Presentation
Patient with chronic kidney disease on hemodialysis for almost 1 year.
Patient Data
X-rays evidence the salt and pepper sign in the skull (pepper pot skull).
Rugger jersey spine.
Subperiosteal bone resorption of the inferior margin of the 8th left rib, highlighted in blue.
Radiographs demonstrate subperiosteal bone resorption, brown tumors and bone erosions with ankylosis.
Yellow arrows: subperiosteal bone resorption of the radial aspects of 2nd, 3rd, 4th and 5th finger proximal phalanges of the right hand.
Pink circle: ankylosis of the right fifth distal interphalangeal joint.
Lesion highlighted in green: brown tumor on 2nd proximal phalanx of the right hand.
Purple arrows: subperiosteal bone resorption of the radial aspects of 2nd, 3rd and 4th finger proximal phalanges of the left hand.
Red circle: ankylosis of the left fifth proximal interphalangeal joint.
Lesion highlighted in blue: brown tumor on 3rd metacarpal of the left hand.
Case Discussion
Secondary hyperparathyroidism is a quite common complex alteration in bone and mineral metabolism that occurs as a direct result of chronic kidney disease. The patient presented in this case has stage 5 chronic kidney disease and has been undergoing hemodialysis therapy for almost a year. Secondary hyperparathyroidism was suspected due to laboratory exam alterations and confirmed through the radiographs shown above. Although she developed this complication only some months after the diagnosis of stage 5 chronic kidney disease, patients who are classified as stage 3 or 4 are already at risk for secondary hyperparathyroidism. The early identification and treatment of this condition is crucial to preventing or controlling the consequences of this complication.
Contributed by Dr. Guilherme Pioli Resende M.D. and Dr. Marcello Antônio de Rezende Basilio M.D.