Endocrine Abstracts

Brown tumour is a fibrous tissue mass containing hemosiderin-pigmented macrophages/ multinucleated giant cells, replacing/expanding part of bone in primary hyperparathyroidism. We present a case with brown tumour who was treated as simple bone cyst.

A 22-year-old lady presented to rheumatology with pain in arms and legs. Investigations revealed severe vitamin D/B12/folate/iron deficiency with positive IgA. Gliadin antibodies and duodenal biopsy confirmed coeliac disease. B12/folate/iron/vitamin supplements were commenced. Patient missed her follow-up appointments. Few months later she presented with fracture right proximal humerus. X-ray showed cortical thinning with pathological fracture secondary to bone cyst. Bone scans showed increased activity in shoulders and hips. Fracture was treated conservatively. Tertiary orthopaedic evaluation concluded bone cyst with fibrous dysplasia without any deformity. Patient discharged with advice on regular follow-up.

She then presented with positive pregnancy test. Antenatal investigations revealed corrected calcium 2.78 mmol/l (2.12–2.55)/phosphate0.76/alkaline phosphatase1776. At 10 weeks pregnancy she suffered a miscarriage.

Tertiary orthopaedic re-evaluation concluded she had fibrous dysplasia with deformity and proximal humeral osteotomy with bone graft and intramedullary nail fixation were planned.

Investigations at endocrinology referral revealed corrected calcium 2.71 (2.12–2.55), phosphate0.73, creatinine 38, PTH997(15–65 ng/l), vitamin D<6.Ultrasound and setamibi showed 3.6×1.5 cm mass in left lower pole of thyroid consistent with parathyroid adenoma. Bone scans showed extensive increased activity throughout skeleton consistent with hyperparathyroidism. Sketelal survey showed large lytic lesions in acetabulum,lesser trochanter, femoral neck and large multiloculated cystic lesion in upper right humerus with subperiostal bone resorption in middle/terminal phalanges in hands.

In conclusion patient has brown tumours due to primary hyperpararathyroidism and severe vitamin D deficiency due to coeliac disease.

Questions:
a. What should be her immediate management plan?

b. After parathyroidectomy she is high risk for hungry bone syndrome. What measures should be taken to prevent this?

c. How to treat her severe vitamin D deficiency?

d. Could severe PHP and osteomalacia be the cause for her miscarriage?