Abstract
A 77-year-old man, who received a renal transplant 13 years before for IgA glomerulonephritis, was referred after he developed bilateral mid-tibial aching pain that did not improve with simple analgesia. He had recently been changed from low-dose cyclosporine to tacrolimus, but the pain did not improve when this was reversed. He had a history of focal prostatic adenocarcinoma, cryptococcal lung infection, osteoporosis treated with alendronate for 2 years and multiple squamous cell carcinomas, including one requiring left neck dissection and radiotherapy. Upon physical examination, he had gouty tophi and marked bilateral tibial tenderness but had no other clinical findings. Laboratory investigations included an elevated intact parathyroid hormone value of 7.9 pmol/L (1.6 to 6.9), bone specific alkaline phosphatase of 22 µg/L (3.7 to 20.9), urinary deoxypyridinoline/creatinine ratio of 7.2 nmol/mmol (2.5 to 5.4) and C-reactive protein. Chest X-ray and tibial X-rays were normal, but there was marrow oedema and a prominent periosteal reaction on magnetic resonance imaging. A radionuclide bone scan showed increased symmetrical, linear uptake in both tibiae and the left femur, and uptake was also noted in both clinically asymptomatic humeri. Tibial bone biopsy disclosed small deposits of poorly differentiated metastatic cancer and a follow-up chest CT revealed a lung lesion. It was concluded that the bone pain and periostitis was caused by primary lung cancer with metastatic disease to bone, and an associated hypertrophic osteoarthropathy.
References
Grotz WH, Breitenfeldt MK, Braune SW, Allmann KH, Krause TM et al (2001) Calcineurin-inhibitor induced pain syndrome (CIPS): a severe disabling complication after organ transplantation. Transpl Int 14(1):16–23
Elder GJ (2006) From marrow oedema to osteonecrosis: common paths in the development of post-transplant bone pain. Nephrology (Carlton) 11(6):560–567
Shane E, Burr D, Ebeling PR et al (2010) Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 25(11):2267–2294
Yavropoulou MP, Giusti A, Ramautar SD, Dijkstra S, Hamdy NAT et al (2012) Low-energy fractures of the humeral shaft and bisphosphonate use. J Bone Miner Res 27(6):1425–1431
Martinez-Lavin M, Matucci-Cerinic M, Jajic I et al (1993) Hypertrophic osteoarthropathy: consensus on its definition, classification, assessment and diagnostic criteria. J Rheumatol 20:1386–1387
Castory M, Sinibaldi L, Mingarelli R, Lachman RS, Rimoin DL et al (2005) Pachydermoperiostosis: an update. Clin Genet 68:477–486
Martinez-Ferrer, Peris P, Alos L, Morales-Ruiz M, Guanabens N (2009) Prostaglandin E2 and bone turnover markers in the evaluation of Primary hypertrophic osteoarthropathy (pachydermoperiostosis): a case report. Clin Rheumatol 28(10):1229–1233
Silveri F, De Angelis R, Argentari F et al (1996) Hypertrophic osteoarthropathy: endothelium and platelet function. Clin Rheumatol 15:435–439
Kawai T, Hiroi S, Torikata C (1997) Expression in lung carcinoma of platelet-derived growth factor and its receptors. Lab Invest 77:431–436
Silveira LH, Martinez-Lavin M, Pineda C et al (2000) Vascular endothelial growth factor and Hypertrophic osteoarthropathy. Clin Exp Rheumatol 18:57–62
Pineda C (1992) Diagnostic imaging in hypertrophic osteoarthropathy. Clin Exp Rheumatol 10(Suppl 7):27–33
Russo R, Lee A, Mansberg R, Emmett L (2009) Hypertrophic pulmonary osteoarthropathy demonstrated on SPECT/CT. Clin Nucl Med 34(9):628–631
King MM, Nelson DA (2008) Hypertrophic osteoarthropathy effectively treated with zolnedronic acid. Clin Lung Cancer 9(3):179–182
Saeed H, Massarweh S (2012) Images in clinical medicine. Hypertrophic pulmonary osteoarthropathy and tripe palms. N Engl J Med 366(4):360
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Myint, T.M.M., Vucak-Dzumhur, M., Ebeling, P.R. et al. A case report of disabling bone pain after long-term kidney transplantation. Osteoporos Int 25, 769–772 (2014). https://doi.org/10.1007/s00198-013-2425-3
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DOI: https://doi.org/10.1007/s00198-013-2425-3