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Lin YY, Weng SF, Yang TT, Lee YW, Liu JH, Hsieh YS. Unusual body weight loss due to primary hyperparathyroidism: A case study with literature review. Heliyon 2024; 10:e28333. [PMID: 38524572 PMCID: PMC10957424 DOI: 10.1016/j.heliyon.2024.e28333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 03/26/2024] Open
Abstract
Brown tumors (osteitis fibrosa cystica) are rare pathognomonic signs that occur in patients with primary hyperparathyroidism (PHPT). Brown tumors can exist in multiple bones and can easily be misdiagnosed as a metastatic tumor or multiple myeloma. It is also localized in the forearm, humerus, and leg. The symptoms of hypercalcemia, pathologic fracture, and bodyweight loss may increase the diagnostic difficulty of brown tumors because multiple myeloma and bone metastasis also show the same symptoms. We studied a 68-year-old woman who had experienced unusual bodyweight loss in the past 6 months (56kg-40kg) and bone pain. She went to the hospital after a fall with a complaint of bone pain. An X-ray revealed a left bubbly-like cystic change and multiple fractures at the left ulna midshaft. Upon investigation, the level of intact parathyroid hormone was ascertained to be 1800 (normal: 10-60) pg/ml. Microscopically, the tumor demonstrated a benign bone lesion and was compatible with osteitis fibrosa cystica due to PHPT. The parathyroid scan (Tc-99 m sestamibi) indicated right parathyroid hyperplasia, which was later confirmed by a parathyroidectomy. She was diagnosed with osteitis fibrosa cystica associated with PHPT due to a parathyroid adenoma. PHPT can be presented with multiple fractures, bone pain, and bodyweight loss. Therefore, if a patient presents these symptoms, PHPT should be considered.
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Affiliation(s)
- Yan-Yu Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, 11031, Republic of China, Taiwan
| | - Shuen-Fu Weng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, 11031, Republic of China, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ting-Teng Yang
- Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, 11031, Republic of China, Taiwan
| | - Yi-Wei Lee
- Department of Internal Medicine, Taipei Medical University Hospital, Taipei City, 11031, Republic of China, Taiwan
| | - Ju-Han Liu
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei City, 11230, Republic of China, Taiwan
| | - Yu-Shan Hsieh
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei City, 11230, Republic of China, Taiwan
- Department of Research, Taipei Medical University Hospital, Taipei City, 11031, Republic of China, Taiwan
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Haouzi MA, Benbouzid Y, Baidriss Y, Kharmaz M, Zouaidia F, Sfar K. Pathological subtrochanteric fracture revealing a primary hyperparathyroidism: A case report. Int J Surg Case Rep 2023; 106:108158. [PMID: 37062190 PMCID: PMC10130473 DOI: 10.1016/j.ijscr.2023.108158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023] Open
Abstract
INTRODUCTION Primary hyperparathyroidism is the third most common endocrine disorder after diabetes and thyroid disease. Nevertheless, a pathological fracture revealing primary hyperparathyroidism is not commonly described. CASE PRESENTATION We present the case of a 30-year-old male patient who was admitted with a subtrochanteric pathologic fracture of her left femur after a trivial fall. Due to suspicion of bone metastases, a thoraco-abdomino-pelvic CT scan was requested. It revealed multiple irregular circumscribed lytic bone lesions in the ribs, the right scapula, the dorsal spine, and the pelvic girdle; bilateral renal lithiasis; and a nodule contiguous to the left posterior thyroid lobe. A surgical biopsy of the bone lesion was performed. Histopathological examination confirmed the diagnosis of primary hyperparathyroidism with a brown tumor. Laboratory tests showed increased both calcium and PTH levels. The patient underwent cephalomedullary nail fixation with bipolar locking. After that, a parathyroidectomy was performed. At six months' follow-up, the functional result was satisfactory. CLINICAL DISCUSSION Primary hyperparathyroidism is the most common cause of hypercalcemia. It occurs as a result of a parathyroid adenoma in 80 % of cases. Definitive diagnosis should be made by clinical history, radiological findings and confirmed by biochemical tests including serum parathyroid hormone (PTH), alkaline phosphatase, calcium, phosphate, and vitamin D levels. CONCLUSION This case report emphasizes the need of including brown tumors in the differential diagnosis of multifocal osteolytic bone lesions, in order to ensure appropriate treatment.
