Osteoporosis del varón: hallazgos clínicos y de la densitometría ósea en 70 casos / Frequency and causes of osteoporosis among males referred for bone densitometry

Background: Among males, osteoporosis is less common than in women, but can also be a health issue. Aim: To report the frequency and clinical manifestations of osteoporosis among males referred to perform a bone densitometry. Material and Methods: All densitometries performed during one year at a clinical institution were analyzed and those corresponding to males aged over 18 years were selected to review the clinical record of the patient. Osteoporosis was defined as a bone mineral density T score < -2.5 among males aged over 50 years or a Z score below -2.0 and a history of osteoporotic fracture among males aged less than 50 years. Results: Of 5792 densitometries performed, 439 (8 percent) corresponded to males aged more than 18 years. Among these 156 (82 percent aged more than 50 years) had an abnormal densitometry. Seventy patients had osteoporosis, (67 percent only by DXA) and the rest had an osteoporotic fracture. Mean age and body mass index of the latter was 62 +/- 15 years and 25.9+/- 3 kg/m2, respectively. Forty two percent had osteoporosis in the spine, 35 percent in the hip and 23 percent in both sites. Thirty six of the 70 patients with osteoporosis (51 percent) had a history of osteoporotic fracture in column, hip, wrist and other sites in 55, 11, 8 and 26 percent respectively. Seventy eight percent of these patients were aged more than 50 years. The most common causes of osteoporosis were idiopathic in21 percent, induced by glucocorticoids in 20 percent, associated with vitamin D deficiency in 16 percent and associated to chronic renal failure in 14 percent. Conclusions: One of six male referred for bone densitometry have osteoporosis, usually associated with other underlying diseases. In half of these patients, osteoporosisis severe.

Macroadenoma cervical palpable: Una presentación muy inusual de hiperparatiroidismo primario / Cervical macroadenoma causing hyperparathyroidism: Report of one case

We report a 59-year-old man with a history of hypertension, recurrent renal stones and a severe hypercalcemia of 14.9 mg/dl with a serum phosphorus of 2.4 mg/dl and a serum albumin of 3.6 g/dl. Physical examination showed a 4 cm left cervical nodule, consistent with the diagnosis of thyroid nodule. Parathyroid hormone (PTH) levels were 844 pg/mL (normal 15-65 pg/ml) and a cervical ultrasound examination disclosed a solid nodule in the lower left lobe of 40 x 30 x 25 mm, adjacent to the thyroid parenchyma. Abdominal ultrasound revealed bilateral renal stones. Parathyroid scintigraphy showed a high uptake of the left lower parathyroid mass and a bone densitometry showed bone density t scores of -1.2 in the spine, -2.0 in the right femoral neck and -3.5 in the distal radius. A review of his medical record revealed the presence of hypercalcemia for at least 4 years. He was admitted for hydration and administration of 4 mg zoledronic acid iv. At 24 hours, serum calcium dropped to 11.0 mg/dl, and a left thyroid lobectomy was performed including the lower left parathyroid gland. The pathology report showed a 22.6 g parathyroid adenoma. Intraoperatory PTH descended > 50%, consistent with successful parathyroidectomy. At 7 days after surgery serum calcium was 8.8 mg/dl, phosphorus 2.1 mg/dl, alkaline phosphatase 166 U/L, albumin 3.9 g/dL, PTH 230 pg/ml and 25-OH vitamin D 12.4 ng/ml. This finding was interpreted as secondary hyperparathyroidism due to vitamin D deficiency and “hungry bone”, being less likely the presence of residual or metastatic parathyroid tissue. A cholecalciferol load was administered, with significant descent of PTH.

