Brown tumor of the mandible as first manifestation of atypical parathyroid adenoma

Primary hyperparathyroidism presenting as a brown tumor in the mandible: A case report

A brown tumor is a non-neoplastic lesion resulting from an abnormality of bone metabolism in the context of hyperparathyroidism. We report the case of a 51-year-old woman who initially consulted for edentulism and a growing mandibular mass. She benefited from a radiological and biological assessment which made the diagnosis of primary hyperparathyroidism combined with a parathyroid adenoma. We remind through this observation the difficulty to establish a correct diagnosis in patients with an osteolytic process of the maxilla and the necessity to look for hyperparathyroidism in front of a giant cell lesion given the insidious character of this endocrinopathy.

[The case of late diagnosis of giant parathyroid adenoma in combination with fibrocystic osteitis and brown tumor of the upper jaw: a case report]

In this case report the authors inform about late diagnosis of giant adenoma of the parathyroid gland with primary hyperparathyroidism (PHPT) and the development of fibrocystic osteitis with a «brown» tumor of the upper jaw. The patient has been under the care endocrinologist with type 2 diabetes mellitus and multinodular goiter for 8 years.The last 5 years there was a clinical manifestation of PHPT, but the diagnosis was made by an oncologist after the detection of a «brown» tumor of the upper jaw. According to multispiral computed tomography and scintigraphy with 99mTc-MIBI, a focal lesion was found in the upper jaw on the right, lytic foci in the bones of the cranial vault, pelvis, lower extremities, ribs on the right, as well as a giant parathyroid adenoma on the right. According to the increased risk of the patient having a malignant neoplasm of the parathyroid gland, an extended surgical treatment of PHPT in the enblock volume was carried out with the achievement of remission of the PHPT. This clinical case illustrates a variant of the severe course of PHPT with the development of such a rare complication as fibrocystic osteitis and demonstrates the importance of timely diagnosis.

Primary hyperparathyroidism presenting as a brown tumor in the mandible: a case report

BACKGROUND

Primary hyperparathyroidism is characterized by hypercalcemia and elevated or inappropriately normal serum levels of parathyroid hormone. Brown tumor of bone is a rare non-neoplastic lesion resulted from abnormal bone metabolism in hyperparathyroidism. However, nowadays, skeletal disease caused by primary hyperparathyroidism is uncommon. We report a case of brown tumor in the mandible as the initial exhibition of primary hyperparathyroidism associated with an atypical parathyroid adenoma.

CASE PRESENTATION

The patient was a 49-year-old female, she had a pain mass on the right mandible a year ago and was treated with root canal therapy and marginal resection. After seven months, the mass recurred and enlarged. Enhanced CT scan, laboratory examination, Ultrasonography, ^99mTc-MIBI SPECT-CT scintiscan and pathological examination were used to confirm the diagnosis of brown tumor. The patient's symptom improved after parathyroidectomy.

CONCLUSIONS

^99mTc-MIBI SPECT/CT scintigraphy is a highly sensitive examination of the localization diagnosis of hyperparathyroidism. Brown tumors should be considered in the differential diagnosis of osteolytic lesions to avoid unnecessary and harmful interventions.

Gnathic Bones and Hyperparathyroidism: A Review on the Metabolic Bony Changes Affecting the Mandible and Maxilla in case of Hyperparathyroidism

Parathyroid glands secrete the parathyroid hormone that plays an essential role in bone remodeling. Excessive production of parathyroid hormone causes a common metabolic bone disorder known as hyperparathyroidism that is classified into primary, secondary, or tertiary. In hyperparathyroidism, the late bony complication is manifested as a giant cell osteolytic lesion called "brown tumor." Primary hyperparathyroidism is usually a sporadic disorder, but in minority of cases it occurs in inherited forms, and one of these forms is the hyperparathyroidism-jaw tumor syndrome, which is characterized by primary hyperparathyroidism and ossifying fibroma in the mandible and/or maxilla.

A complex case of brown tumors as initial manifestation of primary hyperparathyroidism in a young female

Brown tumor is one of the lesions that develop in patients with hyperparathyroidism (HPT) and represents the terminal stages of bone remodeling process. Any of the skeletal bones can be affected including the craniomaxillofacial ones. Many a times, brown tumor was detected after a final diagnosis of HPT is made. However, on occasions, brown tumor can be the first clinical sign of the disease. Primary HPT is an uncommon systemic disease usually caused by hyperplasia or adenoma of the parathyroid glands. It causes overproduction of parathormone, which may affect the entire skeleton, causing bone resorption appear as cyst-like lesions called osteitis fibrosa cystica or brown tumors. Here, we report such a rare case in which multiple radiolucent lesions were noticed in the ramus part of the mandible and premolar region bilaterally, as the initial signs of primary HPT are presented in this report.

