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Acromegalic Arthropathy

Acromegaly with Arthropathy

Acromegalic arthropathy (AA) denotes a chronic degeneration of axial or peripheral joints because of acromegaly, which is caused by an excessive production of growth hormones. Early AA is noninflammatory and gradually develops typical osteoarthritic symptoms in later stages. Long-lasting joint pain in hips, shoulders, knees, hands or elbows, as well as a backache and unexplained headache, may indicate an early stage of AA.

Early recognition of AA is imperative since joint degenerations are irreversible in later stages and can only be partly reversed by growth hormone regulation therapies.


Presentation

Acromegalic arthropathy often runs unnoticed for a long time in patients with diffuse and unspecific pain in axial or peripheral joints and in the back. General morning stiffness is also frequently reported. Pain episodes can last from weeks to months. Back pain is typically located in the lumbosacral part with rare involvement of the thoracic and cervical parts [1] [2].

The pain sensation is caused by persistently elevated somatotropin and insulin-like growth factor 1 (IGF-1) levels [3]. The reason for elevated growth hormone levels is often a pituitary tumor or in rare cases an ectopic source of growth hormone production. AA usually persists after tumor removal. AA is progressive and only reversible in early stages. In the initial phase, patients may present with bone, cartilage and soft tissue hypertrophy, peripheral nerve enlargement and carpal tunnel syndrome. Arthropathic symptoms are usually the first indication for acromegaly. 70% of cases suffer from AA complaints at the time of the diagnosis. AA is often diagnosed together with diabetes mellitus, hypertension and arthritis [4] [5].

In principle, all bones and joints can be affected by the endocrine disorder. However, most frequent degenerations involve hips, shoulders, knees, hands or elbows. Excess growth hormone in AA victims leads to an increased bone mineral density (BMD), which may be related to a reduced fracture risk [6]. In the further progression of AA, irreversible joint degeneration leads to a significant impairment of the patient's joint mobility. However, back mobility has been reported to be spared and sometimes even enhanced in AA [2].

