SONOWORLD : parathyroid adenoma medullary nephrocalcinosis

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Thyroid/parathyroid » General

Parathyroid Adenoma causing medullary neprhocalcinosis

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Author(s) :

Diana Gaitini, MD

Presentation A 39 years old woman presents at the clinic suffering from bone and abdominal pains. The patient has been diagnosed as having osteoporosis.

Caption: Transverse scan of the left lower neck

Description: Hypoechoic oval mass posterior to the left thyroid lobe, medial to the internal carotid artery.

Caption: Longitudinal scan of the lower left neck

Description: Hypoechoic oval mass posterior to the lower pole of left thyroid lobe.

Caption: Color Doppler and spectral display, left neck

Description: Within the mass a feeding artery with a low resistance flow is detected.

Caption: Longitudinal scan of the left flank

Description: Hyperechoic pyramids in left kidney

Caption: Longitudinal scan of the left flank

Description: Well demonstrated medullary hyperechogenicity in contrast with the adjacent normal echogenicity in the cortex of left kidney.

Caption: Longitudinal scan of the right flank

Description: The right kidney shows echogenic foci with acoustic shadowing compatible with stones in pyramidal tip or adjacent calyx and hyperechogenicity in the pyramidal base.

Caption: Transverse scan of the right flank, dual image, 2 levels

Description: These selected planes of the right kidney optimally illustrate the hyperechogenic medulla. Acoustic shadowing is incidentally noted in the right image.

Differential Diagnosis Medullary nephrocalcinosis
Renal tubular ectasia
Distal renal tubular acidosis
Hyperparathyroidism

Final Diagnosis Medullary neprhocalcinosis and calyx stone secondary to functional parathyroid adenoma

Discussion

Medullary neprhocalcinosis is defined as calcium deposits in the margin of renal pyramids. Stones may be seen in pyramid tip or in the adjacent calyx. On imaging- plain radiographs, sonograms, or CT- diffuse, fine, renal parenchymal calcifications are demonstrable. Calcification within the lumen of the collecting system represents nephrolithiasis.

Medullary neprhocalcinosis is in most of the cases secondary to hypercalcemic states: hyperparathyroidism, renal tubular acidosis (RTA), bone metastases, renal failure, vitamin D excess and sarcoidosis. Conditions associated with medullary nephrocalcinosis are: medullary sponge kidney, chronic pyelonephritis, renal papillary necrosis, sickle cell disease and Wilson’s disease.

In adults, 40% of cases of medullary nephrocalcinosis are attributed to hyperparathyroidism, and 20% are attributed to RTA. The remaining 40% are divided among the other multiple causes. Conversely, 5% of patients with hyperparathyroidism have nephrocalcinosis. The medullary type accounts for 95% of all nephrocalcinosis, whereas 5% represent cortical nephrocalcinosis

Case References

Krebs CA, Giyanani, VL, Eisenberg RL. Ultrasound atlas of disease processes. Norwalk, CT: Appleton & Lange, 1993: 378.
Gritzmann N, Koischwitz D, Rettenbacher T: Sonography of the thyroid and parathyroid glands. Radiol Clin North Am 2000 Sep; 38(5): 1131-45, xii[Medline].
Resnick D, Niwayama G Parathyroid disorders and renal osteodystrophies In: Resnick D. Diagnosis of bone and joint disorders. 3 ed, Philadelphia: WB Saunders, 1995: 2012-2075

Follow Up Adenoma of parathyroid gland confirmed by surgery. Medullary nephrocalcinosis confirmed on CT.

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