Anna Maria Scarponi

Large-artery stiffness: A reversible marker of cardiovascular risk in primary hyperparathyroidism

OBJECTIVE Patients with primary hyperparathyroidism (pHPT) are at increased risk of cardiovascular mortality. We investigated whether aortic stiffness, an early marker of arteriosclerosis and a strong predictor of cardiovascular risk, is increased in pHPT, and whether it improves after parathyroidectomy. METHODS Twenty-four patients with mild pHPT (age 56 ± 10 years, blood pressure 136/85 mmHg, serum calcium 2.55-3.00 mmol/L) and 48 control subjects individually matched with cases by age, sex and blood pressure underwent aortic (carotid-femoral) and upper-limb (carotid-radial) pulse wave velocity (PWV) determination by applanation tonometry in a case-control study. Subjects with renal disease, diabetes, treated hypertension or overt cardiovascular disease were excluded from the study. Seventeen of the patients with pHPT were re-examined 4 weeks after surgical parathyroidectomy. RESULTS Aortic PWV was significantly higher among pHTP patients (11.4 ± 2 vs 9.6 ± 2 m/s, p<0.001). In a conditional logistic regression analysis, pHPT was independently associated with an increased risk of having an aortic PWV >12 m/s (odds ratio 3.28, 95% confidence interval 1.21-8.93). As expected, surgery was accompanied by a reduction in serum calcium (from 2.77 ± 0.2 to 2.25 ± 0.1 mmol/L, p<0.001) and parathyroid hormone (from 29.6 ± 10 to 3.3 ± 2 pmol/L, p<0.001). Aortic PWV decreased after surgery (from 10.9 ± 2 to 9.8 ± 2 m/s, p=0.003). The change in aortic PWV remained significant also after adjustment for changes in blood pressure (p<0.01). Changes in upper-limb PWV generally paralleled those in aortic PWV. CONCLUSION pHPT is associated with increased aortic stiffness, which improves after parathyroidectomy. Our data demonstrate that aortic stiffness may improve upon removal of hyperparathyroid stimuli.

Diffuse muscoskeletal pain and proximal myopathy: do not forget hypovitaminosis D.

A 20-year-old vegetarian man was admitted to our hospital complaining of muscle weakness and gait disturbances of 4 years duration. For the past 5 years, he had major depression and had confined himself at home. He exhibited tenderness upon palpation of the chest, sternum and proximal muscles. Hypocalcemia, hypophosphatemia, vitamin D deficiency, increased levels of alkaline phosphatase, and intact parathyroid hormone were noted. An x-ray skeletal survey revealed generalized osteopenia, multiple vertebral and costal fractures, and a pelvis deformed into the shape of a triangle. A diagnosis of osteomalacia secondary to vitamin D deficiency from lack of exposure to sunlight and to inadequacy of the diet was made. The patient was started on a treatment with 20,000 IU of vitamin D3 once a week plus 1 g/d of calcium. Eight months later, gait disturbances have significantly improved and laboratory findings have all normalized.

Cervical spondylodiscitis with spinal epidural abscess caused by Aggregatibacter aphrophilus

Spondylodiscitis caused by Aggregatibacter aphrophilus, formerly known as Haemophilus paraphrophilus, is an unusual condition and can be very difficult to diagnose. We report a case of cervical spondylodiscitis complicated by spinal epidural abscess in a 63-year-old woman, without underlying predisposing conditions. The source of infection was identified as a periodontal infection. The patient was successfully treated with systemic antibiotics.

Postprandial Endothelial Impairment and Reduced Glutathione Levels in Postmenopausal Women

Background/Aim: Postmenopausal age is characterized by a higher risk for coronary heart disease (CHD) and postprandial lipemia is strictly related with the evidence of CHD. The aim of the study was to clarify the vascular effects of postprandial state in postmenopausal women. Methods: Ten postmenopausal women (mean age 57 ± 8 years) without vascular risk factors and history of cardiovascular disease underwent an oral fat load test. Endothelial function, expressed as brachial flow-mediated vasodilation (FMV), lipid parameters and reduced glutathione (GSH) were evaluated at baseline and 2, 4 and 6 h after the load. Results: FMV showed a significant decrease at the 2nd hour (2.3 ± 2.6%, vs. baseline 7.7 ± 2.8%, p < 0.05) and overlapping to the basal value after 4 h. Triglycerides increased postprandially at the 2nd and 4th hour (1.6 ± 0.6 µmol/l, 1.8 ± 0.5 µmol/l vs. baseline 0.9 ± 0.4 µmol/l, p < 0.05), decreasing thereafter. GSH decreased at the 2nd hour of the postprandial phase (5.1 ± 1.9 µmol/l vs. baseline 8.4 ± 1.9 µmol/l, p < 0.05), normalizing successively. At the univariate analysis a negative correlation was found between FMV and triglyceride changes (r = –0.37, p < 0.05) and a positive one between FMV and GSH modifications (r = 0.40, p < 0.05). Conclusion: These data demonstrated that postprandial lipemia transiently impairs endothelial reactivity by an oxidative burden, partly dependent to triglyceride increase.