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Affiliation(s)
- M A Haouzi
- Department of Orthopaedic Surgery & Traumatology, Ibn Sina Hospital, University Mohamed V, Rabat, Morocco.
| | - Y Benbouzid
- Department of Orthopaedic Surgery & Traumatology, Ibn Sina Hospital, University Mohamed V, Rabat, Morocco
| | - Y Baidriss
- Department of Orthopaedic Surgery & Traumatology, Ibn Sina Hospital, University Mohamed V, Rabat, Morocco
| | - M Kharmaz
- Department of Orthopaedic Surgery & Traumatology, Ibn Sina Hospital, University Mohamed V, Rabat, Morocco
| | - F Zouaidia
- Department of Pathological Anatomy, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - K Sfar
- Emergency Radiology Department, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
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Jarrar SM, Daoud SS, Jbarah OF, Albustami IS. Paraparesis As a Rare First Presentation Of Primary Hyperparathyroidism-Related Brown Tumor in The Thoracic Spine: Case report and literature review. Ann Med Surg (Lond) 2021; 63:102197. [PMID: 33717480 PMCID: PMC7933711 DOI: 10.1016/j.amsu.2021.102197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction and importance Brown tumor (BT) is defined as osteolytic lesion of an underlying state of hyperparathyroidism. Hyperparathyroidism will activate osteoclasts which initiate active bone resorption foci of lytic-cysts with hemosiderin depositions that pigment it with its characteristic brown pathologic gross appearance. Devastating fractures and injuries can occur to affected bones and surrounding tissue that require emergent intervention and correction. Case presentation We present a case of a medically free 31-year-old female patient, who presented complaining of unsteadiness and progressive lower limbs weakness over 40 days of duration. Subsequent lab tests showed elevated PTH levels, along with 3.5 × 1.8 cm heterogeneous soft tissue mass involving the right pedicle on T7 level compressing the corresponding level of the spinal cord. Surgical management aimed to decompress the spinal cord and to obtain a biopsy for histopathologic examination which revealed a brown tumor. Neck ultrasound and Sestamibi scan indicated the presence of hyperactive and hyperplastic parathyroid tissue most suggestive of parathyroid adenoma. Clinical discussion Various presentations of Brown Tumor depend on the bone affected, despite the rarity of spinal involvement, yet expanding tumors can manifest either with back pain, radicular pain, paresthesia, weakness, paralysis, or incontinence. The highest incidence rates of spinal brown tumors affect adults over the age of 40. Management goals are to decompress the neuronal tissue emergently and to prevent further bony lytic deterioration. Conclusion The objective of this study is to provide an overview of primary hyperparathyroidism-related spinal brown tumors, presentation, and summary of previously reported similar cases in the literature. Brown tumors are rare manifestation of today's primary hyperparathyroidism clinical presentation and context when compared with secondary hyperparathyroidism. Up to 3% of patients with primary hyperparathyroidism develops BTs, the incidence is furtherly declining due to screening and health assessment programs. Brown tumors are destructive lesions that could be single or multiple at any site involving long bones, hands, mandible, pelvis and ribs, which are way more common sites than the spine. Almost half of Primary Hyperparathyroidism-Related Brown Tumors of the spine were found to affect the thoracic region. While sacral region was least to be affected.
