Letter to the Editor
Exophthalmos and hyperparathyroidism
Exoftalmos e hiperparatiroidismo
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class="elsevierStyleSimplePara elsevierViewall">CT scan (A): atelectasis/bibasal condensation with symmetrical effusion, pericardial effusion. Skin biopsy (B): focal intracellular epidermal spongiosis, mild edema and hepatic extravasation; and; dermal vessels occupied by inflammatory cells (increase: lymphocytes and polymorphonuclear cells with eosinophilic isolates).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Adoración Martín-Gómez, Mercedes Caba Molina, Gracia Cruz Caparros, Encarnación Guerrero Sánchez, Abelardo Caballero González, Mercedes Gómez Morales" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M. 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It appears as a consequence of an increase in osteoclastic activity and fibroblastic proliferation in the context of severe primary or secondary hyperparathyroidism (2ndHPTH), the latter occurring in chronic kidney disease (CKD) due to decreased vitamin activity D at the renal level, with decreased phosphorus excretion and a tendency to hypocalcemia, which stimulates the growth of parathyroid glands. By microscopy the brown tumor is characterized by an increase in osteoclast activity, expansion of bone resorption and formation of new bone tissue; there are irregularities in the of the trabecular tissue thickness and peritrabecular fibrosis. The presence of multinucleated giant cells and interstitial hemorrhage with hemosiderin deposits gives it the characteristic brown appearance.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Complete regression or disappearance of the brown tumor usually occurs after parathyroidectomy, although depending on the location and local destruction capacity, it can cause compression or pathological fractures. Generally, it is a multiple lesion that preferentially affects the ribs, clavicles, mandible and pelvis<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a>; orbital involvement is infrequent.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 27-year-old woman with CKD secondary to nephronoptisis that underwent 2 renal transplants, the first one anticipated at 7 years of age and the second at 9 years, with loss of both due to chronic graft nephropathy. She finally started hemodialysis at 23 years of age. After 4 years on hemodialysis and with a history of more than 5 months of evolution, the patient showed severe secondary HP with a maximum PTHi of 4876<span class="elsevierStyleHsp" style=""></span>pg/ml, hypercalcemia and normo- and hyperphosphatemia that is not controlled despite treatment with cinacalcet, vitamin D analogs and phosphate binders. 99mTc-sestamibi scan shows pathological uptake of the radiotracer in all parathyroid glands demonstrating a polyglandular hyperplasia. In addition, physical examination is remarkable for the progressive and pronounced appearance of an exophthalmos with caudal displacement of the left orbit and a decrease in vision. Reconstructive orthopedic CT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and MRI describe several cystic-looking bone radiolucent lesions of 3 left periorbital brown tumors located respectively in the orbit ceiling with extension to the ipsilateral frontal sinus, In the left upper jaw and in the ascending branch of the left mandible with secondary arterial occlusion. With these findings, a total parathyroidectomy was performed with suprasternal autotransplantation to control 2nd HPTH and to achieve the reduction of tumors. After the intervention, PTHi levels fall rapidly with development of a hungry bone syndrome that requires high doses of calcium, vitamin D and hemodialysis with calcium of 1.75<span class="elsevierStyleHsp" style=""></span>μmol/l, which ensures the success of the intervention. Two months later, the analytical improvement is not accompanied by reduction of clinical symptoms; exophthalmos and compressive optic neuropathy continues. The CT scan shows an increase in size of the orbital ceiling lesion requiring excision. Microscopic examination revealed brown bone tumor.