Patient came to clinic with history of 3 years worsen
polyarthralgia. He has been diagnosed and managed as degenerative arthritis in
BacLieu Province Hospital for a year. The pain localized in left shoulder,
right knee, hips and left ankle. Patient also experienced general fatigue and
weight loss (5kg a year). MSK Ultrasound is indicated as first tool, goes along with blood tests.
Ultrasound
of right knee: shows patient area of pain doesn’t come from joint but the
bone. It exists erosion of periosteal of proximal tibia and hypervascularity in surrounding soft tissue. By switching to more
penetrative linear probe, a hyperechoic bone mass is seen beneath periosteal
erosion. Mass is homoechogeneity and has anechoic cysts inside.
Image 1:
Erosion of periosteal of proximal tibia and hypervascularity in surrounding soft tissue
Image 2: A hyperechoic bone mass is
seen beneath periosteal erosion. Mass is
homoechogeneity with anechoic cysts inside. Second images shows normal articular
cartilage and not fit for degenerative arthritis.
Ultrasound of left ankle:
Same condition as proximal tibia as in the distal end. Mass
is better demonstrated with infiltrative border. During examination, patient
feels imminent pain at place that probe compresses. Ankle joint is normal.
Image 3: Mass is
better demonstrated with infiltrative border in distal end of tibia
Ultrasound of shoulder:
Shoulder rotator cuff are normal. Area of pain is at left A-C
joint. In comparison to normal right side, same apperance of bone mass revealed at clavicular end.
Image 4: Shoulder rotator cuff are normal. Area of pain is
left A-C joint. In comparison to normal right side, same bone mass at clavicular end revealed.
Conclusion : Multiple distal bone masses suggest few
differential diagnosis: Metastasis, Multiple myeloma metastasis.
Those could be pseudo-mass coming from bone erosion in osteclastic
hyperactivity in hyperparathyroidism.
Althought the lesions are common in middle diaphysis but not in the distal/proximal end. Radiologist did a quick
check on the neck to rule out tumor of parathyroid gland.
Ultrasound of the neck: detected at right lower lobe of thyroid a parathyroid tumor, 3.7x1.4mm, enlarged with capsule and hypervascular on
colour Doppler mode.
Image 5: Right parathyroid tumor, 3.7x1.4mm,
enlarged with capsule and hypervascular signals on colour Doppler mode.
Image 6: Pelvis X-Ray: shows multiple scattered oval-shaped
bone radiolucent, losing bone general density.
Image 7 : Right ankle XRay:
radiolucent oval-shaped lesion at distal tibia end in comparison to ultrasound.
Image 8: Right ankle
XRay: radiolucent erosion lesion at
distal clavicular end as compared to ultrasound.
Patient is preferred to endocrinologist and full body
scan to perform looking for bone fracture as common complication because patient suffering illness for a long time.
Patient blood tests confirmed diagnosis: hypercalcemia and normal RF quantitative. Serum PTH value elevated >1200
Patient underwent
surgery to remove the tumor. Pathological result : Parathyroid adenoma.
After the surgery, PTH value drops to normal value, serum calcium also drops below normal line and had been got oral calcium supply as he discharged from hospital.
Follow up on 3 months
later, patient recovered and experienced no pain. He has already can go back to work.
Discussion and conclusion:
Primary hyperpaprathyroidism is caused by parathyroid tumor excretes PTH. That activates
re-absortion calcium in kidneys, increase absorption in colons and bone loss.
Osteoclastic hyperactivity produces subperiosteal erosions, endosteal
cavitation and replacement of marrow spaces by vascular granulations and fibrous
tissue. Brown tumor is known as Osteoitis fibrosa cystica. Pseudo-tumour,
fluid-filled cysts contents hemorrhage and giant cell wrap within fibrous
stroma. Giving rise to brownish, tumour-like masses. The lesion can be single or
multiple. Well-defined and commonly affecting the facial bone, pelvis, ribs and
femoral bone. The classical which should always be sought is sub-periosteal
cortical resorption of middle phalanges.
But bone lesions in tibia end and clavicle ends of this case seem not to be so
classical findings (in diaphysis instead).