Asymptomatic
  • Regarding clinical presentation: 17 (35.4%) were asymptomatic, 10 (20.8%) presented knee pain, ten arthralgias, 5 (10.4%) shoulder knee pain, other being more rare.[endocrine-abstracts.org]
  • It should be realized that the most of these fractures were asymptomatic. Fractures were also evident in men, especially in the presence of hypogonadism.[link.springer.com]
  • Patients may be asymptomatic between attacks. During an attack the Achilles tendon is warm, erythematous, swollen, and tender to palpation.[what-when-how.com]
  • Magnetic resonace imaging (MRI) shows an increase in the amplitude and intensity of the median nerve signal in the patients with symptomatic carpal tunnel syndrome compared to asymptomatic patients [ 16 ].[ojrd.biomedcentral.com]
  • Osteoporosis accounts for approximately 1.5 million fractures in the United States each year Osteoporosis: Approximately 1/3 of all vertebral fractures are painful but 2/3 are asymptomatic Hip fractures are assoc w/ permanent disability in nearly 50%[rheumpearls.com]
Hand Pain
  • High levels of pain and functional impairment at baseline were related to clinical progression of hand pain and functional limitations. High baseline BMI was a risk factor for functional deterioration in the lower limb.[ncbi.nlm.nih.gov]
  • See When Hand Pain Is Osteoarthritis Exercise-induced compartment syndrome – this condition causes pain over the front of the shinbone, usually occurring after periods of activity.[arthritis-health.com]
Regurgitation
  • Wooley, MD Advances and diagnostic imaging in a surgical technique have changed the approach to mitral valve regurgitation. This chapter provides an expert's perspective.[books.google.com]
  • Complications: Increased cardiovascular morbidity and mortality from hypertension, cardiomyopathy, heart failure, or valvular regurgitation.[rheumaknowledgy.com]
  • Treatment should be stopped if echocardiography shows new or worsened valvular regurgitation, valvular restriction or valve leaflet thickening [ 11 ].[patient.info]
  • […] control also results in better control of hypertension and cardiac function, reducing the use of antihypertensive drugs. 33 Furthermore, we recently observed 34 that somatostatin analogues did not significantly modify the incidence and severity of valve regurgitation[touchendocrinology.com]
Arthritis
  • We describe 2 cases of acromegaly presenting with rheumatologic manifestations, the first resembling seronegative rheumatoid arthritis, the second, post traumatic low back syndrome.[ncbi.nlm.nih.gov]
  • Also Read Identifying The Symptoms Of Joint Arthritis Signs And Symptoms Of Joint Arthritis The Various Causes Of Joint Arthritis Enlarged Tongue Enlarged tongue is yet another significant symptom of Acromegalic arthropathy.[findarthritistreatment.com]
  • AA is often diagnosed together with diabetes mellitus, hypertension and arthritis. In principle, all bones and joints can be affected by the endocrine disorder. However, most frequent degenerations involve hips, shoulders, knees, hands or elbows.[symptoma.com]
  • Track disease progression and treat patients more effectively with the information on genetic findings, imaging outcomes, cell and biologic therapies, rheumatoid arthritis, and SLE.[books.google.com]
  • […] osteomyelitis Sarcoidosis Sarcoidose Saturnine gout Saturnine gigt Scheuermann's osteochondritis Scheuermanns osteochondritis Scleroderma Sklerodermi Septic arthritis Septisk arthritis Seronegative arthritis Seronegative gigt Shigella arthritis Shigella[k10.dk]
Osteophyte
  • RESULTS: Progression of osteophytes and JSN was observed in 72 and 74% of patients respectively. Higher age predisposed for osteophyte progression.[ncbi.nlm.nih.gov]
  • The hip joint changes in acromegaly represent a peculiar arthropathy, which is characterized by prominent, proboscis-like medial osteophytes, moderate chronic lymphoplasmacytic synovitis, an irregular pitting of the subchondral bone observed roentgenographically[ncbi.nlm.nih.gov]
  • A case of a female patient with characteristic hand joint and sesamoid bone osteophytic changes related to acromegalic arthropathy is presented.[ncbi.nlm.nih.gov]
  • Osteophytes, cartilage defects, bone marrow lesions and subchondral cysts were assessed by the Knee Osteoarthritis Scoring System (KOSS) method.[ncbi.nlm.nih.gov]
  • Kloppenburg, Arthropathy in long-term cured acromegaly is characterised by osteophytes without joint space narrowing: a comparison with generalised osteoarthritis. Ann. Rheum. Dis. 70 , 320–325 (2011) PubMed CrossRef Google Scholar 2. N.R.[link.springer.com]
Back Pain
  • A reported combination of persisting and long-lasting joint pain, unspecific back pain and unexplained headache episodes should guide the clinical investigations.[symptoma.com]
  • Later in life, the patient may be prone to back pain due to osteoarthritis.[arthritis-health.com]
  • It can result in a loss of height, severe back pain, and change in posture.[disabled-world.com]
  • Approximately half of the patients with acromegaly experience back pain, which is predominantly lumbosacral. Hypermobility of the spine may be a contributing factor in back pain.[what-when-how.com]
  • Articular overgrowth of synovial tissue and arthropathy leading to arthralgia and osteoarthritis in 24%, back pain and kyphosis. Visceral hypertrophy - eg, heart, thyroid (with a multinodular goitre), liver and spleen.[patient.info]
Osteopenia
  • […] changes in acromegaly represent a peculiar arthropathy, which is characterized by prominent, proboscis-like medial osteophytes, moderate chronic lymphoplasmacytic synovitis, an irregular pitting of the subchondral bone observed roentgenographically, and osteopenia[ncbi.nlm.nih.gov]
  • Radiographs may show juxtaarticular osteopenia and cystic lesions. Large bone cysts have been noted in a few patients. Xanthoma and bone cysts are also observed in other lipoprotein disorders.[what-when-how.com]
  • […] obstruction Metabolic: [1] [2] [6] Insulin resistance Impaired glucose metabolism Diabetes mellitus Visceral: [1] [6] Organ enlargement Colon polyps Fluid retention Renal failure Musculoskeletal: [2] Arthropathy/osteoarthritis Carpal tunnel syndrome Osteopenia[physio-pedia.com]
  • Almost all hip fractures occur as a result of falls Patients on steroids fracture at a higher T-score than do patients with other types of osteoporosis Radiographic signs of Gaucher disease include bone infarcts, osteopenia and â œErlenmeyer flask⠝[rheumpearls.com]
Morning Stiffness
  • General morning stiffness is also frequently reported. Pain episodes can last from weeks to months. Back pain is typically located in the lumbosacral part with rare involvement of the thoracic and cervical parts.[symptoma.com]
  • Patients with OA typically have morning stiffness lasting for OA most commonly affects the hips, knees, and hands (PIP and DIP joints). If used, intra-articular steroid i...[5minuteconsult.com]
  • Patients may experience morning stiffness. Joint tenderness and periarticular hyperesthesia may also be present, as may synovial thickening.[what-when-how.com]
Narrow Face
  • Characteristic facial features include a long, narrow face; a high forehead; flushed (reddened) cheeks; and a small, pointed chin. In addition, the outside corners of the eyes may point downward (down-slanting palpebral fissures).[icdlist.com]

Workup

Acromegalic arthropathy diagnosis is based on the thorough history, physical examination, radiography and laboratory tests.

