Massive periarticular calcification in a hemodialysis patient with a recurrent parathyroid adenoma

Abstract

A 51-year-old male presented with the complaint of gradually increasing swelling, pain, and a hard lump in the right shoulder he noticed five months ago. The patient was diagnosed with glomerulonephritis 11 years ago, and he has had a regular hemodialysis history three times a week for 10 years. Moreover, he had a history of total thyroidectomy and parathyroidectomy operation due to thyroid nodules suspected for malignancy on ultrasound and secondary hyperparathyroidism five years ago. Parathyroid ultrasound revealed well-circumscribed, homogeneous, solid nodules consistent with parathyroid adenoma were detected at the posteroinferior of both thyroid lobes. However, a preoperative Technetium-99m sestamibi scintigraphy was not available. At that time, the preoperative serum calcium level was 11.2 mg/dL (reference range, 8.6–10.2 mg/dL), phosphate level 7.9 mg/dL (reference range, 2.6–4.5 mg/dL), parathyroid hormone level 1230 pg/mL (reference range, 15–65 pg/mL) and 25-hydroxyvitamin D level of 9.4 ng/ml (reference range, 21–29 ng/ml). Histopathologically, four parathyroids with nodular hyperplasia and a papillary thyroid cancer were detected in the surgical specimen’s histopathology, and the patient received radioactive iodine treatment. Two weeks after the operation, serum calcium (10.1 mg/dL; reference range, 8.6–10.2 mg/dL), phosphate (4.4 mg/dL; reference range, 2.6–4.5 mg/dL), and parathyroid hormone levels (63.1 pg/mL, reference range, 15–65 pg/mL) returned to the normal ranges. The routine control of the patient, which was performed a year ago, was unremarkable. His medications included levothyroxine 150 μg/day, calcium acetate 3 g/day, 1000 IU/ day vitamin D, and sevelamer hydrochloride 2.4 g/day. On physical examination, a solid mass ~5 cm in diameter was detected in the anterior of the right shoulder, and a limited movement of the right arm was found. Other physical examination findings were unremarkable, and he denied any trauma. Shoulder X-ray was demonstrated widespread calcifications around the right humeral head and expansile rib lesions (Fig. 1a). For further evaluation, computed tomography (CT) of the chest was obtained. CT showed extensive soft-tissue calcifications around the right shoulder joint without any bony destruction (Fig. 1b, c). Moreover, CT showed lytic and expansile rib lesions, which were previously known and were histopathologically diagnosed with brown tumor 5 years ago. In laboratory examinations; elevated creatinine (5.1 mg/ dL, normal range 0.7–1.1 mg / dL), urea (79 mg/dL, normal range; <50 mg/dL), phosphorus (5.18 mg/dL, normal range; 2.6–4.5 mg/dL), thyroid-stimulating hormone (38.5 mU/L, normal range; 0.27–4.2 mU/L), and parathyroid hormone (4243 ng/L, normal range; 15–65 ng/L) levels were detected. Other laboratory values, including serum calcium (9.6 mg/dL; reference range, 8.6–10.2 mg/dL) and D vitamin (21.2 ng/ml; reference range, 21–29 ng/ml) levels, were within normal limits. The patient was suspected of having recurrent hyperparathyroidism, and a mediastinal lesion was found on Technetium-99 m sestamibi scintigraphy. Cinacalcet 30 mg per day was started, and the patient underwent surgery. The histopathology of the mediastinal lesion was consistent with parathyroid adenoma, and the post-surgery course was uneventful. Three months after the surgery, serum calcium (9.6 mg/dL; reference range, 8.6–10.2 mg/dL), phosphate (4.3 mg/dL; reference range, 2.6–4.5 mg/dL), and parathyroid hormone levels (59.7 pg/mL, reference range, 15–65 pg/mL) returned to the normal ranges. Moreover, serum 25-hydroxyvitamin D level was found to be normal (27.1 ng/ml; reference range, 21–29 ng/ml). Periarticular soft-tissue calcifications are rare in hemodialysis patients with an estimated prevalence of * Furkan Ufuk [email protected]