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Radiological images of osteitis fibrosa cystica and renal nephrolithiasis in a patient with pathological fracture due to severe primary hyperparathyroidism
  1. Dayanidhi Meher,
  2. Vishal Agarwal,
  3. Binod Prusty and
  4. Bijay Ketan Das
  1. Endocrinology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
  1. Correspondence to Dr Dayanidhi Meher; dayanidhi.meher{at}

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A woman in her 30s, presented to our department with a history of non-healing fracture of the left femur since the last 1 year. Her physical examination was unremarkable. On evaluation, her serum calcium level was 3.59 mmol/L (normal range 2.25–2.74 mmol/L) with vitamin D(25-OH) level of 121.25 nmol/L (normal range 50–162.5 nmol/L), serum phosphorus level of 0.58 mmol/L (normal range 0.80–1.45 mmol/L), serum albumin level of 39 g/L (normal range 35–55 g/L) and serum alkaline phosphatase level of 400 U/L (normal range 35–104 U/L). X-ray of skull lateral view revealed the osteolytic cystic lesion over the skull (figure 1), along with similar osteolytic and cystic lesions over the left femur bone (figure 2). The serum parathyroid hormone assay turned out to be 106.51 pmol/L (normal range 1.59–6.89 pmol/L). X-ray of abdomen revealed multiple renal stones bilaterally (figure 3) and X-ray of hands showed multiple osteolytic lesions as well (figure 4). With these evidences, a diagnosis of primary hyperparathyroidism was confirmed.

Figure 1

Osteolytic lesion (arrow) over the parietal region along with classic ‘salt and pepper’ appearance on lateral view skull radiograph.

Figure 2

Osteolytic lesions (arrow) in left femur along with pathological fracture.

Figure 3

Mutiple renal stones (arrow) bilaterally in both kidneys on plain picture erect abdomen radiograph.

Figure 4

Multiple osteolytic lesions (arrow) on plain picture radiograph of hand.

According to the literature, the classical clinical manifestations of hyperparathyroidism are related to renal stones and bone disease.1 Osteitis fibrosa cystica is a rare manifestation of primary hyperparathyroidism.2 Multiple lytic bone lesions may be misdiagnosed on CT scan as metastatic carcinoma, bone cysts, osteosarcoma and especially giant-cell tumour.3 Thus, whenever radiographic evidences of multiple lytic bone lesions are present along with hypercalcaemia, primary hyperparathyroidism must be ruled out as the cause.

Patient’s perspective

I was worried when I found that pain in my left thigh has persisted even after operative procedure for the fracture which occurred one year ago. When I came to know that all my sufferings are due to a disorder of the gland known as parathyroid, me and my family members were worried about further proceedings, but thankfully my doctors made me believe that it is a treatable condition. I am thankful to the doctors and their team who helped to diagnose this. I hope that others will learn more about this rare condition from my case.

Learning points

  • Patients with severe hyperparathyroidism can present with pathological fractures or non-healing fractures.

  • Osteitis fibrosa cystica can mimic osteolytic bone tumour in appearance on plain radiographs and CT scans.

Ethics statements

Patient consent for publication



  • Contributors DM, VA, BP and BKD were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content. DM gave final approval of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.