A reported combination of persisting and long-lasting joint pain, unspecific back pain and unexplained headache episodes should guide the clinical investigations. An immediate assessment of joint swelling, crepitus, tissue tenderness near the affected joint and joint mobility is indicated because a thickening of periarticular tissues is often described [2] [7].

Bone hypertrophy can be assessed with radiography. Increased cartilage thickness, widened joint spaces and the observation of osteophytosis near joint margins in knees and hips and in the intracondylar notch of knees. Osteophytosis has also been reported in thoracic and lumbar vertebrae along with frequent dorsal kyphosis. Synovial effusion is rare but possible [2].

Diagnosis must be finalized with irrefutable proof of elevated serum growth hormone (GH) and IGF-1 levels. Only a random GH value of less than 0.04 µg/l can definitely rule out AA. The best evidence is provided by the inability to suppress GH secretion to less than 1 µg/l within 2 hours after an oral glucose load of 75 g. Further endocrinological workup may be required to control excess growth hormone production [8] [9] [10].

Joint Space Narrowing
  • Radiographic progression of joint disease was defined by the Osteoarthritis Research Society International classification as a 1-point increase in joint space narrowing (JSN) or osteophyte scores on radiographs of the hands, knees, and hips obtained at[ncbi.nlm.nih.gov]
  • However, persistent abnormal GH secretion despite somatostatin analogs is not a straight forward explanation, since active acromegaly is associated with joint space widening, rather than with joint space narrowing.[link.springer.com]
  • A comparison between patients with and without joint space narrowing (JSN). Growth Horm IGF Res 2013;23:159-164.[karger.com]
  • With breakdown and loss of cartilage,the joint space narrows, and subchondral sclerosis and osteophytes appear on radiographs. Joint examination reveals marked crepitus and hypermobility.Joint fluid is noninflammatory.[what-when-how.com]

Treatment

  • An early diagnosis is crucial to obtaining the optimal treatment due to the potential reversibility of the lesions in an early stage. The aim of this case report is to draw attention to the possible articular involvement of acromegaly.[ncbi.nlm.nih.gov]
  • Arthropathy and quality of life should be carefully evaluated in acromegalic patients, despite successful long-term treatment.[endocrine-abstracts.org]
  • In addition, T2 relaxation times of cartilage are high in active patients, indicating unhealthy cartilage with increased water content, which is (partially) reversible by adequate treatment.[ncbi.nlm.nih.gov]
  • In previous studies, GH secretion was still slightly abnormal during treatment with SMS analogs, despite appropriate biochemical control according to current criteria [ 5 ].[link.springer.com]
  • If the disease is left untreated for long time, the osteo-articular sequelae cannot be modified by any treatment of acromegaly.[ncbi.nlm.nih.gov]

Prognosis

  • OBJECTIVE: Arthropathy is an invalidating complication of acromegaly, of which the prognosis and determinants are currently unknown in treated acromegaly.[ncbi.nlm.nih.gov]
  • […] of chapters throughout allows readers to easily scan through for the information required Useful summary boxes outline the main points of each condition including aetiology, pathology, epidemiology, clinical features, investigations, management and prognosis[books.google.de]
  • Prognosis: While the disease can be controlled, in most cases the joint findings of acromegaly are not reversed with correction of growth hormone overproduction.[rheumaknowledgy.com]
  • Prognosis High levels of GH, even when the patient has no symptoms, are associated with a 1.72 increase in all-cause mortality compared with the general population, mainly due to cardiovascular complications [ 2 ].[patient.info]
  • Treatment and prognosis The treatment of choice is resection of the secreting adenoma, usually via the transsphenoidal approach .[radiopaedia.org]

Etiology

  • Etiology Pathophysiology Excess GH secretion before the conclusion of longitudinal growth (i.e., prior to epiphyseal plate closure) leads to pituitary gigantism with a possible height of 2 m.[amboss.com]
  • Is adolescent osteomalacia an etiological factor in sympathetic dystrophy? JOURNAL OF BACK AND MUSCULOSKELETAL REHABILITATION / vol.21, pp.67-70 / 2008 Karkucak M.[profdrmuratkarkucak.com]
  • […] values seen in patients with acromegaly. [2] Growth hormone concentrations of less than 2.5 ng/ml are associated with mortality rates similar to the normal population. [4] Thus normalization of GH levels is currently defined as below 2.5 ng/ml. [7] Etiology[physio-pedia.com]
  • Mycoplasma hominis as an etiologic agent for septic arthritis in patients who have undergone genitourinary manipulation. Neuropathic joints occur in 25% of patients with syringomyelia. The most common joint is the shoulder with about 80% occurrence.[rheumpearls.com]
  • […] commonly caused by a somatotroph pituitary adenoma with autonomous overproduction of growth hormone (GH) ( Table 1 ). 1 – 7 Its worldwide prevalence is 40–70 cases per million and incidence is approximately three to ten cases per million. 8 – 10 Table 1 Etiology[dovepress.com]

