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Clinical Problem Solving: Radiology
March 2005

Radiology Quiz Case 1—Diagnosis

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Arch Otolaryngol Head Neck Surg. 2005;131(3):276-277. doi:10.1001/archotol.131.3.276

The differential diagnosis of a lytic lesion in a young woman includes aneurysmal bone cyst, cherubism, giant cell tumor, eosinophilic granuloma, brown tumor, and primary bone tumor. Multiple lytic lesions raise the possibility of a metastatic lesion, multiple myeloma, or a multicentric giant cell tumor. The mandibular swelling in the present case was initially misdiagnosed as an epulis because of the grossly thickened mucosa in that area. It was suggested that the reason the patient’s tooth had loosened and fallen off could have been pathologic (eg, carious). This could have been an inciting factor for an epulis, which is a nonspecific term that is usually applied to a benign swelling of the gum. Because the patient had an expected delivery date 3 weeks later and the histopathologic findings were compatible with epulis, we deferred further radiologic investigations and treatment until after her baby was delivered. Two weeks after delivery, she presented with an increase in the size of the swelling. An orthopantogram revealed a soft tissue mass and a lytic lesion in the horizontal ramus of right hemimandible (Figure 2). A computed tomogram demonstrated another large lesion in the ipsilateral aspect of the maxilla, with multiple small lesions in the mandible (Figure 3). Radiologic evaluation of the skull showed a salt-and-pepper appearance, and radiologic examination of both hands revealed multiple lytic areas in the left distal radius and the right fifth metacarpal and subperiosteal erosion of the medial margin of the phalanges (Figure 4). Laboratory tests revealed the following values: serum calcium, 12.0 mg/dL (3.0 mmol/L); phosphorus, 2.4 mg/dL (0.77 mmol/L); alkaline phosphatase, 689 U/L; and parathyroid hormone, 4×10−12 pg/mL (0.4×10−12 pmol/L). The patient was diagnosed as having a brown tumor due to primary hyperparathyroidism (PHP). Sonography of the neck revealed a 1.8× 2.1-cm mass in the posteroinferior region of the left lobe of the thyroid gland. During surgery, the left inferior parathyroid gland, which was located on the lower pole of the left thyroid gland, was found to be enlarged. The adenoma was removed. Other parathyroid glands were normal. The patient had signs of hypocalcemia in the postoperative period but did not require calcium supplementation. She was normocalcemic after nearly 3 weeks.

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