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A 28-year-old woman was admitted to the hospital with end-stage renal disease (ESRD) in order to begin haemodialysis. At that time, a chest radiograph showed no abnormalities (fig 1A). Since then, the patient had been receiving haemodialysis at another hospital. Twenty years later, secondary hyperparathyroidism was pointed out at another hospital. At that time, bone densitometry (dual x ray absorptiometry) had confirmed severe osteoporosis, with measurements of the lumber spine and femur greater than 5 and 3 SD below that of a young adult (T score), respectively.
After an interval of 31 years, she was admitted to our hospital with chest pain. There were not any other symptoms at that time. On physical examination, the evidence of paradoxical motion of a portion of the chest wall suggested flail chest. The laboratory results were as follows: creatinine10.0 mg/dl, intact parathyroid hormone 220.6 pg/ml, and alkaline phosphatase 262 IU/litre. A chest radiograph showed marked deformity and volume loss of her bony thorax (fig 1B). Flail chest was confirmed by radiogram where three or more segmental rib fractures were identified. Therefore, her chest pain was secondary to osteoporosis and flail chest. A hyperdense mass was also seen in the left retrocardial area. This mass was a hiatus hernia confirmed by CT scan.
The findings such as osteoporosis and chest deformities are not uncommon in ESRD patients. Usually, the deformity of bony thorax is the consequence of normal forces acting on a weakened rib cage. The axillary arc of the rib is prone to fracture and is related to flail chest. Secondary hyperparathyroidism is an important cause of osteoporosis in ESRD patients.1 However, the laboratory data did not support the diagnosis when she was admitted.
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
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