Endocrine Abstracts

A 55-year female from low economic background was referred from the local dental hospital where she had presented with a swelling near her left lower 3rd molar which caused her significant difficulty in eating. On further questioning she conceded to having progressive difficulty in walking and bony pains over the past 6 months with increasing dependency for daily activities. She was frail with proximal muscle weakness and widespread bony tenderness but no other significant neurological abnormalities. She also had two firm non-tender swellings over the lower half of her right forearm and over the right hand. Total calcium 2.3 mmol/l (2.2–2.6), phosphorus 0.63 mmol/l (0.81–1.4), albumin 33 g/l (35–50), alkaline phosphatase 124 U/l (42–98), parathyroid hormone 2842 ng/l (8–51), Serum creatinine 61.9 μmol/l (44–100) and vitamin-D 14.6 ng/ml (30–100). Skeletal X-rays showed radiolucent oval lesions over the lower 1/3rd of radius and the 4th metacarpal base with appearances suggestive of Brown tumours. This diagnosis was confirmed by biopsy of the oral lesion with the overall picture suggestive of long-standing vitamin-D deficiency and secondary hyperparathyroidism. She was commenced on 60 000 units of cholecalciferol weekly. By 6 weeks there was a significant improvement in mobility, bony pains and sense of well-being. At 3 months despite continued overall improvement she re-consulted oral surgeons to request surgical excision of the persistently symptomatic oral lesion. She is awaiting this procedure and biochemical re-assessment.

A Brown tumour is recognised sequelae of long-standing primary hyperparathyroidism but the presence of multiple tumours has not been reported in a patient with vitamin-D deficiency. The persistence of symptomatic oral tumour requiring excision is also unusual.

In conclusion, long standing vitamin D deficiency presents in a variety of ways and a high index of suspicion needs to be maintained in high-risk populations.