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   Table of Contents      
IMAGES IN CLINICAL PRACTICE
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 155-158

Multiple Osteolytic Lesions Due to Primary Hyperparathyroidism


1 Department of General Surgery, MAMC and associated Lok Nayak Hospital, New Delhi, India
2 Department of Radiodiagnosis, MAMC and associated Lok Nayak Hospital, New Delhi, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Saurav Kumar
Department of General Surgery, MAMC and Associated Hospitals, 410, ORDH, New Delhi 110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_56_18

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How to cite this article:
Kumar S, Kumar L, Manchanda A, Batra R, V. R, Vindal A, Garg A, Lal P. Multiple Osteolytic Lesions Due to Primary Hyperparathyroidism. MAMC J Med Sci 2018;4:155-8

How to cite this URL:
Kumar S, Kumar L, Manchanda A, Batra R, V. R, Vindal A, Garg A, Lal P. Multiple Osteolytic Lesions Due to Primary Hyperparathyroidism. MAMC J Med Sci [serial online] 2018 [cited 2019 May 20];4:155-8. Available from: http://www.mamcjms.in/text.asp?2018/4/3/155/249033




  Case History Top


A 22-year-old lady presented to the orthopedic OPD with complaints of pain in left hip and left flank for 4 to 6 months. Biochemical investigations revealed hypercalcemia with serum calcium of 12.6 mg/dL (8.5-10.2 mg/dL) and serum PTH of 920.8 pg/mL (10-65 pg/mL), suggestive of diagnosis of primary hyperparathyroidism. Clinical examination did not reveal any neck swelling [[Figure 1]]. Multiple expansile lytic lesions were seen in bilateral iliac bones and bilateral femora on the radiograph of the pelvis [[Figure 2]]. Radiographs of the skull, bilateral hands and lumbosacral spine were also obtained [[Figure 3][Figure 4][Figure 5]] Ultrasonography of the abdomen showed the presence of multiple bilateral renal calculi measuring between 2 and 8 mm. Ultrasonography of the neck was performed, which showed a 10 × 6.8 mm hypoechoic mass lesion along posteroinferior aspect of right lobe of thyroid [[Figure 6]]. The lesion in the parathyroid gland was further localized with CECT and MRI of the neck. A lesion measuring 2 × 2 cm suggestive of adenoma was seen involving the right inferior parathyroid gland over the sentinel pad of fat [[Figure 7] and [Figure 8]]. MIBI scintigraphy confirmed increased radionuclide uptake in the region of right inferior parathyroid [[Figure 9]]. Right inferior parathyroidectomy was performed [[Figure 10][Figure 11][Figure 12]] under general anesthesia and showed a fall in serum PTH level from 909 pg/mL (preoperative) to 96 pg/mL (post-excision within ten minutes). Patient had an uneventful recovery in postoperative period [[Figure 13]].
Figure 1 Normal neck examination with no swelling on inspection and palpation

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Figure 2 X-ray pelvis—AP view: Multiple expansile lytic lesions seen involving bilateral iliac bones, left femur extending from intertrochanteric region to proximal diaphysis, and right femoral shaft, with few lesions showing marked cortical thinning and a sclerotic rim

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Figure 3 X-ray skull—Lateral view: Few small well-defined lytic lesions seen in skull bones, with mild calvarial thickening posteriorly

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Figure 4 X-ray bilateral hands—PA view: Subperiosteal resorption seen along radial aspect of middle phalanges of second and third digit of left hand and second digit of right hand

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Figure 5 X-ray L-S spine—AP and lateral views: Diffuse osteopenia with coarsening of trabecular pattern seen in lumbar vertebral bodies

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Figure 6 Gray scale USG images at the level of thyroid gland reveal a well-defined homogeneously hypoechoic lesion posterior to right lobe of thyroid gland and medial-to-carotid vessels. On color Doppler, mild vascularity is noted within the lesion

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Figure 7 CECT neck: Axial image reveals a well-defined homogenously hypodense lesion seen posterior to right lobe of thyroid gland and medial-to-carotid vessels suggestive of parathyroid adenoma

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Figure 8 MRI neck: Coronal STIR images reveal a hyperintense oval lesion (black arrow) in the neck on right side posterior and inferior to the thyroid gland, showing homogeneous enhancement on post contrast T1W images (white arrow)

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Figure 9 “A” (20 min) and “B” (2 h): MIBI scintigraphy reveals increased radiotracer uptake along right thyroid gland; the radiotracer activity is noted to persist on the 2 h image

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Figure 10 Intraoperative picture with forceps pointing toward right inferior parathyroid adenoma

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Figure 11 Intraoperative picture with forceps pointing toward tumor bed postadenoma excision

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Figure 12 Excised specimen of right inferior parathyroid gland

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Figure 13 Postoperative image

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Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.




    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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