OSTEOPOROSIS. JOINTS. FINGER CLUBBING. SPINAL ABNORMALITIES

1949 Lowe CU, May CD, Reed SC. Fibrosis of pancreas in infants and children: statistical study of clinical and hereditary features. Am J Dis Child 1949; 78:349-374. [PubMed]
These authors from the University of Minnesota reviewed the hereditary aspects of 134 patients with CF seen over 10 years at the Infant's and Children’s Hospital, Boston where previously May had worked. There were 118 sibships and the authors concluded that the condition was determined by a recessive gene as had Andersen and Hodges (Andersen & Hodges, 1946 above). They noted good weight gain before first symptoms and fair gains thereafter in those who survived. In discussing the clinical features they noted 44 children showed osteoporosis and retarded bone age. They questioned the importance of vitamin A deficiency in the pathogenesis as had others.
This is one of the earliest mentions of osteoporosis in people with CF – a complication that was to become a major problem for adults with CF in the years to come.

1978 Erkkila JC, Warwick WJ, Bradford DS. Spine deformities and cystic fibrosis. Clin Orthop Relat Res 1978; 131:146-150. [PubMed]
Of 203 patients with CF 21.5% had more than 35 degrees of kyphosis – the prevalence increasing with age. The prevalence of significant scoliosis with curves greater than 10 degrees was similar to the general population. (Kumar N, et al. 2004 below found an increased prevalence of 15.6% of scoliosis in Leeds patients - some 20 times expected in people of similar age).

1979 Newman AJ, Ansell BM. Episodic arthritis in children with cystic fibrosis. J Pediatr 1979; 594-595. [PubMed]
Barbara Ansell was the leading UK authority on joint disease in children. Referred to her were five children aged two to 10 years with CF who developed transient episodic arthritis. Although polyarticular in distribution, only one joint may be involved during each attack. There was no radiological or laboratory evidence of juvenile chronic arthritis and no permanent joint limitation occurred.
Further reports followed of arthritis in people with CF (Vaze D. J Pediatr 1980; 96:346) including one with rheumatoid arthritis (Sagransky DM, et al, Am J Dis Child 1980; 134:319-320).
We later reported a clear relationship between the joint problems and the activity of the chest infection in children with CF - the problem obviously worsening during exacerbations of respiratory infection and quite obviously improving during a course of intravenous antibiotic treatment for the exacerbation (Bowler I & Littlewood J. Lancet 1992; 340:244).

1979 Mischler EH, Chesney PJ, Chesney RW, Mazess RB. Demineralization in cystic fibrosis detected by direct photon absorptiometry. Am J Dis Child 1979; 133:632-635. [PubMed]
Bone mineral content, bone width, and their ratio were measured in patients with CF using monoenergetic photon absorptiometry. Serial measurements of the radius and ulna were made in 27 patients with CF and were compared with 968 age-matched controls. Demineralization was found in 37% of the boys and 63% of the girls. Patients under age 10 years had normal bone mineral content and nine of 15 patients aged 13 or older were demineralised (P<0.01). Demineralization correlated with the extent of weight reduction in patients (P<0.001). Patients most likely to be demineralised were adolescent girls.
This appears to be the first study of bone mineral status of children with CF indicating that a sizable proportion of people with CF may be demineralised without having overt rickets. In 1979 most people with CF were children or adolescents.

1979 Sinniah D. Omar A. Quantitation of digital clubbing by shadowgram technique. Arch Dis Child 1979; 54:145-146. [PubMed]
Finger clubbing was quantified from the magnified silhouette of the right index finger in controls and in patients with clubbing; using a simple shadowgram technique obtained using an overhead projector and screen. There was good correlation between clinical assessment and measurement of both the profile angle and the hyponychial angle (figure 27). The hyponychial angle appeared to be a more accurate indicator of clubbing than the profile angle. We used this technique in Leeds to examine the fingers of a series of children with CF (Pitts-Tucker et al. 1986 below)

1986 Pitts-Tucker TJ, Miller MG, Littlewood JM. Finger clubbing in cystic fibrosis. Arch Dis Child 1986; 61:576-579. [PubMed]
We were interested in physical signs which may be useful and were impressed by the study of Sinniah & Omar, using the shadowgram, outling the finger as a silouette on a screen using an overhead projector, to quantitate finger clubbing (1979 above) . Finger clubbing was measured in 73 of 105 patients with CF undergoing full Comprehensive Assessment at the Leeds Regional Paediatric CF Unit. Predictably, the degree of clubbing correlated well with the chest x-ray score, indices of pulmonary function and infection but not with weight, height, age, liver function, or degree of fat malabsorption. The presence of clubbing in a person with CF suggests appreciable pulmonary involvement. Most probably progression indicates deterioration in pulmonary state. In both instances increased efforts should be made to treat the infection.
This study was first presented by our CF Research Fellow Dr Mike Miller at the European CF Working Group Meeting in Israel. There was much hilarity that we people in Leeds had just realised clubbing was associated with chest problems! However, despite the hilarity it was one of the most discussed presentations of the session. People seemed hungry for some clinical signs that would be helpful in their work. Others later observed that finger clubbing regressed in some patients after successful lung transplantation.