Loss of bone mineral density and secondary hyperparathyroidism are complications of autologous stem cell transplantation

Patients who underwent autologous stem cell transplantation (ASCT) are prone to decreased bone mineral density (BMD). We measured BMD in 180 patients who underwent ASCT for hematologic malignancies. Patients were evaluated with a median of 6.2 years after ASCT. Twenty patients who received only chemotherapy were evaluated as controls. The loss of bone mass was greater during the first year after ASCT, since majority of patients recover BMD and normalize bone turnover markers during the following years. After ASCT, over half of the patients show osteopenia or osteoporosis independent of the sex. According to the results of other groups, our results emphasize the potential usefulness of antiresorptive agents to prevent or treat post-ASCT osteopenia or osteoporosis, and the importance of the measurement of BMD as an integral component to the follow-up of ASCT.

Association between thyroid hormone levels, the number of circulating osteoprogenitor cells, and bone mineral density in euthyroid postmenopausal women.

In postmenopausal women, an association between reduced bone mineral density (BMD) and increased number of circulating osteoprogenitor cells (COPs) has been found. Although an increased thyroid function is associated with BMD, thyroid hormones stimulate osteoblast function in vitro. We investigated whether thyroid hormones within the reference range were correlated with the number of COPs and stimulate mineralization in vitro. The number of COPs, defined as CD34+/alkaline phosphatase (AP)+ or CD34+/osteocalcin (OCN)+ cells, was quantified by fluorescence-activated cell sorting (FACS) analysis in 150 euthyroid postmenopausal women. Participants underwent measurement of serum free thyroxine (FT4), thyroid-stimulating hormone levels, and femur BMD. CD34+ cells were isolated from healthy volunteers irrespective of AP or OCN expression, and the effect of triiodothyronine (0.5-10 pmol/L)) on their ability to form mineralized nodules in vitro was studied. The number of COPs was highest among women with high-normal FT4 levels (>1.09 ng/dL). The FT4 levels were correlated positively with circulating log-CD34+/AP+ (r = 0.32, P < .001) and log-CD34/OCN+ cells (r = 0.36, P < .001) and inversely with total femur BMD (r = -0.17, P = .036) but not with femoral neck BMD. In a multivariate analysis, the FT4 levels were positively correlated with the number of COPs, independent of age and BMD. The ability of CD34+ cells to form mineralized nodules increased after exposure from low up to high-normal triiodothyronine concentrations (P for trend = .003). Among euthyroid postmenopausal women, high-normal FT4 levels are correlated with an increased number of circulating immature osteoprogenitor cells and a very mild BMD reduction. Exposure of CD34+ cells to physiological triiodothyronine concentrations stimulates mineralization in vitro.

STRONGYLOIDES STERCORALIS INFECTION IN A PATIENT WITH CROHN'S DISEASE

Our patient had prostatic enlargement and a history of recurrent urinary tract infections, which are among the risk factors described for men with urinary tract infection due to Gardnerella vaginalis (8). In the literature, we found only five cases of men with bacteremia due to this organism. In three of these patients, the bacteremia was preceded by transurethral prostatic resection and, as in our case, it was impossible to establish microbiologically the source of bacteremia (3, 5, 6). Another patient had a urethral stenosis (2), and the fifth patient had a lung abscess but not urinary tract infection (4).

Relationships between global physical activity and bone mineral density in a group of male and female italian students

BACKGROUND Peak of bone mass (PBM) is generally reached about the age of 18 both in boys and girls. Maximizing PBM during growth may contribute to fracture risk reduction in adulthood and in the elderly. The aim of our study was to evaluate the effects on bone mineral density (BMD) of global physical activity (PA), carried out in the past 15 years, in a population of 70 healthy, young male and female subjects aged 22 to 25. METHODS BMD of the lumbar spine and total hip was measured using dual-energy X-ray absorptiometry (DEXA); global PA, resulting from sports-related, occupational and commuting PA, was evaluated using validated questionnaires. RESULTS Women spent more time than men both in sports-related, occupational and commuting PA in the age range between 10-15 years. In the female group global PA positively correlated with BMD of the lumbar spine (r=0.38; P=0.02) and the total hip (r=0.36; P=0.04) and BMD of the lumbar spine was independently predicted by global PA and Body Mass Index. CONCLUSIONS Our retrospective cross-sectional study indicates that global PA, not only sports-related PA, performed during prepubertal age, is associated with a greater PBM in women.

An unusual emphysema

An 87 year-old woman with a history of hypertension, type 2 diabetes and post-menopausal osteoporosis presented with a 5-day history of low-grade intermittent fever, epigastric pain and shortness of breath. At admission, patient was normotensive but tachycardic (HR 106 beats/min) and tachypneic (RR 26 breaths/min), and oxygen saturation was 96% while she was breathing ambient air. Respiratory examination revealed decreased breath sounds in the left base with dullness on percussion; examination of heart and abdomen was unremarkable. Initial laboratory work-up showed neutrophilic leukocytosis (WBC22.500/mm, neutrophils 92%) and elevated values of erythrocyte sedimentation rate (120 mm/h), C-reactive protein (18 mg/dL) and procalcitonin (0.2 ng/mL). Electrocardiogram showed sinus tachycardia and troponin I was within normal limits. Blood and stool cultures were negative. A chest X-ray disclosed aortic ectasia and left sided pleural effusion. A computed tomography scan of the chest revealed the presence of descending thoracic aortic aneurysmwith focal dissection and multiple bubbles of gas infiltrating the aortic wall (Fig. 1. Panels A & B).