Primary hyperparathyroidism with brown tumor

Case contributed by Matt Skalski
Diagnosis almost certain


Insidious onset of shoulder pain.

Patient Data

Age: 30 years
Gender: Male

A well-defined, mildly expansile lesion is observed in the distal clavicle approximately 1cm proximal to the distal articular surface. The lesion is soap-bubbly in appearance with mild cortical thinning. There is no evidence of cortical violation or overlying periosteal reaction. 

Overall bone density appears moderately diminished. The acromioclavicular joint appears widened, with an indistinct distal clavicular articular surface. The cortex along the medial aspect of the humeral neck appears thinned and feathery on the external rotation view.

The lungs and mediastinum are unremarkable bilaterally. There is a focal indentation of the tracheal air shadow on the left at the level of T4. 

Note the prominent resorption of the distal clavicle on the left, in addition to the previously described lesion in the right clavicle. 

The patient is hyperkyphotic, likely secondary to long-standing osteopenia. 

There is faint nephrocalcinosis bilaterally within the renal pyramids, and a large renal stone within the superior pole of the left kidney. 

Again noted is moderate osteopenia, with ill-defined lytic destruction of the left pubic bone which also appears mildly enlarged. There is a transverse linear lucent line through the left superior pubic ramus that is suspicious for a pathological fracture. 

The SI joints are minimally indistinct bilaterally. 

There are well-defined, soap-bubbly lesions with sclerotic margins within the ilii bilaterally, in the regions of the right ASIS and left AIIS. 

Case Discussion

After histology reported a giant cell tumor in the right clavicle, radiology requested that the patient's blood calcium level be checked, wondering if this tumor might be the "other osteoclastoma." The calcium came back 15, solidifying the diagnosis of HPT. Subsequently the patient went on to have his parathryoid gland resected, which the surgeon reported was extremely large. 

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