1988 Gibbens DT, Gilsanz V, Boechat MI, Dufer D, Carlson ME, Wang CI. Osteoporosis in cystic fibrosis. J Pediatr 1988; 113:295-300. [PubMed]
Although osteoporosis had been noted in a number of previous publications, this was one of the early papers mainly dealing with osteoporosis, a complication which would become an increasingly common problem as the average age of people with CF increased. Vertebral bone density of 57 CF patients (aged 3-21 yrs) was compared with 57 matched controls. The bone density in people with CF was 10% less than in controls and worse in those with in a poor nutritional state. (For earlier mention of osteoporosis Mischler et al, 1979 above).

1998 Aris RM, Renner JB, Winders AD, Buell HE, Riggs DB, Lester GE, Ontjes DA. Increased rate of fractures and severe kyphosis: sequelae of living into adulthood with cystic fibrosis. Ann Int Med 1998; 128:186-193. [PubMed]
Bone mineral density was measured with dual-energy x-ray absorptiometry, patient-reported fracture events were confirmed by radiography, and kyphosis angles were measured by using the Cobb method. Mean bone mineral densities for the spine, femur, and total body were severely depressed in patients with cystic fibrosis, averaging 2 SDs below those of age-matched normal controls (P<0.001). Patient interviews showed that 54 fractures had occurred over 1410 patient-years, and chest radiographs showed evidence of 14 additional rib and 62 additional vertebral compression fractures. The database (which covered 1410 patient-years) showed that fracture rates were approximately twofold greater in women with cystic fibrosis aged 16 to 34 years (P = 0.015) and men with cystic fibrosis aged 25 to 45 years (P = 0.04) than in the general population. Vertebral compression and rib fractures were 100- and 10-fold more common than expected, respectively (P<0.001 for both comparisons). The mean kyphosis angle (+/- SD) for this group was markedly abnormal (44 +/- 14 degrees; 62% > or = 40 degrees) and probably contributed to diminished stature (mean height loss, 5.8 cm in men with CF and 5.9 cm in women with cystic fibrosis). Cumulative prednisone dose, body mass index, and age at puberty were the strongest predictors of bone mineral density.

Although osteoporosis had been mentioned in a number of previous reports, this was the first major study on osteoporosis in adults with cystic fibrosis. The study drew attention to the fact that osteoporosis is almost universal in adults with late-stage CF and its complications include increased fracture rates and severe kyphosis. The findings stimulated a great deal of research into osteoporosis in adults with cystic fibrosis. Later the subject was reviewed in many publications and in a consensus document from the UK Cystic Fibrosis Trust (Bone Mineralisation in Cystic Fibrosis. UK Cystic Fibrosis Trust Bone Mineralisation Working Group. February 2007. Full text available on the UK CF Trust website www.cftrust.org,uk) .

1999 Howarth CS, Selby PL, Webb AK, Dodd AK, Musson H, McL Niven R, Economu G, Horrocks AW, Freemont AJ, Mawer EB, Adams EJ. Low bone density in adults with cystic fibrosis. Thorax 1999; 54:961-967. [PubMed]
An early detailed study of a population of 151 adults aged 15-52 ears with CF from Manchester using DEXA and quantitative computed tomography and biochemical markers of bone turnover. 34% of adults with CF had BMD Z scores of -2 or less at one or more skeletal sites. The respiratory function and physical activity were related to the BMD Z scores. Markers of bone turnover were negatively related and vitamin D positively related to the BMD Z scores despite supplementation with vitamin D.

Dr Charlie Haworth (figure 48) has major contributions to the increasingly important bone problems in CF both when working n Manchester and after moving to Papworth CF Adult centre where he is now Director. Subsequent reviews and consensus statements on bone problems in CF followed from North America and the UK..

