A 31-year-old female patient complained a mass in her maxilla and mandible. The mass was gradually increasing in size over the last 6 months. The mass caused talking disturbances, swallowing difficulty, dilating gap between upper teeth, and narrowing gap between lower teeth. She also complained hard masses in her fingers and the middle of chest. There was a decrease in height (15 cm in 8 years) and weight (19 kg in 8 years). The patient was on end stage of renal failure and has been treated with hemodialysis 2 times per week for eight years since 2008. The patient was planned to be performed renal transplantation. Comorbidities were reported among this patient, which are chronic heart failure, grade II hypertension, lung tuberculosis on therapy, and hepatitis C. The physical examination showed facial asymmetry with mass in the palatum durum, measured 4 x 3 cm in size (Figure 5). Palpation revealed hard consistency originated from the bone, smooth surface, and no tenderness.
X-ray of the maxilla and mandible showed diffused decreasing bone density and multiple lytic lesion, which suggest metabolic bone disease or renal osteodystrophy or hyperparathyroidism (Figure 6). BNO showed compression fracture in thoracolumbar vertebrae and multiple calcification in soft tissue abdominal and pelvic region compatible with renal osteodystrophy. Bone survey also showed the decreased bone density. Facial CT with contrast showed diffuse hyperostosis, lytic lesion in the mandible bone, maxillary bone, cranium, and multiple calcification in the soft tissue which is compatible with osteorenal dystrophy (Figure 7). Thyroid ultrasonography showed bilateral multiple cysts in the thyroid, a firm lesion with calcification in the left parathyroid fossa, and oval lesion in the left pericarotid. Parathyroid scan showed an increased activity in the inferior aspect of left thyroid which was suggestive of parathyroid adenoma.
Laboratory examination showed the elevated ureum (202 mg/dL), creatinine (11.1 mg/dL), and normal calcium level (9.7 mg/dL). In November 2016, PTH level was >5000 pg/mL and phosphate level was 6.1 mg/dL.
Physical examination and laboratory examination lead us to brown tumor as the diagnosis due to secondary hyperparathyroidism. The treatment for this patient was subtotal parathyroidectomy with frozen section and intraoperative PTH evaluation. Intraoperative parathyroid hormone level was evaluated following subtotal parathyroidectomy. The result decreased to normal range 10.37 pg/mL (normal range: 10-65 pg/mL). Frozen section revealed hyperplasia of the parathyroid. Calcium level was evaluated every day for 7 days, and the result ranged from 5.0 mg/dL to 7.4 mg/dL. The parathyroid hormone on the 3rd month following the surgery was 4.31 pg/mL. Definitive pathology anatomy result revealed hyperplasia of the parathyroid with water clear cell parathyroid adenoma.
The masses in the maxilla, mandible, and sternum were observed to be significantly regressed. This patient then underwent renal transplantation approximately 4 months following parathyroidectomy. One month following the renal transplantation, PTH level was 6 pg/mL.