David R. Pennes

Isotretinoin therapy is associated with early skeletal radiographic changes

Eight patients with disorders of keratinization (six with ichthyosis, one with Dariers disease, and one with palmar-plantar keratoderma) were treated with isotretinoin for 9 months (1 patient) to 1 year (7 patients). The patients ranged from 5 to 26 years of age. The average isotretinoin dose was 2 mg/kg/day (range, 1.0-2.9 mg/kg/day). Radiographic skeletal surveys were performed prior to therapy, and after 6 months and 1 year of therapy. After 1 year of isotretinoin treatment, six of the eight patients had small but unequivocal skeletal hyperostoses. Five of the patients had multiple hyperostoses. While only two patients were judged to have hyperostoses after 6 months of isotretinoin therapy during prospective evaluation, retrospective comparison with the radiographs obtained after 1 year revealed skeletal hyperostoses after 6 months of treatment in an additional three patients. Between 6 months and 1 year of therapy, some of the hyperostoses remained unchanged while others had progressed. In three patients, hyperostoses were seen at 12 months that were not detectable at 6 months. Based on this prospective study of skeletal changes during isotretinoin therapy, we recommend that patients taking high doses of isotretinoin for long periods be monitored radiographically.

Retinoid-induced ossification of the posterior longitudinal ligament.

Vitamin A and its synthetic congeners are known to produce a variety of skeletal abnormalities in patients on prolonged treatment with these medications. Two patients are described who developed posterior longitudinal ligament ossification following treatment with the synthetic retinoid 13-cis-retinoic acid. In both cases, this finding became apparent after other retinoid-induced skeletal abnormalities were observed and was less marked than the ossification of the anterior longitudinal ligament. Although spinal cord compression did not occur in our patients, patients on long-term retinoid therapy should be carefully observed for this complication.

Long-term radiographic follow-up after isotretinoin therapy

We evaluated the effects of long- and short-term isotretinoin therapy on the skeletons of patients. Eight patients who were treated with isotretinoin for disorders of keratinization received frequent radiographic evaluations for 4 to 9 years. Seven patients developed multiple hyperostoses at the spine and extremities. Hyperostoses increased in size and number over the course of therapy, although relatively few sites were symptomatic. Hyperostoses typically developed first in the spine and later in the extremities, where both bilaterally symmetric and asymmetric involvement was observed. After 5 years of therapy one patient did not develop hyperostosis. In a group of nine patients who received a relatively high dose of isotretinoin in 1982 for the treatment of acne, two patients developed tiny, asymptomatic hyperostoses. One patient had hyperostoses 1 year after isotretinoin therapy, which remained unchanged 3 years later, whereas the other patient had one hyperostosis 4 years after therapy had been stopped. Although we suspect that these hyperostoses were retinoid induced, they should not be of concern for the patient needing routine isotretinoin therapy for the treatment of cystic acne.

CT evaluation of mediastinal masses

CT is an important modality for imaging mediastinal masses, and certain CT attenuation features (fat, calcium, or water attenuation, contrast enhancement) are well known to suggest specific diagnoses. In a series of 132 consecutive patients with tissue-proven mediastinal masses, these specific CT features were present in only 16. We evaluated the ability of CT to differentiate soft tissue mediastinal masses based on morphology and distribution of disease. Metastatic disease and lymphoma accounted for 69% of masses in this series, and CT could not generally differentiate them. However, CT was helpful in differential diagnosis in certain settings. CT demonstration of multiple mediastinal masses when conventional radiographs showed a single mass generally excluded diagnoses such as thymoma and teratoma. CT demonstration of a single middle mediastinal mass, frequently missed by conventional radiography, made metastatic disease a much more likely diagnosis than lymphoma. Finally, CT demonstration of certain ancillary findings strongly favored a diagnosis of lymphoma (axillary adenopathy) or metastatic disease (solitary pulmonary mass, focal liver lesions, bone lesions).

What Hath God Wrought

Introduction: 1. Balaam spoke the words above to Balak, telling him nothing could stop God’s very great blessings. 2. The full context is found in Number 23:18-24, which describes certain blessing and favor on Israel. 3. Balak could mark his calendar from this time, for their success would be – What hath God wrought! 4. The words are no question at all – the words are a powerful exclamation as to the great work of God. 5. The words deserve an exclamation .... for Israel taking Canaan ... but God in Christ did much more! 6. The gifts and calling of God in Jesus Christ are without repentance by eternal decree (Rom 11:29). 7. He does not see iniquity or perversity in us, for He has forgotten our sins and clothed us with Christ. 8. There is no enchantment or divination against Gentiles, the church of God, for Jesus defeated Satan. 9. The most powerful foe, though weak in comparison, has been openly exposed at the cross of Jesus. 10. What hath God wrought! At Jesus Christ’s birth! His ministry! His death! Resurrection! Ascension!

Carpal Ligamentous Laxity with Bilateral Perilunate Dislocation in Marfan Syndrome

A case of persistent bilateral perilunate dislocation unrelated to trauma in a patient with Marfan syndrome is discussed. This finding is believed to be a manifestation of the generalized ligamentous laxity occurring in this disorder. Radiographs of eight additional Marfan syndrome patients failed to demonstrate similar carpal instability. Because some carpal derangements are dynamic events, stress views or wrist fluoroscopy may be necessary to demonstrate unsuspected carpal instability in Marfan patients.