Primary Hyperparathyroidism Complicated by Osteomalacia

Abstract

neck ultrasound showed a large parathyroid tumour beside the right lower lobe of the thyroid measuring 2·3 ern in diameter. Bone mineral density (BMD) was measured using a Hologic QDR 2000 Dual Energy X-ray Densitometer (Hologic, Waltham, MA, USA). Bone mineral density (BMD) of the whole body, lumbar spine and hip was 0-492, 0·562 and 0·108 g/cm 2 , respectively. Total T-score of the hip was -7,42. Bone biopsy of the posterior superior iliac crest showed mixed hyperparathyroidism and osteomalacia. There was evidence of active bone resorption with trabeculae showing a focal irregular scalloped appearance, abutted by osteoclasts and vascular fibroblastic tissue. There was prominent paratrabecular fibroblastic proliferation in the marrow with many dilated vessels. In other areas, the osteoid was thickened and the mineralization front could not be seen Additional key phrases: hypercalcaemia; 25-hydroxyvitamin D; alkaline phosphatase ultrasound-guided ethanol injection; remineralization CASE HISTORYA 66-year-old Chinese man was referred for investigation of weakness. He complained of weakness and wasting of the thighs for 4 years and low back pain for 2 years. He was homebound for 2 years and had very little exposure to sunlight. Home helpers brought him three meals a day. He also complained of polydipsia, polyuria and constipation at times. In the past, he had been an intravenous drug addict but had discontinued the habit 2 years earlier. He also smoked and suffered from chronic obstructive airways disease.The patient weighed 31·8 kg and he was 144 ern tall. He had a kyphoscoliosis and pseudoclubbing of the fingers. The gluteal and quadriceps muscles were weak and wasted. Reflexes and sensation were normal. He had poor chest expansion. The peak expiratory flow rate was 140 L/min. His blood pressure was 150/ 90 mmHg.Investigations indicated evidence of severe hyperparathyroidism and increased bone turnover as shown in Table 1. Serum total 25 hydroxyvitamin D (250HD) was within the reference range. There was no aminoaciduria or glycosuria. The patient's urea was 12·6 mmol/L on admission and became normalized (8 mmol/L) upon rehydration.His skull X-ray (Fig. la) showed a pepper-pot appearance and the hand X-rays revealed distal resorption of terminal phalanges consistent with hyperparathyroidism. A looser's zone was identified over the left ulnar bone. There was generalized osteopenia and bone softening of the pelvis. Both femurs were fractured and the inferior pubic rami were widened. The chest Xray showed fracture of the right clavicle in addition to multiple bullae in the upper zones. A

Spontaneous necrosis of parathyroid adenoma: biochemical and imaging follow-up for two years

“…9 13 15 However, in most reported cases, the necrotic parathyroid adenoma were excised 913 15 A recent report by Nylen et al showed that the primary hyperparathyroidism could enter remission even without surgical excision 2. By contrast, our patient exhibited recurrence of the disease 9 months after the acute event and the repeated CT 3 months after the event still showed a 5-mm soft tissue mass suggesting a remnant adenoma.…”

“…There have been reports of primary hyperparathyroidism entering remission after parathyroid gland necrosis 29 13 15 However, in most reported cases, the necrotic parathyroid adenoma were excised 913 15 A recent report by Nylen et al showed that the primary hyperparathyroidism could enter remission even without surgical excision 2.…”