Interest of PET-scan in the management of severe hyperparathyroidism

A 48-year-old woman on haemodialysis developed progressive and diffuse bone pain especially in the left thigh, with progressive halting. She was adequately dialysed, and her ideal body weight was stable. She had no signs of systemic infection. Her medical history included two renal transplantations for ESRD secondary to chronic interstitial nephritis. Haemodialysis had been resumed 2 years earlier due to chronic allograft nephropathy. ESRD was complicated by severe secondary hyperparathyroidism for more than 5 years with PTH values systematically above 2500 (normal <85) pg/ml and alkaline phosphatase level ranging between 400 and 1000 (normal <95) UI/l. The patient denied parathyroidectomy several times. Hands and femoral (Figure 1) bone X-rays showed multiple lytic lesions, specific of hyperparathyroidism. A total body bone scintigraphy (Tc99m-diphosphonat hydroxyethylene) showed numerous tumoural lesions, mainly localized at the level of the long bones and the ribs (Figure 2). An 18-F-fluorodeoxyglucose (FDG) positron emission tomography (PET scan) demonstrated numerous bone lesions disseminated in the skeleton (Figures 3 and 4).