondary hyperparathyroidism radiography findings misled the outside hospital to an incorrect secondary to renal osteodystrophy that was mistaken for acute diagnosis of osteomyelitis, resulting in unnecessary and incorrect osteomyelitis.
    [Show full text]
  • Immunopathologic Studies in Relapsing Polychondritis
    Immunopathologic Studies in Relapsing Polychondritis Jerome H. Herman, Marie V. Dennis J Clin Invest. 1973;52(3):549-558. https://doi.org/10.1172/JCI107215. Research Article Serial studies have been performed on three patients with relapsing polychondritis in an attempt to define a potential immunopathologic role for degradation constituents of cartilage in the causation and/or perpetuation of the inflammation observed. Crude proteoglycan preparations derived by disruptive and differential centrifugation techniques from human costal cartilage, intact chondrocytes grown as monolayers, their homogenates and products of synthesis provided antigenic material for investigation. Circulating antibody to such antigens could not be detected by immunodiffusion, hemagglutination, immunofluorescence or complement mediated chondrocyte cytotoxicity as assessed by 51Cr release. Similarly, radiolabeled incorporation studies attempting to detect de novo synthesis of such antibody by circulating peripheral blood lymphocytes as assessed by radioimmunodiffusion, immune absorption to neuraminidase treated and untreated chondrocytes and immune coprecipitation were negative. Delayed hypersensitivity to cartilage constituents was studied by peripheral lymphocyte transformation employing [3H]thymidine incorporation and the release of macrophage aggregation factor. Positive results were obtained which correlated with periods of overt disease activity. Similar results were observed in patients with classical rheumatoid arthritis manifesting destructive articular changes. This study suggests that cartilage antigenic components may facilitate perpetuation of cartilage inflammation by cellular immune mechanisms. Find the latest version: https://jci.me/107215/pdf Immunopathologic Studies in Relapsing Polychondritis JERoME H. HERmAN and MARIE V. DENNIS From the Division of Immunology, Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio 45229 A B S T R A C T Serial studies have been performed on as hematologic and serologic disturbances.
    [Show full text]
  • CKD: Bone Mineral Metabolism Peter Birks, Nephrology Fellow
    CKD: Bone Mineral Metabolism Peter Birks, Nephrology Fellow CKD - KDIGO Definition and Classification of CKD ◦ CKD: abnormalities of kidney structure/function for > 3 months with health implications ≥1 marker of kidney damage: ACR ≥30 mg/g Urine sediment abnormalities Electrolyte and other abnormalities due to tubular disorders Abnormalities detected by histology Structural abnormalities (imaging) History of kidney transplant OR GFR < 60 Parathyroid glands 4 glands behind thyroid in front of neck Parathyroid physiology Parathyroid hormone Normal circumstances PTH: ◦ Increases calcium ◦ Lowers PO4 (the renal excretion outweighs the bone release and gut absorption) ◦ Increases Vitamin D Controlled by feedback ◦ Low Ca and high PO4 increase PTH ◦ High Ca and low PO4 decrease PTH In renal disease: Gets all messed up! Decreased phosphate clearance: High Po4 Low 1,25 OH vitamin D = Low Ca Phosphate binds calcium = Low Ca Low calcium, high phosphate, and low VitD all feedback to cause more PTH release This is referred to as secondary hyperparathyroidism Usually not seen until GFR < 45 Who cares Chronically high PTH ◦ High bone turnover = renal osteodystrophy Osteoporosis/fractures Osteomalacia Osteitis fibrosa cystica High phosphate ◦ Associated with faster progression CKD ◦ Associated with higher mortality Calcium-phosphate precipitation ◦ Soft tissue, blood vessels (eg: coronary arteries) Low 1,25 OH-VitD ◦ Immune status, cardiac health? KDIGO KDIGO: Kidney Disease Improving Global Outcomes Most recent update regarding
    [Show full text]
  • A Case of Acute Osteomyelitis: an Update on Diagnosis and Treatment
    International Journal of Environmental Research and Public Health Review A Case of Acute Osteomyelitis: An Update on Diagnosis and Treatment Elena Chiappini 1,*, Greta Mastrangelo 1 and Simone Lazzeri 2 1 Infectious Disease Unit, Meyer University Hospital, University of Florence, Florence 50100, Italy; [email protected] 2 Orthopedics and Traumatology, Meyer University Hospital, Florence 50100, Italy; [email protected] * Correspondence: elena.chiappini@unifi.it; Tel.: +39-055-566-2830 Academic Editor: Karin Nielsen-Saines Received: 25 February 2016; Accepted: 23 May 2016; Published: 27 May 2016 Abstract: Osteomyelitis in children is a serious disease in children requiring early diagnosis and treatment to minimize the risk of sequelae. Therefore, it is of primary importance to recognize the signs and symptoms at the onset and to properly use the available diagnostic tools. It is important to maintain a high index of suspicion and be aware of the evolving epidemiology and of the emergence of antibiotic resistant and aggressive strains requiring careful monitoring and targeted therapy. Hereby we present an instructive case and review the literature data on diagnosis and treatment. Keywords: acute hematogenous osteomyelitis; children; bone infection; infection biomarkers; osteomyelitis treatment 1. Case Presentation A previously healthy 18-month-old boy presented at the emergency department with left hip pain and a limp following a minor trauma. His mother reported that he had presented fever for three days, cough and rhinitis about 15 days before the trauma, and had been treated with ibuprofen for 7 days (10 mg/kg dose every 8 h, orally) by his physician. The child presented with a limited and painful range of motion of the left hip and could not bear weight on that side.
    [Show full text]
  • Paleopathological Analysis of a Sub-Adult Allosaurus Fragilis (MOR
    Paleopathological analysis of a sub-adult Allosaurus fragilis (MOR 693) from the Upper Jurassic Morrison Formation with multiple injuries and infections by Rebecca Rochelle Laws A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Earth Sciences Montana State University © Copyright by Rebecca Rochelle Laws (1996) Abstract: A sub-adult Allosaurus fragilis (Museum of the Rockies specimen number 693 or MOR 693; "Big Al") with nineteen abnormal skeletal elements was discovered in 1991 in the Upper Jurassic Morrison Formation in Big Horn County, Wyoming at what became known as the "Big Al" site. This site is 300 meters northeast of the Howe Quarry, excavated in 1934 by Barnum Brown. The opisthotonic position of the allosaur indicated that rigor mortis occurred before burial. Although the skeleton was found within a fluvially-deposited sandstone, the presence of mud chips in the sandstone matrix and virtual completeness of the skeleton showed that the skeleton was not transported very far, if at all. The specific goals of this study are to: 1) provide a complete description and analysis of the abnormal bones of the sub-adult, male, A. fragilis, 2) develop a better understanding of how the bones of this allosaur reacted to infection and trauma, and 3) contribute to the pathological bone database so that future comparative studies are possible, and the hypothesis that certain abnormalities characterize taxa may be evaluated. The morphology of each of the 19 abnormal bones is described and each disfigurement is classified as to its cause: 5 trauma-induced; 2 infection-induced; 1 trauma- and infection-induced; 4 trauma-induced or aberrant, specific origin unknown; 4 aberrant; and 3 aberrant, specific origin unknown.
    [Show full text]