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Abstract: FR-PO551

Osteitis Fibrosa Cystica in Renal Osteodystrophy Masquerading as Malignancy

Session Information

Category: Trainee Case Report

  • 402 Bone and Mineral Metabolism: Clinical

Authors

  • Chandra, Samira Zannat, Jacobi medical center, NYCHHC, Bronx, New York, United States
  • Devkota, Kriti, Upstate Medical University, Syracuse, New York, United States
  • Jim, Belinda, Albert Einstein College of Medicine, New Hyde Park, New York, United States
Introduction

High bone turnover in renal osteodystrophy is a rare clinical entity nowadays due to early diagnosis and treatment of secondary hyperparathyroidism. Since it is a diagnosis of exclusion, a formidable diagnostic challenge exists when the likelihood of malignancy is high in an elderly ESRD patient.

Case Description

A 64-year-old African American man with a history of HTN, cardiomyopathy with ICD and ESRD on hemodialysis was admitted for pathological fracture of L2 with no neuro deficit. Imaging showed generalized osteopenia, burst fracture of L2, radiolucent foci all over the spine. Preliminary diagnosis of malignancy was made, and cord compression was ruled out. Biopsy from L2 revealed- i. reactive bone with prominent peri-trabecular fibrosis, ii. patchy hemosiderin-laden macrophages and iii. increased number of multinucleated osteoclasts indicative of bone resorption. Skeletal survey was inconclusive for malignancy or myeloma. Contrast CT abdomen and pelvis reported cortical erosion of symphysis pubis by a mass measuring 3.7 cm x 4.3 cm. Biopsy from the mass revealed- focal granulation tissue and hemosiderin-laden macrophages. Blood work for myeloma showed only polyclonal gammopathy on SPEP. Serology for tumor markers was negative and TB was ruled out. Meanwhile, the patient received multiple units of PRBC, periodic filgrastim and darbepoetin injection for pancytopenia. Bone marrow biopsy reported high normocellular marrow, polyclonal plasma cells, hemosiderin-laden macrophages, extensive peri-trabecular fibrosis and bony remodeling with osteoblasts. Then the PTH level was checked and found to be 2020 pg/ml. Neck ultrasound showed all four parathyroid hyperplasias. Finally, the patient underwent parathyroidectomy. The patient improved slowly and was sent home after a while. On follow up visit, the patient reported an increased sense of well-being. Follow up lab revealed- normalization of CBC requiring no further PRBC transfusion or filgrastim injection.

Discussion

This case illustrates the importance of considering secondary hyperparathyroidism as the possibility of a lytic bony lesion in the ESRD population. High bone turnover in hyperparathyroidism can manifest as osteitis fibrosa cystica (lytic lesion), brown tumor (both lytic and expansile mass) and/or peri-trabecular bone marrow fibrosis. Clinical and histopathological co-relation is crucial for such a diagnosis.