Jeno I. Sebes

Unusual Roentgenographic Presentations of Multiple Myeloma

Three unusual roentgenographic manifestations of multiple myeloma have been presented: diffuse sclerosis, coexistent myeloma, amyloidosis, and solitary destructive myeloma involving almost an entire long bone. These appearances usually present diagnostic problems and a definite diagnosis is seldom made without biopsy or pertinent laboratory data. It is to be emphasized, nevertheless, that these manifestations are being recognized more and more frequently. Multiple myeloma should, therefore, be included when one considers the differential diagnosis of atypical skeletal roentgenograms.

Hypoparathyroidism Counteracts Risk Factors for Osteoporosis

Although increased bone density has been reported in patients with hypoparathyroidism, it is not known whether hypoparathyroidism can overcome the influence of risk factors for osteoporosis and whether the increased bone density is uniform throughout the entire skeleton or greater in certain regions depending on the bone composition and location. In the current study, bone density was measured in patients with postsurgical hypoparathyroidism and risk factors for osteoporosis. Bone mineral density was determined in eight patients with post-surgical hypoparathyroidism, one with idio-pathic hypoparathyroidism, and two with pseu-dohypoparathyroidism in eight different areas of the skeleton using well established methods: single photon absorptiometry of the radius, dual energy x-ray absorptiometry of the spine, hip, and the whole skeleton, and quantitative computed tomography of the spine. Risk factors for osteoporosis were documented in each subject. The data showed that despite the presence of 1–4 risk factors for osteoporosis, patients with postsurgical hypoparathyroidism had bone mineral density above the normal mean in most locations. The locations with the highest increment were the Wards triangle and the trochanter area of the proximal femur (dual energy x-ray absorptiometry) (Wards: Z score + 1.59 ± 0.57, P < 0.03; trochanter 1.31 ± 0.42, P < 0.02). The elevation of bone density was not observed in one patient with idiopathic hypoparathyroidism, and variable results were observed in two patients with pseudohypoparathyroidism. Based on these findings, in postsurgical hypoparathyroidism, the bone mineral density is above the normal mean despite the presence of risk factors for osteoporosis, and both cortical and trabecular bone are affected.

Calcaneal abnormalities and erosive bone disease associated with sickle cell anemia

Although the arthritis of sickle cell anemia has generally been considered noninflammatory, published studies suggest the existence of an inflammatory variety. The common association of bone abnormalities with inflammatory arthritis precipitated a radiographic evaluation of 100 patients, chosen at random from those followed at the University of Tennessee Sickle Cell Center. Erosive disease was identified in 14 percent. This was correlated with clinical manifestations in a longitudinal manner. Loss of definition of the cortical margin in the superior aspect of the calcaneus appears to be erosive in nature. It has not been observed previously and may be pathognomonic for sickle cell anemia. Arthrographic and gross pathologic material is presented in support of this hypothesis.

Diltiazem in the treatment of calcinosis in juvenile dermatomyositis.

Subcutaneous calcifications occur in a variety of diseases, including juvenile dermatomyositis. These calcifications cause disabling symptoms that do not always respond to immunosuppressant therapy. The calcium antagonist diltiazem reduces subcutaneous calcifications in CREST syndrome and in isolated cases of children with dermatomyositis. Our study was performed to determine the effects of diltiazem when used as adjunctive therapy in children with dermatomyositis.

Effect of Calcitriol and Pamidronate in Multiple Myeloma

Addition of bisphosphonates to standard treatment of multiple myeloma (MM) decreases bone pain and skeletal events without influencing bone healing. Calcitriol, besides its established effects on bone remodeling and calcium metabolism, has both immunoregulatory and cell differentiating effects in vitro and in vivo. Moreover, low serum calcitriol has been reported in MM. We tested the effects of supportive treatment with calcitriol and pamidronate on bone disease in two stage-III-B MM patients with diffuse bone involvement, normal serum calcium, and low serum calcitriol. Complete blood counts, serum calcium, creatinine, quantitative serum and urine immunoglobulins, and biochemical indices of bone turnover, serum calcidiol, calcitriol, parathyroid hormone, skeletal radiographs, and bone mineral density by dual x-ray absorbtiometry were measured every 1-6 months for 16 months in the first patient and 7 months in the second patient. Both patients showed a dramatic improvement of MM activity and in bone disease documented by serial radiographs in the first patient and by increased bone mineral density (approximately 15%) in the second. The reduced serum calcitriol in both patients and the elevated parathyroid hormone observed in the first patient before treatment returned to normal. Supportive treatment with pamidronate does not induce bone healing in MM. Therefore, the results observed with the addition of calcitriol suggest that this hormone may have contributed to the apparent arrest of the progression of MM and caused stimulation of bone healing.

Case report 129

Address reprint requests to: Randall L. Scott, M.D., Department of Diagnostic Radiology, University of Tennessee College of Medicine, Walter F. Chandler Building, 865 Jefferson Avenue, Memphis, TN 38163, USA multiple soft tissue masses of the face and chest wall. Physical examination at the time of admission showed an 8 x 9 cm smooth, hard, fixed, non-tender mass in the region of the right mandibular angle. A similar lesion was observed in the mid-forehead region. The laboratory data were normal. A complete skeletal survey, including studies of the skull and mandible, was obtained (Figs. 1, 2, and 3) as well as barium studies of the gastrointestinal tract (Fig. 4).