Quiz page answers December 2004

Quiz page answers December 2004

AJKD QUIZ PAGE ANSWERS DECEMBER 2004 A 53-year-old woman with end-stage renal failure of unknown cause, who had been treated with long-term peritone...

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AJKD

QUIZ PAGE ANSWERS DECEMBER 2004

A 53-year-old woman with end-stage renal failure of unknown cause, who had been treated with long-term peritoneal dialysis for 2 years, presented to her nephrologist because of a dry cough of 5 weeks’ duration. Other medical problems included arterial hypertension, hyperlipidemia, and hyperparathyroidism secondary to her chronic kidney disease. She was not taking angiotensin-converting enzyme inhibitors. On auscultation, her breathing sounds were normal. A chest x-ray was performed, followed by a computed tomographic (CT) scan of the chest.

Figure 34E.

What does the chest x-ray show?

The chest x-ray shows prominence of the sixth right rib (arrow).

Figure 34F.

What does the CT scan show?

The CT scan shows a mass within the outer aspect of the sixth rib with osteal density. There is also an area of soft tissue density (arrow).

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QUIZ PAGE ANSWERS (continued)

Figures 34C and D. After the CT scan, a surgical procedure was done. What do you see on light microscopy of the tissue taken during the procedure?

A rib showing a lytic lesion composed of numerous giant cells with interstitial hemorrhage, hemosiderin deposits, and plumb fibroblasts.

What is your final diagnosis? A brown tumor in the sixth right rib secondary to hyperparathyroidism. Brown tumor is a cellular process caused by a rapid lysis of the bone due to high parathyroid hormone levels. Hemorrhage into the bone space gives the tumor its typical brown color. Although a brown tumor can manifest in any bone, it rarely has been described in the ribs. In this patient, the destructive changes in the bone caused an inflammation in the adjacent pleura, which provoked the chronic cough. The cough disappeared after a resection of the rib. The patient underwent a successful parathyroidectomy, after which her intact parathyroid hormone level decreased from 1,535 pg/mL (ng/L) before surgery to 3 pg/mL (ng/L) afterwards.

Final diagnosis: A brown tumor in the sixth right rib secondary to hyperparathyroidism Case provided by Daniel Agmon, MD, Meir Zohar, MD, and Geoffrey Boner, MD, Department of Nephrology, Sanz Medical Center, Netanya, Israel.

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