Tratamiento quirúrgico del hiperparatiroidismo asociado a insuficiencia renal crónica: Experience in 71 patients / Surgical treatment of renal hyperparathyroidism

Background: Surgery is an effective method for the management of renal hyperparathyroidism. Aim: To report the clinical presentation and results of surgical treatment of renal hyperparathyroidism. Material and Methods: Retrospective analysis of 58 patients aged 46 ± 11 years with secondary hyperparathyroidism (HPT2) and 13 patients aged 53 ± 11 years with tertiary hyperparathyroidism (HPT3), operated at a clinical hospital. Results: In 55 cases (77.4%) the indications for surgery were complications of excess parathyroid hormone (PTH) and in 16 patients (22.6%) a failure of medical treatment. Total parathyroidectomy with intraoperative measurement of PTH (PTHop) plus a forearm parathyroid autograft was performed in 54 (93.1%) patients with HPT2 and in all patients with HPT3. PTHop decreased ≥ 75% in 51 patients (88%) with HPT2 and in 9 patients (69.2%) with HPT3, respectively. Cure of the disease was achieved in 52 (89.7%) and 11 (84.6%) patients with HPT2 and 3, respectively. Median follow-up was 41 months. Five (9.6%) patients with HPT2 and two patients (18.2%) with HPT3 had a recurrence of the disease. Conclusions: In patients with renal hyperparathyroidism, the primary indication for surgery was the presence of complications of PTH excess. A drop in PTHop ≥ 75% from baseline predicts healing in 98% and 100% of cases with secondary or tertiary HPT respectively. Surgery was a safe and effective treatment in both groups.

Hiperparatiroidismo primario: manejo quirúrgico / Primary hyperparathyroidism: surgical treatment

Background: Primary hyperparathyroidism (HPTP) is the most common cause of hypercalcaemia in the ambulatory setting. This condition affects between 0.1 -2 percent of the population. Surgery is the only curative treatment. Objective: The aim of the study is to present our 10-year surgical experience. Methods: Analytical-descriptive study. We included all patients diagnosed with HPTP treated with surgery in our hospital between June 2003 and June 2013. Results: 173 patients underwent surgery for HPTP. The mean age was 57.5 +/- 13.5 years. Asymptomatic in 98 cases (56.6 percent). Resection the abnormal parathyroid glands was performed in all cases with intraoperative PTH monitoring. In 167 patients (96.5 percent) intraoperative PTH declined ≥ 50 percent. The median follow-up was 61 months (1-117 months). Cure was achieved in 169 patients (97.7 percent). Four cases (2.3 percent) had recurrence. Conclusions: Surgery is effective and safe for the treatment of HPTP. A decline in intraoperative PTH > 50 percent predicts cure in 97.7 percent of cases.

Introducción: El hiperparatiroidismo primario (HPTP), es una entidad frecuente que afecta entre el 0,1 y 2 por ciento de la población. La cirugía es el único tratamiento curativo. Objetivo: Evaluar la eficacia y riesgos del tratamiento quirúrgico del HPTP. Material y Métodos: Estudio analítico-descriptivo. Se incluyó a todos los pacientes con diagnóstico de HPTP referidos para cirugía al Hospital Clínico de la Pontificia Universidad Católica de Chile entre junio de 2003 y junio de 2013. Resultados: 173 pacientes fueron operados en nuestra institución por HPTP. El promedio de edad de los pacientes fue de 57,5 +/- 13,5 años. La forma de presentación fue asintomática en 98 casos (56,6 por ciento) y sintomática en 75 casos (43,4 por ciento). Todos los pacientes fueron tratados con resección de la o las glándulas hiperfuncionantes con medición de PTH intraoperatoria. En 167 pacientes (96,5 por ciento) se logró caída de PTH intraoperatoria > 50 por ciento. Catorce pacientes (8,1 por ciento) presentaron complicaciones post operatorias. La mediana de hospitalización fue de 2 días (1 a 23 días). La mediana de seguimiento fue de 61 meses (6 a 117 meses). Se logró curación en 169 pacientes (97,7 por ciento). Cuatro casos (2,3 por ciento) presentaron recidiva. Conclusiones: La cirugía es eficaz y segura para el tratamiento del hiperparatiroidismo primario. Una caída de PTH intraoperatoria > 50 por ciento del valor basal predice curación en 97,7 por ciento de los casos.