2001 Haworth CS. Selby PL. Adams JE. Mawer EB. Horrocks AW. Webb AK. Effect of intravenous pamidronate on bone mineral density in adults with cystic fibrosis. Thorax 2001; 56:314-316. [PubMed]

The aim of this study was to assess the effect of intravenous pamidronate on BMD in these subjects. Intravenous pamidronate increases axial BMD in adults with cystic fibrosis, but the high incidence of bone pain associated with this treatment might limit its use.

2002 Elkin SL. Vedi S. Bord S. Garrahan NJ. Hodson ME. Compston JE. Histomorphometric analysis of bone biopsies from the iliac crest of adults with cystic fibrosis.
Am J Respir Crit Care 2002; 166:1470-4. [PubMed]
This study reports the results of quantitative analysis of iliac bone histology in adults with cystic fibrosis (CF) and low bone mineral density (BMD). Twenty patients with CF had bone biopsies taken after double tetracycline labeling. Histomorphometric measurements were made by image analysis, and data were compared with those of healthy control subjects. Cancellous bone area was lower in the patients with CF (p = 0.003), and there was a trend towards a decrease in cancellous bone connectivity. Bone formation rate at tissue level was significantly lower in patients with CF (p = 0.0002). Wall width, representing the amount of bone formed within individual remodeling units, was decreased (p < 0.0001), as was mineralizing perimeter and mineral apposition rate. Analysis of resorption cavities revealed lower cavity area, reconstructed surface lengths, and cavity depths (p < 0.003) in patients with CF, whereas eroded surface area was higher (p = 0.0004). Our results demonstrate low cancellous bone volume in adult patients with CF with low BMD, the main cause of which appears to be low bone formation at tissue and cellular level. Osteomalacia was diagnosed in one patient. This condition should be excluded as a cause of low bone mineral density in patients with CF and vitamin D insufficiency corrected.

2002 Garske LA. Bell SC. Pamidronate results in symptom control of hypertrophic pulmonary osteoarthropathy in cystic fibrosis. Chest 2002; 121:1363-4. [PubMed]
Hypertrophic pulmonary osteoarthropathy (HPOA) may complicate the advanced lung disease that is associated with cystic fibrosis, resulting in severe joint pain and early-morning stiffness. Symptoms are usually controlled with the administration of non-steroidal anti-inflammatory drugs, physiotherapy, and, on occasions, oral corticosteroids. This report describes a case of refractory HPOA with complete remission following the administration of IV pamidronate, which is a potent inhibitor of osteoclastic bone resorption. Symptom relief resulted for up to 3 months, but repeated courses of pamidronate have been required to maintain symptom control.

This is a practically useful report of a treatment for hypertrophic pulmonary osteoarthropathy where other measures have failed.

2004 Haworth CS. Jones AM. Adams JE. Selby PL. Webb AK. Randomised double blind placebo controlled trial investigating the effect of calcium and vitamin D supplementation on bone mineral density and bone metabolism in adult patients with cystic fibrosis. J Cyst Fibros 2004; 3:233-236. [PubMed]
Patients were invited to participate if they had a BMD Z score of -1 or less in the lumbar spine, proximal femur or distal forearm. Patients were randomised to receive calcium 1 g+vitamin D 800 IU or placebo daily, in addition to their regular vitamin D supplements (900 IU/day). Calcium and vitamin D supplementation reduced the rate of bone turnover and bone loss in adult patients with cystic fibrosis, but these changes did not reach statistical significance. These data suggest that a longer term trial of this simple intervention would be justified.

2004 Amital H. Applbaum YH. Vasiliev L. Rubinow A. Hypertrophic pulmonary osteoarthropathy: control of pain and symptoms with pamidronate. Clin Rheumatol 2004; 23:330-332. [PubMed]
This case presents a patient with hypertrophic osteoarthropathy of the lower extremities that developed secondary to congenital cyanotic heart disease. The major clinical manifestation was severe bilateral leg pain. The pain that was debilitating in nature completely resolved following a single administration of 60 mg pamidronate. Hypertrophic osteoarthropathy (HOA) is an acquired, uncommon disorder of obscure etiology. It has been described mainly in association with chronic suppurative pulmonary diseases, bronchogenic carcinoma and lung metastases, cystic fibrosis, and cyanotic congenital malformations of the heart.

Although this was not a patient with CF it is possible that this treatment may be helpful in some patients with CF.

