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Rapid Resolution of Uremic Tumoral Calcinosis After Parathyroidectomy
MEDICAL IMAGES
Rapid Resolution of Uremic Tumoral Calcinosis After Parathyroidectomy Szu-Yuan Li, MD, and Chiao-Lin Chuang, MD
A
54-year-old man developed a progressively enlarging painless mass on both forearms with limited range of flexion following 8 years of continuous ambulatory peritoneal dialysis (Figure 1, A.). Computed tomography showed amorphous, cystic, and multilobulated calcification at the medial aspect of his elbow joints, about 6 ⫻ 4 ⫻ 9 cm in size (Figure 1, B). His serum calcium, phosphate, and intact parathyroid hormone levels were 10.5 mg/dL, 6.0 mg/dL, and 1257 pg/mL, respectively. A sonogram disclosed evidence of 4 heterogeneous hypoechoic nodules ranging from 0.7 to 2.2 cm in the bilateral retrothyroid gland region. Conservative therapy with dietary phosphate restriction, noncalcemic phosphate binders, and vitamin D did not alleviate its progression. With a diagnosis of tertiary hyperparathyroidism with tumoral calcinosis, the
A
patient underwent parathyroidectomy, and the calcified mass disappeared within 2 months (Figure 2). Uremic tumoral calcinosis is an uncommon but serious complication of end-stage renal disease. It is characterized by massive extraosseous calcification in periarticular tissues, leading to limited range of joint movement, pain, and skin ulceration. Calcinosis has been reported to comprise calcium phosphate, hydroxyapatite, and a mixture of carbonate apatite and calcium carbonate.1 Surgical excision of the calcinosis lesion usually leads to unsatisfactory results because of local recurrence. Resolution of the calcinosis has been reported in cases receiving renal transplant and long-term daily nocturnal hemodialysis.2-3 Rapid regression of the calcified mass after parathyroid-
From the Division of Nephrology (S.-Y.L.) and Division of General Medicine (C.-L.C.), Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan.
B
FIGURE 1. A 54-year-old man developed a progressively enlarging painless mass on both forearms (A). Computed tomography showed amorphous, cystic, and multilobulated calcification at the medial aspect of the elbow joints (B). Mayo Clin Proc. 䡲 November 2012;87(11):e97-e98 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.08.014 www.mayoclinicproceedings.org 䡲 © 2012 Mayo Foundation for Medical Education and Research
e97
MAYO CLINIC PROCEEDINGS
FIGURE 2. The calcified mass disappeared within 2 months after parathyroidectomy.
ectomy in this case indicates that parathyroid hormone plays a pivotal role in disease progression. Parathyroidectomy may be a safe and promising therapy. Correspondence: Address to Chiao-Lin Chuang, MD, Division of General Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Rd, Taipei 112, Taiwan (clchuang@ vghtpe.gov.tw)
e98
1.
Hamada J, Tamai K, Ono W, Saotome K. Uremic tumoral calcinosis in hemodialysis patients: clinicopathological findings and identification of calcific deposits. J Rheumatol. 2006;33(1): 119-126. 2. Kim SJ, Goldstein M, Szabo T, Pierratos A. Resolution of massive uremic tumoral calcinosis with daily nocturnal home hemodialysis. Am J Kidney Dis. 2003;41(3):E12. 3. Buchkremer F, Farese S. Uremic tumoral calcinosis improved by kidney transplantation. Kidney Int. 2008;74(11):1498.
Mayo Clin Proc. 䡲 November 2012;87(11):e97-e98 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.08.014 www.mayoclinicproceedings.org
Rapid Resolution of Uremic Tumoral Calcinosis After Parathyroidectomy Szu-Yuan Li, MD, and Chiao-Lin Chuang, MD
A
54-year-old man developed a progressively enlarging painless mass on both forearms with limited range of flexion following 8 years of continuous ambulatory peritoneal dialysis (Figure 1, A.). Computed tomography showed amorphous, cystic, and multilobulated calcification at the medial aspect of his elbow joints, about 6 ⫻ 4 ⫻ 9 cm in size (Figure 1, B). His serum calcium, phosphate, and intact parathyroid hormone levels were 10.5 mg/dL, 6.0 mg/dL, and 1257 pg/mL, respectively. A sonogram disclosed evidence of 4 heterogeneous hypoechoic nodules ranging from 0.7 to 2.2 cm in the bilateral retrothyroid gland region. Conservative therapy with dietary phosphate restriction, noncalcemic phosphate binders, and vitamin D did not alleviate its progression. With a diagnosis of tertiary hyperparathyroidism with tumoral calcinosis, the
A
patient underwent parathyroidectomy, and the calcified mass disappeared within 2 months (Figure 2). Uremic tumoral calcinosis is an uncommon but serious complication of end-stage renal disease. It is characterized by massive extraosseous calcification in periarticular tissues, leading to limited range of joint movement, pain, and skin ulceration. Calcinosis has been reported to comprise calcium phosphate, hydroxyapatite, and a mixture of carbonate apatite and calcium carbonate.1 Surgical excision of the calcinosis lesion usually leads to unsatisfactory results because of local recurrence. Resolution of the calcinosis has been reported in cases receiving renal transplant and long-term daily nocturnal hemodialysis.2-3 Rapid regression of the calcified mass after parathyroid-
From the Division of Nephrology (S.-Y.L.) and Division of General Medicine (C.-L.C.), Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan.
B
FIGURE 1. A 54-year-old man developed a progressively enlarging painless mass on both forearms (A). Computed tomography showed amorphous, cystic, and multilobulated calcification at the medial aspect of the elbow joints (B). Mayo Clin Proc. 䡲 November 2012;87(11):e97-e98 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.08.014 www.mayoclinicproceedings.org 䡲 © 2012 Mayo Foundation for Medical Education and Research
e97
MAYO CLINIC PROCEEDINGS
FIGURE 2. The calcified mass disappeared within 2 months after parathyroidectomy.
ectomy in this case indicates that parathyroid hormone plays a pivotal role in disease progression. Parathyroidectomy may be a safe and promising therapy. Correspondence: Address to Chiao-Lin Chuang, MD, Division of General Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Rd, Taipei 112, Taiwan (clchuang@ vghtpe.gov.tw)
e98
1.
Hamada J, Tamai K, Ono W, Saotome K. Uremic tumoral calcinosis in hemodialysis patients: clinicopathological findings and identification of calcific deposits. J Rheumatol. 2006;33(1): 119-126. 2. Kim SJ, Goldstein M, Szabo T, Pierratos A. Resolution of massive uremic tumoral calcinosis with daily nocturnal home hemodialysis. Am J Kidney Dis. 2003;41(3):E12. 3. Buchkremer F, Farese S. Uremic tumoral calcinosis improved by kidney transplantation. Kidney Int. 2008;74(11):1498.
Mayo Clin Proc. 䡲 November 2012;87(11):e97-e98 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.08.014 www.mayoclinicproceedings.org