Caracterización del compromiso óseo previo al trasplante hepático / Bone mineral density of patients with cirrhosis prior to liver transplantation

Osteoporosis is a common complication after liver transplantation. Aim: To assess bone mineral density of patients prior to liver transplantation. Material and Methods: Retrospective review of medical records of patients with liver cirrhosis, subjected to liver transplantation that had a measurement of bone mineral density prior to the operation. Results: Twenty nine of 112 transplanted patients complied with the inclusion criteria. Their mean age was 55 +/- 11 years, their body mass index was 26.9 +/- 3.2 k/m2, 73 percent were males and the period of clinical evolution prior to transplantation lasted 3.7 +/-2.9 years. Twenty four percent had an alcoholic liver disease, 21 percent C hepatitis and 14 percent non-alcoholic steatohepatitis. The main risk factors for osteoporosis were medication intake in 79 percent, alcohol in 52 percent, smoking in 41 percent and concomitant diseases in 31 percent. Bone mineral density was normal in 31 percent and showed osteopenia and osteoporosis in 48 and 21 percent of patients, respectively. Patients with a normal mineral density were younger than the rest of patients (46.9 +/- 13.4 and 58.5 +/- 7.4 years respectively p < 0.01). Conclusions: Patients subjected to liver transplantation had a high frequency of osteoporosis or osteopenia prior to the surgical procedure.

Efectos de la cirugía bariátrica sobre el metabolismo óseo / Effects of bariatric surgery on bone health

There is concern about the long term complications of bariatric surgery and among these, the derangements in bone metabolism that could increase the risk of osteopororosis. Most studies show an elevated bone turnover in operated patients with loss of bone mass, that are partially explained by the development of a secondary hyperparathyroidism. We have shown that, among postmenopausal women, bone resorption remains elevated, even five years after the operation, although not associated to loss of bone mass. The pathophysiology of these alterations is complex and includes an reduction in mechanical load and calcium absorption and postoperative changes in signaling hormones that have an effect on bone, coming from adipose tissue (estrogens, leptin and adiponectin), liver (insulin like growth factor-1), pancreas (insulin and amylin) or the bowel (ghrelin, glucagon-like peptide 2, peptide YY, gastric inhibitory polypeptide). Available evidence suggest that bariatric surgery should be considered a risk factor for osteoporosis. We recommend the incorporation of bone health in pre operative evaluation. We also give suggestions to prevent the adverse effects of bariatric surgery on bone health.

Actualizaciones en vitamina D / Updates in vitamin D

La importancia de la vitamina D en la homeostasis cálcica y salud ósea es ampliamente conocida. Su función principal es mantener niveles normales de calcio en el líquido extracelular, para lo cual estimula la absorción intestinal de calcio y su salida desde el hueso al extracelular. Estudios de casos-controles y ensayos controlados han demostrado que la hipovitaminosis D aumenta el riesgo de fracturas osteoporóticas y que éste disminuye con la suplementación farmacológica o ingesta dietética adecuada de vitamina D. La hipovitaminosis D es muy frecuente a nivel global y también en Chile, incluso en sujetos aparentemente sanos. En años recientes múltiples evidencias sugieren que la vitamina D también tiene importantes efectos no calcémicos en patologías como cáncer, enfermedades autoinmunes y cardiovasculares. En este artículo se revisa la importancia actual de la vitamina D en la osteoporosis, así como información relevante de los efectos no calcémicos de la vitamina D.

The importance of vitamin D in calcium homeostasis and bone health is widely known. Its main function is to maintain normal calcium levels in extracellular fluid, stimulating the intestinal absorption of calcium and its exit from the bone. Case-control studies and controlled trials have shown that vitamin D deficiency increases the risk of osteoporotic fractures and that the same decreases with pharmacological or dietary supplementation of adequate doses of vitamin D. Vitamin D deficiency is highly prevalent worldwide and also in Chile, even in apparently healthy subjects. In recent years many evidences suggest that vitamin D also has important non-calcemic effects in pathologies such as cancer, and autoimmune and cardiovascular diseases. In this article we review the current climportance of vitamin D in osteoporosis, as well as significant data about the non-calcemic effects of vitamin D.