A complex case of brown tumors as initial manifestation of primary hyperparathyroidism in a young female

Brown tumor is one of the lesions that develop in patients with hyperparathyroidism (HPT) and represents the terminal stages of bone remodeling process. Any of the skeletal bones can be affected including the craniomaxillofacial ones. Many a times, brown tumor was detected after a final diagnosis of HPT is made. However, on occasions, brown tumor can be the first clinical sign of the disease. Primary HPT is an uncommon systemic disease usually caused by hyperplasia or adenoma of the parathyroid glands. It causes overproduction of parathormone, which may affect the entire skeleton, causing bone resorption appear as cyst-like lesions called osteitis fibrosa cystica or brown tumors. Here, we report such a rare case in which multiple radiolucent lesions were noticed in the ramus part of the mandible and premolar region bilaterally, as the initial signs of primary HPT are presented in this report.

Brown Tumour in the Mandible and Skull Osteosclerosis Associated with Primary Hyperparathyroidism - A Case Report

BACKGROUND:

The hyperparathyroidism (HPT) is a condition in which the parathyroid hormone (PTH) levels in the blood are increased. HPT is categorised into primary, secondary and tertiary. A rare entity that occurs in the lower jaw in association with HPT is the so-called brown tumour, which an osteolytic lesion is predominantly occurring in the lower jaw. It is usually a manifestation of the late stage of the disease. Osteosclerotic changes in other bones are almost always associated with renal osteodystrophy in secondary HPT and are extremely rare in primary HPT. This article reports a rare case of a brown tumour in the mandible as the first sign of a severe primary HPT, associated with osteosclerotic changes on the skull.

CASE REPORT:

A brown tumour in the mandible was diagnosed in 60 - year old female patient with no previous history of systemic disease. The x - rays showed radiolucent osteolytic lesion in the frontal area of the mandible affecting the lamina dura of the frontal teeth, and skull osteosclerosis in the form of salt and pepper sign. The blood analyses revealed increased values of PTH, calcitonin and β – cross-laps, indicating a primary HPT. The scintigraphy of the parathyroid glands showed a presence of adenoma in the left lower lobe. The tumour lesion was surgically removed together with the lower frontal teeth, and this was followed by total parathyroidectomy. The follow - up of one year did not reveal any signs of recurrence.

CONCLUSION:

It is critical to ensure that every osteolytic lesion in the maxillofacial region is examined thoroughly. Moreover, a proper and detailed systemic investigation should be performed. Patients should undergo regular check-ups to prevent late complications of HPT.

Hyperparathyroidism during Pregnancy- A Diagnostic and Therapeutic Challenge

Primary Hyperparathyroidism (PHP) is a rare event in pregnancy; Maternal complications in PHP patients can be as high as 67%. It can be overlooked easily because of many similar complaints shared by hyperparathyroidism and pregnancy such as nausea and vomiting, gastritis, bone aches, easy fatigability. Hypercalcemic crisis can develop resulting in coma and death. Neonatal effects are tetany and death in about 80% of cases. We report a case, of an antenatal woman at 30 weeks gestation with complains of painful swelling in left lower jaw and below right knee, pain over right hip joint and frequent episodes of gastritis. She was finally diagnosed to have primary hyperparathyroidism and brown tumour due to parathyroid adenoma. The baby was kept in Neonatal Intensive Care Unit (NICU) for three weeks, in view of prematurity with respiratory distress and later developed sepsis with DIC. The patient's signs and symptoms regressed after parathyroid surgery and the baby was healthy at the time of discharge. This case highlights the progressive deterioration of the patient because of lack of awareness of this disease process and its impact on maternal and foetal morbidity.

