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Abstract: PO0361

Palatal Brown Tumor in a Dialysis Patient

Session Information

Category: Trainee Case Report

  • 402 Bone and Mineral Metabolism: Clinical

Authors

  • Habib, Nawal, University of California San Diego, La Jolla, California, United States
  • Mullaney, Scott, University of California San Diego, La Jolla, California, United States
  • Bullen, Alexander, University of California San Diego, La Jolla, California, United States
  • Trzebinska, Danuta, University of California San Diego, La Jolla, California, United States
  • Rubenzik, Tamara T., University of California San Diego, La Jolla, California, United States
Introduction

Secondary hyperparathyroidism (SHPT) is a common complication of end stage kidney disease (ESKD) causing loss of bone density through increased osteoclastic activity. Imbalanced bone resorption and peri-trabecular fibrosis causes formation of hemosiderin-laden giant cell granulomas – brown tumors. Here is a case of palatal brown tumor in an ESKD patient which led to complications of hungry bone syndrome after parathyroidectomy.

Case Description

A 57 yo F with ESKD on HD and SHPT presented with a growing palatal mass. She reported difficulty chewing and shortness of breath. A friable mass was located over the hard palate. Labs showed serum calcium (Ca) 9.5 mg/dL, PTH 4477 pg/mL, phosphate 5.1 mg/dL, and alkaline phosphatase (ALP) 1124 U/L. Parathyroid scan showed a focus of activity in the left thyroid bed. She underwent a mass resection and parathyroidectomy. Pathology revealed an atypical parathyroid adenoma without features of carcinoma. Her postoperative course was complicated by hungry bone syndrome with prolonged hypocalcemia, hypomagnesemia and hypophosphatemia which persisted despite aggressive Ca supplementation and high Ca dialysate. She was also started on teriparatide to stimulate osteoblast activity and bone formation. After a long hospital course, she was discharged on oral supplemental Ca and calcitriol with close follow-up.

Discussion

Despite the advent of effective management strategies for renal osteodystrophy, we must be mindful of brown tumors. Surgical excision with parathyroidectomy is the preferred treatment. Post-operatively, patients must be monitored for hungry bone syndrome. As bone formation increases, rising ALP levels can serve as a biomarker for increasing Ca requirements requiring escalating dosage of supplements. Teriparatide is a recombinant human PTH which can be used to augment bone density.