Tratamiento quirúrgico del hiperparatiroidismo secundario a insuficiencia renal crónica / Surgical treatment of secondary hyperparathyroidism in hemodialysis: report of one case

Hyperparathyroidim secondary to chronic renal failure is a common form of presentation of renal osteodystrophy in patients on chronic hemodialysis. Treatment is based on the maintenance of adequate serum calcium and phosphate levels. However, when hyperparathyroid hyperplasia acquires a nodular form, it becomes refractory to medical treatment and total parathyroidectomy is indicated. We report a 37 years old male on hemodialysis, with a progressive secondary hyperparathyroidism that required the excision of the two superior parathyroid glands at the age of 29.Hyperparathyroidsm was not modified, serum PTH remained excessively high and the patient had a non traumatic femoral fracture. Therefore he was subjected to the excision of the two remaining parathyroid glands. During the postoperative period he had a severe hungry bone syndrome, but was discharged in good conditions, 15 days after the operation.

Hiperparatiroidismo primario en el adolescente: caso clínico / Primary hyperparathyroidism in an adolescent: report of one case

We report a 13 year-old mate with a history of multiple fractures and kidney stones. The laboratory showed a hypercalcemia of 11.5 mg/dl, a PTH of 112.6 pg/ml and 24 hour urinary calcium of 571 mg. Bone densitometry showed spine and fémur Z scores of -2.9 and -1.6, respectively, kidney ultrasound showed nephrocalcinosis and a MIBI-SPECT scintigram showed a higher uptake in the ríght lower parathyroid gland. The diagnosis of primary hyperparathyroidism was made and the patient was operated, excising the ríght lower parathyroid gland. After surgery, serum calcium and PTH levels returned to normal values. In children, the proportion of cases with parathyroid hyperplasia is higher than in adults. Therefore, during surgery all four parathyroid glands must be explored. There is also a higher frequency of ectopic adenomas. Family history must be explored to discard the presence of a multiple endocrine neoplasia (MEN I or II), a familial hyperparathyroidism or a syndrome of primary hyperparathyroidism associated to mandibular tumor.

Hiperplasia suprarrenal no clásica, características clínicas y genéticas / Clinical and genetic features of non classical adrenal hyperplasia

Background: The non classical form of congenital adrenal hyperplasia (NCAH) is increasingly recognized inhyperandrogenic patients, with variable phenotypic expression. Aim: To determine the clinical, hormonal, andgenetic characteristics of a group of patients with NCAH. Patients and methods: The medical records of 57NCAH patients were retrospectively reviewed. The diagnosis was established by basal or post-ACTH-stimulation 17-hydroxyprogesterone (17-OHP) levels >7 ng/mL and > 15 ng/mL, respectively. Patients with post-ACTH 17-OHP levels between 10-15 ng/mL, and with one identified allele o without genetic tests, were consideredas heterozygous. Genotyping for 10 mutations was performed by PCR. Results: The average age of diagnosis was 12.4 +/- 0.9 years. Six patients were male. Pubarche and hirsutism were the clinical signs more frequently described in patients below 10 years of age (25/29) and over 10 years of age (11/24), respectively. A basal 17-OHP > 7 ng/mL was observed in 36 patients; the post ACTH 17-OHP was between 10-15 and > 15 ng/mL in 5 and 17 patients, respectively. Genotype analyses were performed in 38 patients. V281L was carried on approximately 68.4 percent of all alleles and 29 percent of patients carried severe mutations. Only one of five possible carrier patients, was diagnosed as NCAH after the genetic test (V281L/ In2splice). Conclusions: Males with NCAH were apparently sub-diagnosed. Pubarche and hirsutism were the more frequently reported signs. The genetic test is complementary in the diagnosis of NCAH. One third of the patients carried a classic mutation and could have an increased risk to have siblings with Classical CAH.

