Case study Group 2 presentation

Patient profile

• HN 3095-57

• Female 60 years old

• Hometown : Sa Kaeo province

• Occupation : farmer

• No drug and food allergy

Chief complain

• Left neck mass 10 years PTA that gradually

growth.

Present illness

• Left neck mass

• Chronic bone pain

• U/D : HT , Gout

Physical Examination

• BP 120/80 , Body temp 37.5⁰C , RR 22 , PR

88

• Left neck mass 4 cm. smooth surface, soft

consistency move by swallowing.

Problem list

• Left neck mass 4 cm. smooth surface, soft

consistency move by swallowing.

• Chronic bone pain.

Differential Diagnosis

• Thyroid mass

• Parathyroid mass

• Lymphadenopathy

Provisional Diagnosis

• Thyroid cancer with bone metastasis

Lab investigation

• Hb 9 g/dl (12-16)

• Hct 24.8 % (36-47)

• Red Cell Count 3.79 x 10^6 / mm3 (3.8-5.4)

• MCV 65.4 fL (80-95)

• MCHC 36.3 g/dl (32-36)

• RDW 16 % (12-14)

• White Cell Count 13.43 x 10^3/mm3 (4-10)

Lab investigation

• BUN 8.4 mg/dl (6-20)

• Cr (enzymatic) 1.21 H mg/dl (0.51-0.95)

• eGFR (MDRD) 48.24 ml/min ( >90 )

• eGFR (CKD-EPI) 48.75 ml/min ( >90 )

• PTH 129 H pg/ml (15-65)

Lab investigation

Mg 0.5 mg/dl (1.7-2.55)

P 3.92 mg/dl (2.7-4.5)

Na 108 mmol/l (136-145)

K 5.87 mmol/l (3.5-5.1)

Cl 73 mmol/l (98-107)

HCO3 13.3 mmol/l (22-29)

Anion gap 27.54 (8-20)

Lab investigation

Color : yellow

Specific gravity : 1.005 (1.005-1.030)

pH : 6.5 (5-7)

Glucose : Negative

Protein : trace (<30 mg/l)

Erythrocyte : 4+

WBC : 5-10/HPF

Urobilinogen , Bilirubin : Negative

Lab investigation

• ICD9 needle aspiration of thyroid gland.

ICD10 disorder of thyroid.

• FNA : benign follicular nodule

• U/S thyroid

• U/S kidney

• CT : Whole abdomen , Head and Neck , Chest

• Plain film : Hand , Skull , Hip , Spine , Chest , Abdomen

Approach Film

A large well defined heterogeneous hypoechoic mass site 4.6 x 2.4 x 2.4 cm. at posterior left lobe thyroid.

Approach Film

Geographic osteolytic lesion at right humerusand clavicle and mass in anterior rib

Approach Film

Diffuse osteolytic lesion that has resulted in “Salt and pepper appearance”

Approach Film

Lytic lesions at right middle phalanx of index finger

cortical resorption of the middle phalanges terminal tuft resorption at distal phalanx of both hand

Approach Film

Geographic osteolytic lesion at both femur

Approach Film

Approach Film

Diffuse osteoporosis , increase radiolucent spine and biconcave of vertebral body : “Fish vertebrae”

Approach Film

Approach Film

Osteolytic lesions with ballooning medullary canal of anterior aspect of hard palate

Approach Film

Radiopaque lesion at both kidney

Approach Film

Medullary nephrocalcinosis of both kidneysand hyperechoic lesion with posterior acoustic shadow

Approach Film

Tiny stone at left distal ureter

Approach Film

Tiny stone at left UVJ

Conclusion

Thai female 60 years old present with

left neck mass 4 cm. smooth surface, soft

consistency move by swallowing

U/S thyroid : well defined heterogeneous hypoechoic mass at posterior left thyroid

U/S kidney : hyperechoic lesion with posterior acoustic shadow at both kidney

CT chest : mass in right anterior rib

Conclusion

CT head and neck : mass at posterior left thyroid and osteolytic lesion at anterior aspect of hard palate

CT whole abdomen : medullarynephrocalcinosis of both kidney and two tiny stone at left distal ureter and left UVJ

Plain film : “salt and pepper skull” , osteitisfibrosa cystica , osteoporosis (increased radiolucent on vertebral body)

Conclusion

Final diagnosis : hyperparathyroidism due to parathyroid adenoma

Treatment

• Parathyroidectomy

• Calciferol (Vitamin D2)

• Calcium carbonate

• Ferrous fumarate

• Alfacalcidol (analog Vitamin D)

• Folic acid

Knowledge : hyperparathyroidism

Hyperparathyroidism

• Primary Hyperparathyroidism

• Secondary Hyperparathyroidism

• Tertiary Hyperparathyroidism

Primary Hyperparathyroidismone or more of your parathyroid glands

become enlarged and overactive. Due to

• Parathyroid adenoma : most common cause

• Parathyroid hyperplasia : usually affects more

than one gland at the same time

• Parathyroid carcinoma : Very rarely

Primary Hyperparathyroidism• Clinical presentation

- asymptom

- symptom

- muskuloskeletal

cortical bone loss

bone & joint pain

osteitis fibrosa cystica

salt & pepper skull

Primary Hyperparathyroidism• Clinical present

- renal

kidney stone , nephrocalcinosis

- GI

anorexia , nausea & vomiting

conspitation

Primary Hyperparathyroidism

• Clinical present

- neuromuskular & psychologic

proximal myopathy , weakness

- cardiovascular

hypertension

bradycardia

• LAB

– Parathyroid hormone level

– Ionized serum calcium level

Primary Hyperparathyroidism

is the result of another condition that lower

calcium levels.

Include:

• Severe calcium deficiency : Not get enough

calcium from your diet, often because

digestive system.

• Severe vitamin D deficiency.

• Chronic renal failure : most common cause

Secondary Hyperparathyroidism

Secondary Hyperparathyroidism

• Clinical present

- renal failure

- bone disease

osteitis fibrosa cystica

“rugger-jersey spine”

- vitamin D deficiency

- osteomalacia

- increase fracture risk

Secondary Hyperparathyroidism

• LAB

- Parathyroid hormone

- Low – normal serum Calcium

- Phosphate level

- High : renal insufficiency

- Low : vitamin D deficiency

After long standing secondary hyper-

parathyroidism and resulting in hypercalcemia

• Clinical presentation

- Hypercalcemia in the setting of

chronic secondary hyperparathyroidism

• Lab

- Normal or elevated of parathyroid hormone

- Phosphate level is often elevated

Tertiary Hyperparathyroidism

Take home message

Radiological investigations for

primary hyperparathyroidism

• Musculoskeletal : “salt and pepper skull” ,

osteitis fibrosa cystica , osteoporosis , “Fish

vertebrae appearance”

• Renal : Nephrocalcinosis , renal stone