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Affiliation(s)
- Sultan M Jarrar
- Neurosurgery, Department of Clinical Neuroscience, Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
| | - Suleiman S Daoud
- Neurosurgery, Department of Clinical Neuroscience, Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
| | - Omar F Jbarah
- Neurosurgery, Department of Clinical Neuroscience, Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
| | - Iyad S Albustami
- Neurosurgery, Department of Clinical Neuroscience, Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
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Yanevskaya LG, Karonova T, Sleptsov IV, Boriskova ME, Bakhtiyarova AR, Chernikov RA, Pogosian KA, Andreeva AT, Lebedev DA, Grineva EN, Bilezikian JP. Clinical phenotypes of primary hyperparathyroidism in hospitalized patients who underwent parathyroidectomy. Endocr Connect 2021; 10:248-255. [PMID: 33416513 PMCID: PMC7983481 DOI: 10.1530/ec-20-0515] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/05/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The aim of our study was to investigate the distribution of the PHPT clinical manifestations and biochemical features in patients who underwent parathyroidectomy. MATERIALS AND METHODS Medical records of 449 patients from three Medical Centers (Saint-Petersburg, Russia), hospitalized during a period from 2011 to 2018, were reviewed. History and anthropometric data, laboratory results (iPTH, total and iCa, phosphorus, ALP, 24-h urinary calcium, 25(OH)D) and imaging data (ultrasonography, scintigraphy, CT/MRI scan, DXA) were analyzed. RESULTS Three hundred ninety-four patients were included in the final analysis. Median age was 60 years with 94.2% being women. Symptomatic disease was evident in 222 (56.4%) patients, asymptomatic in 172 (43.6%). Skeletal involvement was more common for women, while frequency of other manifestations did not differ in both genders. There was no difference between symptomatic and asymptomatic patients in age. Serum iPTH level was higher in symptomatic patients (202.9 and 181.0 pg/mL, P = 0.022). Serum 25(OH)D level was estimated in few patients and negatively correlated with PTH (r = ¯0.294, P = 0.005), iCa (r = ¯0.268, P = 0.010) and total Ca (r = ¯0.284, P = 0.014) levels. Manifestations of CVD were observed in 67.7% of cases and affected equally both symptomatic and asymptomatic patients (70.7 and 63.4%, P = 0.076). Both age and BMI were higher in patients with CVD, whether or not they were symptomatic (62 and 53 years, P < 0.0001; 30.4 vs 26.0 kg/m2, P < 0.0001, respectively). CONCLUSIONS This experience illustrates that symptomatic phenotype is still the most common form of PHPT.
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Affiliation(s)
- Liubov G Yanevskaya
- Almazov National Medical Research Centre, St. Petersburg, Russia
- Correspondence should be addressed to L G Yanevskaya or T Karonova: or
| | - Tatiana Karonova
- Almazov National Medical Research Centre, St. Petersburg, Russia
- First Pavlov State Medical University, St. Petersburg, Russia
- Correspondence should be addressed to L G Yanevskaya or T Karonova: or
| | - Ilya V Sleptsov
- Saint-Petersburg State University N.I. Pirogov Clinic of High Medical Technologies, St. Petersburg, Russia
| | | | | | - Roman A Chernikov
- Saint-Petersburg State University N.I. Pirogov Clinic of High Medical Technologies, St. Petersburg, Russia
| | | | | | | | - Elena Nikolaevna Grineva
- Almazov National Medical Research Centre, St. Petersburg, Russia
- First Pavlov State Medical University, St. Petersburg, Russia
| | - John P Bilezikian
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Shaaban ATE, Ibrahem M, Saleh A, Haider A, Alyafai A. Brown tumor due to primary hyperparathyroidism resulting in acute paraparesis: Case report and literature review. Surg Neurol Int 2020; 11:355. [PMID: 33194288 PMCID: PMC7656022 DOI: 10.25259/sni_653_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/03/2020] [Indexed: 11/07/2022] Open
Abstract
Background: Brown tumor (Osteoclastoma) is a rare benign, focal, lytic bone lesion most commonly attributed to a parathyroid adenoma; it occurs in approximately 5% of patients with primary hyperparathyroidism, and 13% of patients with secondary hyperparathyroidism. Most tumors are located in the mandible, pelvis, ribs, and large bones; only rarely is it found in the axial spine. Case Description: A 37-year-old male with primary hyperparathyroidism presented with an MR-documented T4 and T5 brown tumor (Osteitis Fibrosa Cystica) resulting in an acute paraparesis. The patient successfully underwent excisional biopsy of an expansile, enhancing, bony destructive lesion at the T4-5 level. Subsequently, he required subtotal excision of a left upper parathyroid tumor. Conclusion: Patient with primary hyperparathyroidism may acutely present with paraparesis attributed to brown tumors of the spine warranting emergent operative decompression.
