Morphometric Analysis of Bone Lesions in a Patient With End-stage Renal Failure Due to Primary Hyperparathyroidism

A 59-year-old man presented for further evaluation of end-stage renal failure accompanied by hypercalcemia. For the past 10 years, his serum calcium levels had been above 10 mg/dL (SI: 2.49 mmol/L) (reference range, 8.7-10.1 mg/dL [SI: 2.17-2.52 mmol/L]) and he had experienced lower back pain and kyphosis of the thoracic spine. On admission, serum creatinine was 6.4 mg/dL (SI: 565.8 μmol/L) (reference range, 0.6-1.1 mg/dL [SI: 53-97 μmol/L]), but serum calcium was elevated 10.3 mg/dL (SI: 2.56 mmol/L) and intact PTH was significantly elevated 2837 pg/mL (SI: 301.0 pmol/L) (reference range, 10-65 pg/mL [SI:1.06-6.90 pmol/L]). Skull X-rays showed the salt and pepper sign and lumbar spine X-rays revealed the rugger jersey sign. A biopsy of the right ilium was performed. Cortical bone showed thinning associated with porosity, cancellous bone showed islanding due to bone loss, and the bone marrow had a high fat content. Some vigorous bone formation by osteoblasts was observed, but osteoclast-mediated bone resorption was predominant, suggesting osteoporosis with severe bone loss. Primary hyperparathyroidism was suspected as the underlying condition, so parathyroidectomy was performed. This case is a rare example of late diagnosis of primary hyperparathyroidism in a patient with end-stage renal failure and severe bone lesions.