Giant mediastinal parathyroid adenoma presenting as bilateral brown tumour of mandible: a rare presentation of primary hyperparathyroidism

Hyperparathyroidism (HPT) is becoming increasingly common endocrinopathy in clinical practice. Nowadays, it is mostly diagnosed in subclinical or early clinical stage. Bony involvement in HPT has seen significant fall in incidence. Brown tumour of bone is exceptionally rare as a first manifestation of primary HPT (PHPT). Its radiological and histopathological features may be mistaken for other bony pathologies. If possibility of underlying HPT is overlooked the disease is bound to recur after surgery adding to morbidity of the patient. Here we present a case of bilateral brown tumour of mandible which was mistakenly treated as giant cell granuloma by surgical curettage. That the patient was harbouring an ectopic parathyroid adenoma with hypercalcemia causing non-specific symptoms was missed by the referring physician. This led to recurrence of the lesion. On subsequent evaluation, a giant mediastinal parathyroid adenoma causing PHPT was detected at our centre and was removed via mini sternotomy approach.

An Endocrine Jaw Lesion: Dentist Perspective in Diagnosis

Brown tumor is a rare nonneoplastic focal giant cell lesion that occurs in hyperparathyroidism patients with a prevalence rate of 0.1% in jaws. We report an extremely rare case of brown tumor in mandible of a 40-year-old female patient that presented as the first clinical manifestation of hyperparathyroidism. Dentist played a pivotal role in the present case by the early diagnosis of lesion and its intervention.

Mandibular Brown Tumor of Secondary Hyperparathyroidism Requiring Extensive Resection: A Forgotten Entity in the Developed World?

Brown tumor of hyperparathyroidism (BTHPT) is rare in the United States and not frequently seen in clinical practice. This is likely because early diagnosis and prompt treatment of this disease process prevent the progression and development of BTHPT. Conversely, BTHPT is more common in underdeveloped countries where fewer patients have access to health care and hyperparathyroidism (HPT) goes untreated. It has been reported that the incidence of BTHPT in underdeveloped countries can be as high as 58 to 69 percent in patients with primary HPT. We present a case report of a patient in the United States with a large mandibular BTHPT requiring an extensive resection in the setting of secondary HPT. Despite being rare in this country, it is important for nephrologists, primary care physicians, and oral health care providers to be able to recognize this entity, so that intervention may be rendered early.

Unusual presentation of primary hyperparathyroidism: report of three cases

BACKGROUND

Primary hyperparathyroidism is an endocrinopathic condition characterized by hypersecretion of parathyroid hormone. Excess parathyroid hormone results in an altered state of osseous metabolism involving bone resorption and tissue change known as osteitis fibrosa cystica, which is the end stage of primary hyperparathyroidism. Osteitis fibrosa cystica is associated with the development of brown tumors, which are rare because hyperparathyroidism is now usually diagnosed and treated before symptoms develop. Brown tumors are rarely the first symptom of hyperparathyroidism and can occasionally be mistaken for malignancy.

CASE PRESENTATION

We herein report three cases of primary hyperparathyroidism with an unusual presentation of brown tumors. All three patients were Asian. In the first case, a 42-year-old man was admitted with a mass mimicking a malignant bone neoplasm in the right mandible as the first manifestation of primary hyperparathyroidism. The second case involved a 25-year-old man admitted with a fracture of his right femur. The third case involved a 43-year-old man with multiple brown tumors in both lower limbs. All three patients underwent successful parathyroidectomy for parathyroid adenomas; one case was complicated by a papillary thyroid carcinoma.

CONCLUSION

Complete evaluation of the medical history and biochemical and radiographic findings is necessary to achieve a correct diagnosis and avoid unnecessary bone resections in patients with primary hyperparathyroidism.

[The interest in the assay of serum calcium before a maxillary tumor: discovery of primary hyperparathyroidism]

L'hyperparathyroïdie primaire (HPP) est une affection fréquente, aujourd'hui découverte fortuitement dans 75 à 80% des cas par un dosage systématique de la calcémie biologique. Le diagnostic de cette affection se base sur la mise en évidence concomitante d'une calcémie élevée, d'un taux de parathormone (PTH) élevé (80% des cas) ou normal (20% des cas), et d'une calciurie supérieure à 150 mg/24 heures. Les manifestations squelettiques graves (ostéite fibrokystique, tumeurs brunes, fractures pathologiques) sont rares de nos jours. Les tumeurs brunes constituent un mode de révélation rare de l'hyperparathyroïdie primaire et leur localisation au niveau des maxillaires est exceptionnelle. Nous rapportons ici la longue histoire de la maladie d'un homme de 42 ans atteint d'une hyperparathyroïdie primitive découverte devant une tuméfaction jugale, une hypercalcémie majeure à 3.92 mmol/l et une tumeur brune maxillaire et nous soulignant le rôle du bilan biologique raisonné et de son interprétation en tant que révélateur diagnostique pour orienter le clinicien vers l'hyperparathyroïdie primaire.