2005 Aris RM, Merkel PA, Bachrach LK, Borowitz DS, Boyle MP, Elkin S, Guise TA, Hardin DS, Haworth CS, Hollick MF, JosephM, O'Brien K, Tullis E, Watts NB, White TB.Consensus statement: Guide to bone health and disease in cystic fibrosis. J Clin Endocrinol Metab 2005; 90:1888-1896. [PubMed]

2007 Bone mineralisation in cystic fibrosis. Report of the UK Cystic Fibrosis Trust Bone Mineralisation Working Group. London. Cystic Fibrosis Trust, february 2007. Conway S (Chairman), Compston J, Cunliffe H, Dodd M, Elkin S, Haworth C, Jaffe A, Morton A, Redfern J, Truscott J. (below)

2000 Conway SP, Morton AM, Oldroyd B, Truscott JG, White H, Smith AH, Haigh I. Osteoporosis and osteopenia in adults and adolescents with cystic fibrosis: prevalence and associated factors. Thorax 2000; 55:798-804. [PubMed]
Sixty six percent of 114 patients attending the Leeds Regional CF Centre had osteopenia or osteoporosis. The clinical score correlated significantly with bone mineral density (BMD) at the lumbar spine and femoral neck, and with total body BMD. Oral steroid use was significantly associated with reduced BMD at the lumbar spine and femoral neck.

Following the first extensive report by Aris et al (1998 above), there was increasing interest in osteoporosis as more people with CF reached adulthood and many of them had osteoporosis. This present study and others confirmed that osteopenia and osteoporosis were common findings in adults with CF, particularly those with severe disease and particularly those who had used significant amounts of corticosteroids.

Fig 11: Mrs Alison Morton

Alison Morton (figure 11) is the senior dietitian on the Leeds Regional Adult CF Unit and closely involved in many publications from that unit and also on the expert advisory committees of the UK CF Trust.

2004 Conway SP, Oldroyd B, Morton A, Truscott JG, Peckham DG. Effect of oral bisphosphonates on bone mineral density and body composition in adult patients with cystic fibrosis: a pilot study. Thorax 2004; 59:699-703. [PubMed]
Approximately two thirds of adult patients with CF have reduced bone mineral density and up to a quarter have osteoporosis at one or more sites. Patients attending the Leeds Regional Adult Cystic Fibrosis Unit with either osteopenia or osteoporosis on dual energy X-ray absorptiometry (DXA) scanning were offered treatment with oral bisphosphonates after exclusion of abnormal vitamin D, calcium, or phosphate levels, abnormal thyroid function, or hypogonadism. The medians of the differences in annual changes in bone parameters between treatment and control groups showed significant differences in bone mineralisation in favour of the treatment group.  The authors concluded that treatment with oral bisphosphonates may improve bone mineralisation in adult patients with CF and suggested a randomised controlled trial.

2004 Kumar N, Balachandran S, Millner PA, Littlewood JM, Conway SP, Dickson RA. Scoliosis in cystic fibrosis: is it idiopathic? Spine 2004; 29:1990-1995. [PubMed]
This is a retrospective study of all the patients registered with the Leeds Regional Adult and Paediatric Cystic Fibrosis units from 1982 to 1997 carried out by Mr Kumar, an orthopaedic surgeon who, at the time, he was working with Professor Bob Dickson (an authority on scoliosis) at St James’s University in Leeds. Of the 316 patients, there were 184 adults (age 17 years and above) and 132 children (age 0-6 years). In the 4- to 16-year age group, the prevalence of scoliosis was 15.6%, which is 20 times the prevalence in 15,793 school children with a similar age and sex distribution from the same geographic area. The majority of curves were single-thoracic, apical around T6-T8 with no side predilection. In the adult population (above 16 years), the prevalence was 9.8%, which is higher than that of the general population. These curves were thoracic, apical around T7-T8, and approximately two thirds of them were right-sided.
The study shows a high prevalence of scoliosis in people with cystic fibrosis. These are benign short midthoracic curves, apical between T6-T8 with no side predilection. Some of these patients from the Eighties were more severely affected with chest and nutritional problems that would be the case in more recent years.

2004 Festini F. Ballarin S. Codamo T. Doro R. Loganes C. Prevalence of pain in adults with cystic fibrosis. J Cyst Fibros 2004; 3:51-57.[PubMed]
This study was aimed at evaluating the prevalence of pain symptoms in adult CF patients, if they are noticed and treated, and the influence of pain symptoms on patients' life. Using a questionnaire, 239 adults with CF there was a high prevalence of painful episodes among CF adult patients, as for both intensity and frequency. In a 2 months period 32.6% of patients experienced episodes of pain described as intense to severe, and 29.7% had more than 10 occurrences of pain in the same location. Headache, gastric pain and backache were the most frequently reported kind of pain. 59.8% of subjects perceived pain episodes as the cause of unfavorable effects on their life. Only 42.6% of those with pain asked a CF center physician for help and another 3.5% a general practitioner.

