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Her Aching Bones: Atypical Parathyroid Adenoma

This unenhanced axial computed tomography (CT) image of the pelvis showed multiple lytic bone lesions with fluid-fluid levels (arrows).

This unenhanced axial computed tomography (CT) image of the pelvis showed multiple lytic bone lesions with fluid-fluid levels (arrows).

A radiologic investigation of lower back pain captured something unusual: multiple osteolytic lesions with fluid-fluid levels. The patient was a 34-year-old Portuguese woman of Romani ethnicity. Previously healthy, she presented to our emergency department with a 6-month history of lumbar pain. Her medical history was unremarkable aside from 2 cesarean sections and a bilateral tubal ligation. She had been smoking 1 cigarette daily since she was 15 years old (0.95 pack year), denied taking medications on a regular basis, and was unemployed.

The pain was localized to the right lumbar area and was referred to the posterior aspect of her right thigh and leg. It had a continuous character, worsening with active lower limb movements and lessening with rest. Over the preceding 2 weeks, the severity had increased to an intensity that the patient rated as 8 out of 10 on a visual analogue pain scale. She was admitted to our department for a diagnostic work-up and pain control.

Assessment

Physical examination revealed grade 1 arterial hypertension, an enlarged thyroid gland with a right-sided mobile elastic lump, tender iliac crests, painful passive and active bilateral lower limb movements despite full strength (Medical Research Council Scale for Testing Muscle Strength grade, 5 out of 5), and normal sensation in all 4 limbs.

Electrocardiography showed sinus rhythm. Conventional radiography in an anteroposterior view revealed an osteolytic lesion on the anterior aspect of the seventh right rib. The cervical, thoracic, lumbar, and abdominal views were unremarkable. An anteroposterior pelvic view disclosed multiple well-defined osteolytic lesions in both iliac bones and femoral heads.

Pelvic computed tomography (CT) and magnetic resonance imaging depicted multiple iliac and sacral osteolytic lesions with fluid-fluid levels. Furthermore, a right retrothyroid heterogeneous vascularized mass was evident on cervical ultrasound and CT images

In summary, our patient had multiple osteolytic lesions with fluid-fluid levels, hyperparathyroidism, and a vascularized heterogeneous retrothyroid mass. Bone lytic lesions with fluid-fluid levels—and especially, multiple lesions—are an infrequent finding rarely reported in the medical literature. Possible causes include metastatic carcinoma, Langerhans cell histiocytosis, and brown tumors associated with hyperparathyroidism.

The combination of a retrothyroid mass and hyperparathyroidism suggested the existence of a benign or malignant lesion of the parathyroid gland with autonomous parathyroid hormone production. A presumptive diagnosis of primary hyperparathyroidism and multiple brown tumors due to a functional parathyroid mass was considered. At this point, parathyroid carcinoma could not be excluded. The patient was referred to the endocrine surgery team, and a right-sided hemithyroidectomy and isthmectomy with central cervical lymphadenectomy was performed, per the recommendation of international oncologic guidelines.4 A pathology examination showed an atypical parathyroid adenoma.

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-Filipe Brogueira Rodrigues, MD, Catarina Bekerman, MD, Joana Briosa Neves, MD, João Sousa, MD, Joana Vieira, MD, António Alves, MD, Ana Palha, MD, José Rocha, MD, Vitor Ramalhinho, MD

This article originally appeared in the March 2016 issue of The American Journal of Medicine.

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