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Affiliation(s)
| | - Mostafa Ibrahem
- Department of Neurosurgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
| | - Ahmed Saleh
- Department of Neurosurgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
| | - Abdulrazzaq Haider
- Department of Pathology, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
| | - Abdulnasser Alyafai
- Department of Neurosurgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
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Proptosis in a child with chronic kidney disease: Answers. Pediatr Nephrol 2020; 35:789-791. [PMID: 31823042 DOI: 10.1007/s00467-019-04423-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
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Jia Q, Gao X, Zhou Z, Lan B, Zhao J, Liu T, Yang X, Wei H, Xiao J. Urgent surgery for spinal instability or neurological impairment caused by spinal brown tumors occurring in the context of end-stage renal disease. J Neurosurg Spine 2019; 30:850-857. [PMID: 30835712 DOI: 10.3171/2018.12.spine181044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal instability or neurological impairment caused by spinal brown tumors (BTs) with end-stage renal disease (ESRD) is an acute condition that needs urgent surgery. There is not much published information on BTs of the mobile spine given the rarity of the disease, and the literature shows inconsistent treatment options and ambiguous follow-up information. The aim of the present study was to elucidate the clinical features, anesthesia management, and surgical treatment for this rare disease through long-term follow-up observations. METHODS Clinical, laboratory, radiological, and perioperative data on 6 consecutive patients with spinal BTs who had been admitted to the authors' institution between 2010 and 2016 were retrospectively reviewed. The literature on spinal BT with secondary hyperparathyroidism was also reviewed. Summaries of the clinical features and anesthesia management are provided. RESULTS The mean age of the 6 patients was 45.5 years (range 35-62 years). Lesions were located in the cervical segment (2 cases) and thoracic segment (4 cases). Localized pain was the most common complaint, and pathological fracture occurred in 5 patients. Elevation of serum alkaline phosphate (AKP) and parathyroid hormone (PTH) was a common phenomenon. Four patients underwent circumferential resection and 2 underwent laminectomy, with parathyroidectomy performed in all patients. The anesthesia process was uneventful for all patients. The mean follow-up was 33 months (range 26-40 months). No spinal lesion progression occurred in any patient. The Karnofsky Performance Status score improved to 80-90 by 3 months after surgery. CONCLUSIONS Although uncommon, spinal BTs should be a diagnostic consideration in patients with ESRD. The thoracic spine is the most frequently affected site. ESRD is not a contraindication for surgery; with the assistance of experienced anesthesiologists, urgent surgery is the preferred option to alleviate neurological impairment and restore spinal stability.