Painful symptoms are surprisingly common in adults with CF a fact that this study from Italy confirms. Recurrent pains are a definite cause of a worsening of the quality of life for adults with CF.

2005 Doyen V. Fournier C. Bautin N. Cortet B. Flipo RM. Wallaert B. Rheumatoid arthritis and cystic fibrosis. [French] Revue des Maladies Respiratoires. 2005; 22:667-671.[PubMed]
Inflammatory arthropathies are rare complications of cystic fibrosis (CF). We describe three cases of rheumatoid arthritis (RA) occurring in patients with this disease. Among the 100 patients under the care of the adult CF centre in Lille 3 presented with RA. This developed at the ages of 17, 44 and 19 years with a FEV1 of 53%, 42% and 94% respectively. Rheumatoid factor and/or anti CCP antibodies were positive. The appearance and progression of RA were associated with exacerbations of bronchial infection and deterioration of respiratory function. In 2 patients the RA was continuously progressive despite intensive treatment involving high dose cortico-steroids, methotrexate (ineffective) followed by leflunomide (complicated by intractable respiratory infection). There is an increased incidence of RA in our patient population with CF. The evolution of the two diseases is related and seems to be dependent on the level of infection leading to therapeutic problems.

2005 Conway SP, Wolfe SP, Brownlee KG, White H, Oldroyd B, Truscott JG, Harvey JM, Shearer MJ. Vitamin K status among children with cystic fibrosis and its relationship to bone mineral density and bone turnover. Pediatrics 2005; 115:1325-1331.[PubMed]
The aim of this study was to assess vitamin K status in an unselected population of children with CF and to investigate any vitamin K effect on bone turnover and bone mineral status. One hundred and six children entered the study. Vitamin K1 deficiency was common (70%) and the authors suggested that routine supplements should be considered.
Through its role in the carboxylation of osteocalcin, vitamin K deficiency may be associated with an uncoupling of the balance between bone resorption and bone formation. However, a cause-effect relationship between vitamin K deficiency and low bone mass has not been proved.

2006 Stephenson A. Jamal S. Dowdell T. Pearce D. Corey M. Tullis E. Prevalence of vertebral fractures in adults with cystic fibrosis and their relationship to bone mineral density. Chest 2006; 130:539-544. [PubMed]
The objectives of this study were to determine the prevalence of morphometric vertebral fractures in a large cohort of adult cystic fibrosis (CF) patients, and to examine the association between fractures and bone mineral density (BMD). DESIGN: Cross-sectional retrospective study. SETTING: A tertiary care academic hospital. Seven percent of adult patients with CF had vertebral fractures as determined by morphometry. Subjects in the fracture group had both clinically and statistically higher BMD as measured by DXA. Our findings raise the intriguing possibility that BMD may not be useful in identifying CF patients with fractures

2007 Bone mineralisation in cystic fibrosis. Cystic Fibrosis Trust Bone Mineralisation Working Group. Conway S (Chairman), Compston J, Cunliffe H, Dodd M, Elkin S, Haworth C, Jaffe A, NMorton A, Redfern J, Truscott J. London. Cystic Fibrosis Trust, February 2007.
A detailed review of the whole subject of bone mineralisation as it applies to cystic fibrosis. Bone mineral density (BMD) is usually normal in children with CF who have well preserved lung function and nutrition. Reduction in BMD Z-scores may appear around puberty and approximately one third of adults with CF have low BMD. The full text is available on the CF Trust website (www.cftrust.org.uk).

2008 Koch AK. Brömme S. Wollschläger B. Horneff G. Keyszer G. Musculoskeletal manifestations and rheumatic symptoms in patients with cystic fibrosis (CF) no observations of CF-specific arthropathy. J Rheumatol 2008; 35:1882-1891. [PubMed]
In CF patients, the prevalence of rheumatic symptoms increases with age and CF severity. Our data suggest an association of infections with P. aeruginosa and A. fumigatus with the occurrence of rheumatic symptoms. However, no association of CF with definite inflammatory joint or connective tissue diseases was observed, and no CF-specific pattern of musculoskeletal symptoms was seen.

We also reported a definite association between the severity of the joint pains and severity of the chest infection as they definitely improved during a course of intravenous antibiotics (Bowler IM, Littlewood JM. Episodic arthritis in cystic fibrosis. lancet 1992; 340:244.[PubMed]

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