Endocrine Abstracts

Traditionally, patients diagnosed with primary hyperparathyroidism present with mild hypercalcaemia and tend to be asymptomatic. Symptomatic patients tend to have severely high calcium and exhibit the classic ’bones, stones, abdominal moans and psychic groans.’ We present a case of a 92-year-old Caucasian gentleman presenting with recurrent falls, postural hypotension and trauma to head and shoulder. X-ray imaging showed small non-specific lucencies in the cervical and upper thoracic vertebral bodies, clavicles and left upper humerus along with an old left clavicular fracture. He was normocalcaemic (2.52 mmol/l) on admission, had normocytic anaemia and had a mild acute kidney injury (AKI) on chronic kidney disease (CKD). The computer tomography (CT) chest, abdomen and pelvis showed multiple punched out lytic lesions within the skeleton bones and an 13 mm elongated nodule behind the right lobe of thyroid. Presence of similar lucencies in shoulder imaging from 2015 and 2016 ruled out the possibility of metastatic disease. Biochemistry revealed raised parathyroid hormone at 35.6 pmol/l (1.6–6.9) and vitamin D deficiency of 24 nmol/l. On two occasions during the admission, his calcium was found to be mildly elevated (2.73 mmol/l). Tests for myeloma screen were inconclusive. He had urinary bence jones protein (BJP), raised kappa and lambda free light chains and no immunoparesis. He was managed with vitamin D and is awaiting further tests, such as sestamibi scan. He will be followed up in endocrine clinic to discuss results. Any bone lesion detected in a patient above the age of 40 years, should have further investigations for myeloma and/or metastatic disease. The differentials in this case are primary hyperparathyroidism as suggested by long standing bone lesions, high PTH and a potential parathyroid lesion or plasma cell neoplasia as suggested by BJP in the urine with kappa light chains. Literature search suggests that lytic lesions, specifically brown tumours can be seen in patients with primary hyperparathyroidism. The diagnosis is still unclear, nevertheless a uniquely delayed presentation of potential primary hyperparathyroidism or both the conditions.