Características de presentación del microcarcinoma papilar del tiroides. Experiencia retrospectiva de los últimos 12 años / Pathological characteristics of thyroid microcarcinoma. A review of 402 biopsies

Background: Thyroid microcarcinoma is a tumor of 10 mm or less, that should have a low risk of mortality. However, a subgroup of these carcinomas is as aggressive as bigger tumors. Aim: To describe the pathological presentation of these tumors, and compare them with larger tumors. Material and methods: All pathological samples of thyroid carcinoma that were obtained between 1992 and 2003, were studied. In all biopsies, the pathological type, tumor size, the focal or multifocal character, the presence of lymph node involvement and the presence of lymphocytic thyroiditis or thyroid hyperplasia, were recorded. Results: One hundred eighteen microcarcinomas and 284 larger tumors were studied. The mean age of patients with microcarcinoma and larger tumors was 42.7±14 and 49.3±16 years respectively (p <0,001) and 83% were female, without gender differences between tumor types. Mean size of microcarcinomas was 8.6 mm and 116 (98%) were papillary carcinomas. Of these, 109 (94%) were well differentiated and seven (6%) were moderately differentiated. Thirty six (31%) were multifocal and in 10 (8,6%), there was lymph node involvement. The mean size of larger tumors was 23.8 mm and 241 (85%) were papillary carcinomas. Of these, 200 (83%) were well differentiated, and 41 (17%) were moderately differentiated. Eighty five (35%) were multifocal and in 44 (18%) there was lymph node involvement. The prevalence of thyroiditis and hyperplasia was significantly higher among microcarcinomas than in larger tumors (15 and 2.5%, respectively, p <0.001, for the former; 32.4 and 1.7%, respectively, p <0.001, for the latter). Conclusions: In this series, one third of microcarcinomas were multifocal and 10% had lymph node involvement. Therefore, the aggressiveness of these tumors is higher than what is reported in the literature and they should be treated with total thyroidectomy.

Osteoporosis asociada a indinavir en paciente infectado por virus de inmunodeficiencia humana: comunicación de un caso y revisión de la literatura / Osteoporosis associated to indinavir in an HIV infected patient. case report and review

Se presenta el caso de un paciente de 45 años portador de VIH que desarrolló osteoporosis secundaria a 33 meses de exposición a sulfato de indinavir como parte de su terapia antiretroviral (TAR). Su manejo consistió en alendronato, calcio y vitamina D junto con modificación de su TAR: suspensión de indinavir e inicio de efavirenz. Luego de 16 meses de tratamiento se verificó un incremento en la densidad mineral ósea de 11 por ciento en promedio. No ocurrieron fracturas ni se constató efectos adversos o interacciones medicamentosas. Se revisa la literatura.

Efectos de la bromocriptina en pacientes con artritis reumatoide activa / Effects of bromocriptine in patients with active rheumatoid arthritis

Background: Neuroendocrine factors play an important role in the expression of autoimmune disease. Proclatin (PRL) can induce T-cell proliferation and macrophage activation. Elevated PRL levels have been described in patients with rheumatoid arthritis and (RA). Aim and Methods: We studiend immunological and clinical effects of PRL suppression in 9 RA patients with active disease, treated for 3 months with bromocriptiner (BRC), an inihibitor of PRL secretion. Results: BRC induced a significant depression of the peripheral blood mononuclear cells response to antigen (p=0.008) and mitogen (p=0.008) which was significantly correlated with improvements in the HAQ disability index (r=0.68; p=0.04) and grip strength (r=0.7; p=0.02). Also, the in-vitro production of IL-2, nitric oxide and poliamines -that are critical for the proliferative response of lymphoid cells- decreased significantly. The group experienced significant improvement of grip strength (p=0.028) and the HAQ disability index (p=0.025), whereas 4 individuals archieved clinical improvement according to the American College of Rheumatology preliminary definition. We conclude that BRC treatment induces a significant depression of in-vitro immune function in RA patients and these changes are related to parameters of disease activity. The effects of BRC on immune function and disease activity in RA patients warrant further investigation