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">At present, only 19 cases have been described with periorbital involvement. In most cases, tumor excision is performed, although other different locations are described in which with the total parathyroidectomy has been followed by remission of the bone lesion.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Our case was resolved with parathyroidectomy and tumor excision (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The prevalence of brown tumor in patients with 2ndHPTH is 1.5–13% in CKD,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> being more frequent in young women.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> However, a cautious differential diagnosis should be made and rule out bone tumor implants. Nowadays, the measurement of and the effective treatment of 2ndHPTH, the appearance of new cases is decreasing.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mora Mora MT, Marín Álvarez JP. Exoftalmos e hiperparatiroidismo. Nefrología. 2017;37:441–443.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 730 "Ancho" => 1500 "Tamanyo" => 130502 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cranial and orbital CT with pre-surgery reconstruction.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 862 "Ancho" => 900 "Tamanyo" => 163872 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cranial and orbital CT with post-surgery reconstruction.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brown tumor of the cervical spine: a case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 10 | 25 |
| 2024 October | 67 | 31 | 98 |
| 2024 September | 60 | 27 | 87 |
| 2024 August | 74 | 73 | 147 |
| 2024 July | 47 | 29 | 76 |
| 2024 June | 66 | 32 | 98 |
| 2024 May | 65 | 25 | 90 |
| 2024 April | 78 | 33 | 111 |
| 2024 March | 49 | 29 | 78 |
| 2024 February | 39 | 28 | 67 |
| 2024 January | 57 | 26 | 83 |
| 2023 December | 32 | 31 | 63 |
| 2023 November | 52 | 43 | 95 |
| 2023 October | 54 | 34 | 88 |
| 2023 September | 38 | 32 | 70 |
| 2023 August | 38 | 32 | 70 |
| 2023 July | 49 | 32 | 81 |
| 2023 June | 93 | 33 | 126 |
| 2023 May | 98 | 28 | 126 |
| 2023 April | 74 | 25 | 99 |
| 2023 March | 128 | 43 | 171 |
| 2023 February | 80 | 20 | 100 |
| 2023 January | 40 | 29 | 69 |
| 2022 December | 62 | 34 | 96 |
| 2022 November | 77 | 28 | 105 |
| 2022 October | 57 | 43 | 100 |
| 2022 September | 58 | 46 | 104 |
| 2022 August | 56 | 48 | 104 |
| 2022 July | 42 | 42 | 84 |
| 2022 June | 74 | 38 | 112 |
| 2022 May | 46 | 53 | 99 |
| 2022 April | 81 | 40 | 121 |
| 2022 March | 75 | 56 | 131 |
| 2022 February | 65 | 64 | 129 |
| 2022 January | 48 | 42 | 90 |
| 2021 December | 61 | 54 | 115 |
| 2021 November | 70 | 37 | 107 |
| 2021 October | 74 | 59 | 133 |
| 2021 September | 61 | 36 | 97 |
| 2021 August | 59 | 45 | 104 |
| 2021 July | 55 | 31 | 86 |
| 2021 June | 61 | 34 | 95 |
| 2021 May | 85 | 43 | 128 |
| 2021 April | 156 | 81 | 237 |
| 2021 March | 87 | 47 | 134 |
| 2021 February | 84 | 30 | 114 |
| 2021 January | 64 | 29 | 93 |
| 2020 December | 45 | 20 | 65 |
| 2020 November | 49 | 24 | 73 |
| 2020 October | 27 | 16 | 43 |
| 2020 September | 40 | 12 | 52 |
| 2020 August | 67 | 19 | 86 |
| 2020 July | 43 | 13 | 56 |
| 2020 June | 39 | 18 | 57 |
| 2020 May | 52 | 9 | 61 |
| 2020 April | 36 | 21 | 57 |
| 2020 March | 43 | 21 | 64 |
| 2020 February | 35 | 23 | 58 |
| 2020 January | 35 | 15 | 50 |
| 2019 December | 55 | 24 | 79 |
| 2019 November | 52 | 28 | 80 |
| 2019 October | 29 | 13 | 42 |
| 2019 September | 33 | 15 | 48 |
| 2019 August | 28 | 13 | 41 |
| 2019 July | 28 | 16 | 44 |
| 2019 June | 34 | 21 | 55 |
| 2019 May | 41 | 14 | 55 |
| 2019 April | 70 | 31 | 101 |
| 2019 March | 62 | 26 | 88 |
| 2019 February | 44 | 23 | 67 |
| 2019 January | 32 | 28 | 60 |
| 2018 December | 157 | 36 | 193 |
| 2018 November | 358 | 31 | 389 |
| 2018 October | 317 | 27 | 344 |
| 2018 September | 139 | 29 | 168 |
| 2018 August | 82 | 18 | 100 |
| 2018 July | 79 | 12 | 91 |
| 2018 June | 89 | 25 | 114 |
| 2018 May | 125 | 21 | 146 |
| 2018 April | 141 | 8 | 149 |
| 2018 March | 154 | 20 | 174 |
| 2018 February | 179 | 4 | 183 |
| 2018 January | 108 | 10 | 118 |
| 2017 December | 144 | 6 | 150 |
| 2017 November | 61 | 8 | 69 |
| 2017 October | 52 | 10 | 62 |
| 2017 September | 66 | 10 | 76 |
| 2017 August | 98 | 10 | 108 |
| 2017 July | 23 | 6 | 29 |
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