Vitamin D deficiency and severe hyperparathyroidism.
The typical manifestations of severe hypercalcemia with osteitis fibrosa cystica have become exceedingly rare. We describe the case of a woman hospitalized for a tibial tumor with functional impotence, leading to a diagnosis of primary hyperparathyroidism (HPT I) associated with profound vitamin D deficiency. This 31-year-old woman was admitted, after two pregnancies complicated by the HELLP syndrome. Preoperative laboratory values were as follows: calcemia 4.05 mmol/l (2.2-2.6); urinary calcium 30 mmol/24 h (1.25-7.5); parathormone (PTH) 1 195 pg/ml (10-60); and 25 OH-vitamin D 13 nmol/l (22-120). Specific MIBI uptake by the tibial lesion oriented the diagnosis towards a brown tumor. After surgical excision of a parathyroid adenoma and the brown tumor (associated with tibial fracture), calcemia fell to 1.55 mmol/l and normalized after three months. Urinary calcium fell to 0.1 mmol/24 h and remained low during the 2 years following surgery. Vitamin D levels rapidly normalized on supplementation (87 nmol/l). PTH levels fell markedly after surgery but remained higher than normal till 2 years after surgery despite normalization of calcemia three months after. Bone repair, estimated by means of bone densitometry, improved from preoperative Z-score values of - 6.54, - 5.20 and - 3.50 in the left femoral neck, right femoral neck and lumbar spine, respectively, to - 0.20, - 1.55 and - 0.28, respectively, one year after surgery. In conclusion, this case illustrates: 1) the severe osseous expression of HPT probably related to vitamin D deficiency; 2) specific MIBI uptake by the bone lesion, orientating the diagnosis towards a brown tumor; 3) the consequences of vitamin D deficiency on postoperative outcome, with transient severe initial hypocalcemia related to bone calcium avidity; 4) a possible link between HPT and the HELLP syndrome.
Jonard
S
S
Service d'Endocrinologie et Maladies Métaboliques, CHU, Lille, France.
Gauthier-Morgenstern
M
M
Douillard
C
C
Leteurtre
E
E
Nocaudie
M
M
Leroy
X
X
Proye
C
C
Marchandise
X
X
Wemeau
J L
JL
Vantyghem
M C
MC
D000328:Adult; D001859:Bone Neoplasms / Q000175:diagnosis* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D005602:France; D006801:Humans; D006961:Hyperparathyroidism / Q000150:complications / Q000175:diagnosis*; D010014:Osteolysis / Q000209:etiology / Q000601:surgery; D013997:Time Factors; D014808:Vitamin D Deficiency / Q000150:complications / Q000175:diagnosis*; D044465:White People