Endocrine Abstracts

Introduction: Tertiary hyperparathyroidism can be developed in cases of persistent or non-curable secondary hyperparathyroidism or in any other case of long-standing hypocalcemia that leads to the autonomous function of at least one parathyroid gland. We present a case of a man with tertiary hyperparathyroidism and excessive maxilla swelling and extensive bone lesions.

Presentation: A 32 years old man, with chronic renal failure on dialysis for twelve years, referred to our department due to an elevated PTH and difficulty in mastication due to an excessive swelling of the maxilla gradually developed over a year. His tertiary hyperparathyroidism was known for five years, but he denied surgery and he was not compliant to cinacalcet treatment. On clinical examination he had an excessive maxilla swelling. Biochemical examination revealed: PTH=4433 pg/ml, Ca=10.7 mg/dl, P=5.9 mg/dl, ALP=631 U/L, 25(OH) D3=3 ng/ml, β-Crosslaps =6148 pg/ml, TP1NP =>10000 pg/ml. Plain bone X-rays showed: salt-and-pepper skull, bone erosions and absorption of distal phalanges and metacarpus of both hands, of the distal edge of the clavicle and of part of the periosteum of the humerus and radius. Generalized osteopenia and thickness of the periosteum of the humerus and femoral bone was also observed. CT head scan showed an abnormal texture, widening and periosteal absorption of both maxilla and mandible. Biopsy of the maxillary swelling showed findings compatible with brown tumour. The patient underwent near total parathyroidectomy and post surgery PTH levels were markedly decreased (PTH =24.5 pg/ml).

Conclusion: Tertiary hyperparathyroidism may have a dramatic clinical outcome if it is left untreated. Brown tumours due to tertiary hyperparathyroidism are very rare and they demand careful investigation and great deal of suspicion for the diagnosis.