A bilaterally recurring exophytic mass on the lower jaw

Brown tumour is a rare focal giant-cell lesion that arises as a direct result of the effect of parathyroid hormone on bone tissue in patients with hyperparathyroidism (HPT). The lesions localise in areas of intense bone resorption, and the bone defect becomes filled with fibroblastic tissue. It can affect the mandible, maxilla, clavicle, ribs and pelvic bones. Therefore, diagnosis requires a systemic investigation for lesion differentiation. The authors present a case of a 27-year-old woman, with a rare case of brown tumour of mandible due to HPT secondary to osteomalacia. The lesion showed a tendency to recur even after excision till her parathyroid levels became normal.

Mandibular brown tumor as the first manifestation of primary hyperparathyroidism: A case report

Patients with primary hyperparathyroidism (brown tumor) are usually asymptomatic and clinical presentation of the tumor in the jaws is rarely the first sign of the disease. We report a 45-year-old female patient who presented with a mandibular swelling as the first sign of the disease.

Brown tumour of the maxilla and mandible: a rare complication of tertiary hyperparathyroidism

Hyperparathyroidism is nowadays diagnosed early and asymptomatically with the improvements in routine biochemical tests and radiological procedures. The late bony complications of the disease have therefore started to decline rapidly. Brown tumours are one of the bony complications of hyperparathyroidism. The mandible is the predominantly affected site in the maxillofacial area. Maxillary involvement is rare. Here, an extremely rare case of a 19-year-old male patient with brown tumours in his maxilla and mandible associated with tertiary hyperparathyroidism is presented. A thorough diagnostic work-up was carried out and treatment options for both hyperparathyroidism and brown tumours were discussed. The importance of different radiological evaluation methods and the consultation between the oral and maxillofacial surgeons, general practitioner dentists, endocrinologists and radiologists are emphasised.

Primary hyperparathyroidism presenting as an exophytic mandibular mass

A 36-year-old female patient presented with a massive painless swelling in the left mandible. The patient's medical history was unremarkable. The initial clinical and radiological evaluation indicated an aggressive odontogenic neoplasm or a metastasis from an unknown primary; the suspicion of a systemic metabolic or endocrine disorder lay low on the list of differential diagnoses. Further investigations revealed gross skeletal changes and a hypoechoic right parathyroid mass. The total serum parathyroid hormone levels and ultrasound-guided fine needle aspiration cytology (FNAC) of the mandibular and parathyroid lesions provided the diagnosis of primary hyperparathyroidism presenting as a mandibular brown tumour. This case thus highlights the importance of a thorough diagnostic work-up for all lesions in the maxillofacial region and also serves to add another facet to the myriad of presentations associated with primary hyperparathyroidism.

Brown tumor with atypical localization in a normocalcemic patient

Brown tumor is a bone lesion secondary to hyperparathyroidism of various etiologies. It is frequently seen in the head and neck region. Brown tumor presents itself on foot very rarely. Hyperparathyroidism is usually associated with high levels of calcium. Being normocalcemic and having the tumor on foot only without any other skeletal system involvement have led to a difficulty in establishing the diagnosis in our case. In our case, Brown tumor was surgically resected en-bloc and reconstructed with nonvascularized tricortical iliac crest. This is the first case in the literature with regard to its localization. Even though serum calcium levels are routinely checked in many clinics parathormone levels should also be looked for differential diagnosis, as this case confirms, in cases with osteolytic bone tumors that causes expansion even if the patient is normocalcemic.

Parathyroid carcinoma: A rare case with mandibular brown tumor

Parathyroid carcinoma constitutes less than 1 % of primary hyperparathyroidism. The male to female ratio is approximately equal and the mean age at presentation is 40 years. In about half of the patients there is a palpable cervical mass, and serum calcium level is usually above 14 mg/dl. In a case report we present a 21-year-old man with a non-tender, non-mobile bulging mandibular mass. He suffered from fatigue, recent weight loss, hoarseness, polydipsia, polyuria, hematuria, recurrent renal stones and bouts of constipation and diarrhea. A mandibular biopsy confirmed brown tumor. Serum calcium level was 15.4 mg/dl. Cervical ultrasound revealed a hypoecho area suspicious of parathyroid adenoma. Parathyroid carcinoma was later confirmed and en bloc resection was performed. During a two-year follow up there has been no evidence of recurrence or hypercalcemia. This unique case of parathyroid carcinoma in conjunction with brown tumor is the second reported case worldwide.