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 humerus and 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
Radiopaque lesion at both kidney Approach Film
Approach Film Medullary nephrocalcinosis of both kidneys and hyperechoic lesion with posterior acoustic shadow
Approach Film Tiny stone at left distal ureter
Tiny stone at left UVJ Approach Film
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 : medullary nephrocalcinosis of both kidney and two tiny stone at left distal ureter and left UVJ Plain film : salt and pepper skull, osteitis fibrosa 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 Hyperparathyroidism one 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
Primary Hyperparathyroidism LAB Parathyroid hormone level Ionized serum calcium level
Secondary Hyperparathyroidism Include: is the result of another condition that lower calcium levels. 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 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
Tertiary Hyperparathyroidism After long standing secondary hyperparathyroidism and resulting in hypercalcemia Clinical presentation Lab - Hypercalcemia in the setting of chronic secondary hyperparathyroidism - Normal or elevated of parathyroid hormone - Phosphate level is often elevated
Take home message Radiological investigations for primary hyperparathyroidism Musculoskeletal : salt and pepper skull, osteitis fibrosa cystica, osteoporosis, Fish vertebrae appearance Renal : Nephrocalcinosis, renal stone