Presentation
Presented with left hip pain for 1 month, aggravating on movement relieving on rest.
Patient Data
Ill-defined lytic area with pathological fracture noted in left iliac bone. A similar lytic area was noted in the right iliac bone.
Multiple altered signal intensity lesions were noted in bilateral iliac wings and ala of the sacrum on the right side. This is hypointense on T1, hyperintense on T2 and IR images. Few septations within. A pathological fracture involving the left iliac wing, with surrounding T2 hyperintensity in gluteal medius and iliacus muscles - suggestive of edema.
These features were consistent with brown tumors. Following this, a 4D CT of the neck was performed.
Hypodense lesion noted in the visceral space of the neck on the left side, posterosuperior to the left lobe of the thyroid gland. This lesion is seen extending superiorly up to the level of the upper border of thyroid cartilage; inferiorly to C6 vertebral level; anteriorly, seen displacing the left lobe of the thyroid gland and seen displacing the carotid vessels posterolaterally. Post-contrast study shows intense heterogeneous arterial enhancement with washout in delayed phases - consistent with parathyroid adenoma.
The left internal jugular vein is small in caliber as compared to the right side.
X-ray KUB revealed bilateral medullary nephrocalcinosis.
Case Discussion
FNAC of the neck swelling was performed.
FNAC (microscopic) – sections show cohesive sheets of tumor cells. Tumor cells are composed of an admixture of chief cells which are uniform cells with round deeply basophilic nuclei and pale eosinophilic cytoplasm and oxyphil cells with abundant granular eosinophilic cytoplasm and small pyknotic nuclei. The background shows hemorrhagic material.
Cellblock – cytological features are of parathyroid adenoma.
Hyperparathyroidism is caused due to excess parathyroid hormone. It can be caused by either an intrinsic abnormal change that alters parathyroid hormone excretion (primary/tertiary hyperparathyroidism), or an extrinsic abnormal change that affects calcium homeostasis and stimulates parathyroid hormone production (secondary hyperparathyroidism). A brown tumor is a rare bone disease caused as a result of hyperparathyroidism. Although brown tumors were first associated with primary hyperparathyroidism, they are now more frequently seen in patients with chronic renal failure and secondary hyperparathyroidism. Treating hyperparathyroidism will help resolve brown tumors.
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