Graves' ophthalmopathy after total thyroidectomy for papillary carcinoma.

We report the case of a 53-year-old woman who underwent two-phase total thyroidectomy (June and December 2001) for a multinodular goiter with incidental discovery at the first procedure of a multicentric papillary carcinoma of the right thyroid lobe. Thyroidectomy was followed by an ablative dose of 131-radioiodine because of the presence of residual tissue in the neck. The various elements of the follow-up are reassuring: no residual tissue was detected at the ultrasonography of the neck and thyroglobulin was undetectable in the absence of antithyroglobulin autoantibodies. In April 2006, the patient developed unilateral Graves' ophthalmopathy with the appearance of antithyrotropin receptor autoantibodies (TRAb). Ophthalmopathy progressively improved, in parallel to the decrease of TRAb. The parallel trend of TRAb and the ophthalmopathy supports the major role of TRAb in the pathogenesis of thyroid-associated ophthalmopathy. This observation also shows the possibility of developing autoantibodies in the absence of detectable thyroid tissue.

Evaluation of in vitro bone resorption: high-performance liquid chromatography measurement of the pyridinolines released in osteoclast cultures.

None of the currently used methods to evaluate bone resorption by osteoclasts cultured on bone substrate measures directly the amounts of degraded bone collagen, which is a direct reflection of the osteoclast "work done." We therefore propose a reliable biochemical method to evaluate the in vitro collagenolysis process. Bone-resorbing activity was evaluated, after HPLC separation, by fluorimetric measurement of hydroxylysylpyridinoline (HP), a collagen cross-link molecule, released in culture supernatants. We first confirm previous data reporting that HP is released in the culture medium in a peptide-conjugated form. After acid hydrolysis, we show that HP is highly correlated with the lacunae area (r = 0.68, P<0.0001) and with the amounts of antigenic collagen fragments (Cross-laps for culture) released in culture medium (r = 0.77, P<0.0002). Using a cysteine protease inhibitor, we observed that lacunae areas are dramatically less inhibited (35% inhibition) than the release of bone-degraded products, including HP and antigenic collagen fragments (96 and 92% inhibition, respectively). Coupled to the resorbed area measurement, biochemical evaluations offer both quantitative and qualitative complementary measurements of the osteoclastic bone-resorbing process.

Long-term observations of vertebral osteoporotic fractures treated by percutaneous vertebroplasty.

OBJECTIVE: To assess the immediate and long-term efficacy and safety of percutaneous vertebroplasty with polymethylmethacrylate (PMMA) for the treatment of refractory pain resulting from osteoporotic vertebral fractures. METHODS: A retrospective, open study of percutaneous vertebroplasty (PV) was conducted with long-term follow-up. PV with PMMA was carried out between 1990 and 1996 in 40 patients with symptomatic osteoporotic vertebral fracture(s) that had not responded to maximum medical therapy. In 1997, each patient was asked to come back to our institution for a physical and spinal X-ray examination. Efficacy was assessed by changes over time in pain on Huskisson's visual analogue scale (VAS). RESULTS: Thirty-four vertebrae treated by PV in 25 patients were evaluated with long-term follow-up. The mean duration of follow-up was 48 months (range 12-84 months). Pain assessed by the VAS significantly (P<0.05) decreased from a mean of 80 mm+/-16 (S.D.) before PV to 37+/-24 mm after 1 month and 34+/-28 mm at the time of maximal follow-up. There was no severe complication related to this treatment, and no progression of vertebral deformity in any of the injected vertebrae. However, there was a slight but significantly increased risk of vertebral fracture in the vicinity of a cemented vertebra (odds ratio 2.27, 95% confidence interval 1.1-4.56). The odds ratio of a vertebral fracture in the vicinity of an uncemented fractured vertebra was 1.44 (0.82-2.55). CONCLUSION: PV appears to be a safe and useful procedure for the treatment of focal back pain secondary to osteoporotic vertebral fracture when conservative treatment has failed.

Polyarthritis following intravesical BCG immunotherapy. Report of a case and review of 26 cases in the literature.

OBJECTIVE: To delineate the characteristics of aseptic arthritis induced by intravesical BCG immunotherapy. METHODS: Review of a personal case and 26 cases from the literature. RESULTS: Mean number of intravesical BCG instillations at arthritis onset was five. Arthritis onset was within two weeks of the last instillation in 90% of cases. Half the patients had fever and half had conjunctivitis or uveitis. Symmetric polyarthritis was the most common pattern (n = 19), followed by oligoarthritis (n = 7). One patient had monoarthritis. The main targets were the knees (81%), ankles (48%), and wrists (40%). Twenty-six percent of patients reported back pain and 11% had sacroiliitis manifesting as pain or radiological changes. Mean erythrocyte sedimentation rate was 89 mm/h and mean C-reactive protein was greater than 70 mg/l. HLA B27 was positive in 56% of cases. Joint fluid usually exhibited inflammatory properties with polymorphonuclear neutrophils as the predominant cell type. Synovial membrane biopsy showed nonspecific synovitis in the six patients who had this investigation. Nonsteroidal antiinflammatory therapy was effective in 75% of cases. Three of the six patients given isoniazid and/or rifampin responded to this treatment. CONCLUSION: Although arthritis induced by intravesical BCG immunotherapy is more often polyarticular than oligoarticular, it shares many features with reactive arthritis.

Pathophysiology and treatment of idiopathic hypercalciuria.

Nearly 50 years after its initial description by Dr. F. Albright, the term idiopathic hypercalciuria (IH) is still in use. The exact mechanism of hypercalciuria is still unknown despite extensive pathophysiologic investigations; recent advances represent the focus of this review. A precise definition of true IH is proposed, taking into account the various nutritional conditions influencing calcium excretion. The potential pathogenic mechanisms are discussed, and the limits of the classical Pak's pathophysiological classification are recalled. The evidence supporting the role of an increased intestinal calcium absorption, a defect in renal tubular calcium reabsorption, or an increased bone loss as a primary mechanism in IH are successively examined. Since overall available human data indicates that all three mechanisms may be found in IH, the hypothesis that a broader disorder encompassing all these various abnormalities may be involved in IH is discussed. Three global hypotheses to account for IH physiopathology are examined: a diffuse defect in fatty acid content of cell membranes, an increased expression of the vitamin D receptor of the 25(OH) vitamin D 1 alpha-hydroxylase, or of the calcium sensor receptor and a monocyte disease. Finally, the available clinical data justifying the therapeutic approaches are reviewed, and guidelines for dietary recommendations regarding calcium and also animal protein, sodium chloride, alcohol, carbohydrate, phosphate, and potassium intakes are proposed, and drug therapy indications are discussed.

Two new cancer locations accompanied with palmar fasciitis and polyarthritis.

Only 35 cases of cancer with palmar fasciitis and polyarthritis have been published to date. We report two new cases, one with a transitional cell carcinoma of the renal pelvis and the other with an adenocarcinoma of the uterus. Neither of these locations has been reported in association with palmar fasciitis and polyarthritis. Palmar fasciitis with polyarthritis can occur in a wide range of cancers and warrants extensive investigations for a malignant tumor.