Limb stiffness and hyperparathyroidism

A 58-year-old man presented with swelling and skin tightening in all four limbs.(Fig. 1) He had muscular weakness in both proximal and distal muscles of all limbs. EMG/ NCV study of limbs was compatible with myopathy without spontaneous activity. He was found to have serum Cr.=3.6 mg/dl in another medical center and kidney biopsy revealed interstitial nephritis with nephrocalcinosis. He had leukocytosis (12,000 /mm3), and was anemic (Hb=7.3 g/ dl). He had elevated ESR (53) and normal CRP. Bone marrow aspirate was normocellular. He had elevated serum Calcium (14.5 & 16 mg/dL) and low normal serum Phosphate (2.8 & 3.7 mg/dl) while his 25(OH) VDlevel was low (15 ng/ml). Serum PTH level was very high ( > 1000 pg/ml L). Parathyroid MIBI scan showed increased uptake. Whole body Tc99-MDP scan showed increased soft tissue uptake throughout limbs. Following hemodialysis to correct herpercalcemia surgical exploration of neck performed and revealed couple of parathyroid masses. Histopathologic examination of the mass was compatible with hyperplasia of parathyroid gland. After the operation PTH decreased to 5 pg/ml and patient discharged with normal serum Calcium and Phosphate and improved muscle force.