Epidemiology

  • […] understanding whilst avoid unnecessary detail thus saving time Uniform style of chapters throughout allows readers to easily scan through for the information required Useful summary boxes outline the main points of each condition including aetiology, pathology, epidemiology[books.google.de]
  • Epidemiology References: [1] [2] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • Colao A, Ferone D, Marzullo P et al (2004) Systemic complications of acromegaly: epidemiology, pathogenesis and managment. Endocr Rev 25:102–152 PubMed CrossRef Google Scholar 3. Marie P (1886) Sur deux cas d’acromegalie.[link.springer.com]
  • Colao A, Ferone D, Marzullo P, Lombardi G: Systemic complications of acromegaly: epidemiology, pathogenesis, and management. Endocr Rev 2004;25:102-152.[karger.com]
  • Epidemiology Acromegaly is a rare disease, with a prevalence of 40 to 70 cases per million inhabitants and an annual incidence of 3 to 4 new cases per million inhabitants [ 1 ].[ojrd.biomedcentral.com]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiologic relationship between these entities remains obscure.[ncbi.nlm.nih.gov]
  • We remain committed to the case method of instruction, and believe that there is no better method to learn medicine than to have an individual patient problem as the basis for study of pathophysiology, natural history, diagnosis and management.[books.google.com]
  • Therefore, it may be possible that SMS analogs contribute to the pathophysiology of the progression of acromegalic arthropathy.[link.springer.com]
  • Etiology Pathophysiology Excess GH secretion before the conclusion of longitudinal growth (i.e., prior to epiphyseal plate closure) leads to pituitary gigantism with a possible height of 2 m.[amboss.com]

Prevention

  • Longitudinal studies are required to assess both the contribution of risk factors for these fractures including vitamin D, (replacement for) hypopituitarism, and of glucocorticoid replacement at a low dose and the optimal treatment modalities to prevent[link.springer.com]
  • Diagnosis and management of acromegaly; the patient’s perspective: This study focuses on early diagnosis of acromegaly as the key success factor in the prevention of related diseases and premature death.[pituitaryworldnews.org]
  • However, when caught early, all of these arthritic conditions and disorders can be treated and the symptoms either reduced or prevented. In many cases, the symptoms can be easily managed with therapies, drugs and lifestyle type changes.[erheumatoidarthritissymptoms.com]
  • Polyps can be a precursor to colon cancer—and people with acromegaly need to be watched for the formation of polyps to prevent them from becoming cancerous. Your doctor will recommend regular colonoscopies to find and treat any polyps.[endocrineweb.com]
  • Prevention There is no known prevention for acromegaly. However, early diagnosis and treatment is needed to improve outcomes. Targeted genetic screening has been suggested in people of Irish descent who have acromegaly or gigantism.[patient.info]

References

Article

  1. Claessen KMJA, Ramautar SR, Pereira AM, et al. Increased clinical symptoms of acromegalic arthropathy in patients with long-term disease control: a prospective follow-up study. Pituitary. 2014;17(1):44-52.
  2. Bluestone R, Bywaters EGL, Hartog M, Holt PJL, Hyde S. Acromegalic arthropathy. Ann Rheum Dis. 1971; 30(3): 243-258.
  3. Giustina A, Chanson P, Kleinberg D, et al. Expert consensus document: A consensus on the medical treatment of acromegaly. Nature Reviews Endocrinology. 2014; 10:243–248.
  4. Tagliafico A, Resmini E, Ferone D, Martinoli C. Musculoskeletal complications of acromegaly: what radiologists should know about early manifestations. Radiologia Medica. 2011;116(5):781-792.
  5. Killinger Z, Kužma M, Sterančáková L, Payer J. Osteoarticular Changes in Acromegaly. International Journal of Endocrinology. 2012; 2012:839282.
  6. Giuseppina P, Graziella B, Laura I, et al. Prevalence of osteoporosis and vertebral fractures in acromegalic patients. Clinical Cases in Mineral and Bone Metabolism. 2011; 8(3): 37–43.
  7. Colao A, Pivonello R, Scarpa R, Vallone G, Ruosi C, Lombardi G. The acromegalic arthropathy. J Endocrinol Invest. 2005;28(8):24-31.
  8. Sata A, Ho KK. Growth hormone measurements in the diagnosis and monitoring of acromegaly. Pituitary. 2007;10:165–172.
  9. Melmed S. Acromegaly pathogenesis and treatment. J Clin Invest. 2009; 119(11), 3189–3202.
  10. Melmed S, Colao A, Barkan A, et al. Guidelines for acromegaly management: an update. J Clin Endocrinol Metab. 2009;94(5):1509–1517.

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Last updated: 2019-07-11 20:42