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Affiliation(s)
- Qi Jia
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Xin Gao
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Zhenhua Zhou
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Bin Lan
- 2Medical Center of Military Unit 32151, Xingtai, Hebei, People's Republic of China
| | - Jian Zhao
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Tielong Liu
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Xinghai Yang
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Haifeng Wei
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
| | - Jianru Xiao
- 1Department of Orthopedic Oncology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai; and
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Heidarpour M, Karami M, Hedayat P, Aminorroaya A. Two rare manifestations of primary hyperparathyroidism: paralysis and peptic ulcer bleeding. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170059. [PMID: 28721219 PMCID: PMC5510439 DOI: 10.1530/edm-17-0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 06/22/2017] [Indexed: 12/14/2022] Open
Abstract
Primary hyperparathyroidism revealed by thoracic spine brown tumor and peptic ulcer bleeding is rare. We presented a case of 33-year-old male patient who was admitted with paraplegia. Thoracic spine magnetic resonance imaging (MRI) showed extradural lesion at T4 level. He underwent surgical decompression in T4. According to histopathologic finding and elevated serum parathormone (PTH) and hypercalcemia (total serum calcium 12.1 mg/dL), the diagnosis of brown tumor was down. Ultrasonography of his neck showed a well-defined lesion of 26 × 14 × 6 mm. The day after surgery, he experienced 2 episodes of melena. Bedside upper gastrointestinal endoscopy showed gastric peptic ulcer with visible vessel. Treatment with intragastric local instillation of epinephrine and argon plasma coagulation was done to stop bleeding. After stabilization of the patient, parathyroidectomy was performed. Histologic study showed the parathyroid adenoma without any manifestation of malignancy. At discharge, serum calcium was normal (8.6 mg/dL). On 40th day of discharge, standing and walking status was normal.
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Affiliation(s)
- Maryam Heidarpour
- Isfahan University of Medical Sciences Isfahan Endocrine and Metabolism Research Center Ringgold Standard Institution, IsfahanIran
| | - Mehdi Karami
- Isfahan University of Medical Sciences Isfahan Endocrine and Metabolism Research Center Ringgold Standard Institution, IsfahanIran
| | - Pegah Hedayat
- Isfahan University of Medical Sciences Isfahan Endocrine and Metabolism Research Center Ringgold Standard Institution, IsfahanIran
| | - Ashraf Aminorroaya
- Isfahan University of Medical Sciences Isfahan Endocrine and Metabolism Research Center Ringgold Standard Institution, IsfahanIran
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Tayfun H, Metin O, Hakan S, Zafer B, Vardar AF. Brown tumor as an unusual but preventable cause of spinal cord compression: Case report and review of the literature. Asian J Neurosurg 2014; 9:40-4. [PMID: 24891890 PMCID: PMC4038866 DOI: 10.4103/1793-5482.131074] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Brown tumor (BT), also known as osteoclastoma, may appear in the context of primary and secondary hyperparathyroidism. Spinal cord compression due to the BT is extremely rare. We present here an unusual case of BT involving thoracal spine and mandible. A 26-year-old woman, who had been on hemodialysis for chronic renal failure for over 6 years, got admitted with dorsal pain and progressive weakness in her lower extremities and gait disturbances. Neurological examination revealed spastic paraparesis and symmetrically hyperactive tendon reflex in the lower extremities. She had hypoesthesia under T10 level. On physical examination, a swelling on the left side of her jaw was also detected. Magnetic resonance imaging (MRI) showed cord compression due to an extradural mass lesion at T8 level. A computerized tomography (CT) scan showed that this expansile lytic lesion was caused by the collapse of vertebra corpus (T8) at that level. CT of the mandible revealed an expansile lytic lesion on left arm of the mandible. Laboratory findings were nearly normal except parathormone level elevation to 1289 pg/mL (normal 30-70 pg/mL). Ultrasound examination showed enlargement of the parathyroid glands. The patient underwent an emergency decompression and stabilization surgery. The lesion was fragile and reddish in appearance and was easy to aspirate. The tumor was reported as "BT." Her weakness in the lower extremities improved in the early postoperative period. Following surgical intervention, the patient was transferred to nephrology clinic for additional medical treatment.
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Affiliation(s)
- Hakan Tayfun
- Haydarpaşa Numune Teaching and Research Hospital, Neurosurgery Clinic, İstanbul, Turkey
| | - Orakdöğen Metin
- Haydarpaşa Numune Teaching and Research Hospital, Neurosurgery Clinic, İstanbul, Turkey
| | - Somay Hakan
- Haydarpaşa Numune Teaching and Research Hospital, Neurosurgery Clinic, İstanbul, Turkey
| | - Berkman Zafer
- Haydarpaşa Numune Teaching and Research Hospital, Neurosurgery Clinic, İstanbul, Turkey
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