Alkaptonuria is a rare autosomal recessive disorder due to a lack of the
enzyme homogentisate dioxygenase, leading to
ochronosis, a process of accumulation of a
melanin-like
polymer of
homogentisic acid in cartilage and other collagenous structures. Patients develop severe osteoarthropathy that resembles
osteoarthritis. Although the diagnosis of
alkaptonuria is not particularly challenging in view of the blue-black discolouration of visible connective tissue and the presence of
homogentisic acid in urine, the natural history of
alkaptonuria remains poorly understood. Patients would benefit immensely from an objective assessment of their disease status and from a clearer understanding of the pathophysiology and associated physical changes.
Isotope bone scans, which are commonly used to identify the extent of involvement of bones in cancerous processes, have also been increasingly used for characterizing the extent of
arthropathy in conditions such as
osteoarthritis and
rheumatoid arthritis. Semiquantitative scores based on the extent of involvement of joints have been used to describe the involvement of large joints in the context of symptomatic treatment for
osteoarthritis. A similar semiquantitative
isotope bone scan score depending on the involvement of the number of large joints in patients with
alkaptonuria can be formulated and validated in a suitable cohort of patients. Bone densitometry measurement using dual-energy X-ray absorptiometry scanning is an internationally accepted tool to assess the risk and extent of
osteoporosis, and is increasingly used to assess the additional fracture risk in patients with
arthropathy. We believe that, currently, nuclear medicine techniques can provide useful information, which can be incorporated into disease severity scores for
alkaptonuria. Once the
biological basis for
alkaptonuria is better understood, it is feasible that nuclear medicine techniques of even greater sensitivity and specificity can be developed, thereby taking advantage of the vast advances in the fields of radiochemistry, radiopharmacy, positron emission tomography-computed tomography and positron emission tomography-magnetic resonance imaging scanning.