Skip to main content

Main menu

  • Home
  • Content
    • Early Access
    • Current Issue
    • Kidney360 Podcasts
    • Subject Collections
    • Archives
    • ASN Meeting Abstracts
    • Saved Searches
  • Clinical Images
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Editorial Team
  • More
    • About Kidney360
    • Advertising
    • Disqus Commenting
    • Email Alerts
    • Feedback
    • Reprint Information
  • ASN Kidney News
  • Other
    • JASN
    • CJASN
    • Kidney News Online
    • American Society of Nephrology

User menu

Search

  • Advanced search
American Society of Nephrology
  • Other
    • JASN
    • CJASN
    • Kidney News Online
    • American Society of Nephrology
Advertisement
American Society of Nephrology

Advanced Search

  • Home
  • Content
    • Early Access
    • Current Issue
    • Kidney360 Podcasts
    • Subject Collections
    • Archives
    • ASN Meeting Abstracts
    • Saved Searches
  • Clinical Images
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Editorial Team
  • More
    • About Kidney360
    • Advertising
    • Disqus Commenting
    • Email Alerts
    • Feedback
    • Reprint Information
  • ASN Kidney News
  • Visit ASN on Facebook
  • Follow Kidney360 on Twitter
  • Community Forum
  • Kidney360 RSS
Clinical Images in Nephrology and Dialysis

Back Pain and Lower Extremity Sensory Loss in an ESKD Patient

Christian Maalouly, Bernard Vô and Laura Labriola
Kidney360 December 2020, 1 (12) 1466-1467; DOI: https://doi.org/10.34067/KID.0003322020
Christian Maalouly
1Department of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Christian Maalouly
Bernard Vô
1Department of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Laura Labriola
1Department of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
2Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data Supps
  • Info & Metrics
  • View PDF
Loading
  • dialysis
  • back pain
  • brown tumor
  • end stage kidney disease
  • hemodialysis
  • hyperparathyroidism
  • lower extremity

Case Description

A 33-year-old man on maintenance hemodialysis for 6 years for ESKD secondary to IgA nephropathy presented with acute back pain and loss of sensation in his feet, in the absence of recent trauma. His past medical history included severe hyperparathyroidism, with intact parathyroid hormone levels (iPTH) more than ten times the upper limit of the normal range (80 pg/ml) for 4 years, despite the prescription of phosphate binders, calcitriol, cinacalcet, and—lately—etelcalcetide. Clinical examination was marked by symmetric sensory loss and weakness in the lower extremities, together with deep-tendon hyperreflexia and Babinski signs. Plasma levels of electrolytes were normal. iPTH (855 pg/ml) and alkaline phosphatase (500 IU/L; normal range, 40–130 IU/L) levels were unchanged. Magnetic resonance imaging of the spine revealed diffuse bone-marrow infiltration and a fracture of the third thoracic vertebra causing cord compression (Figure 1A, arrow).

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Brown tumor of the thoracic spine. (A) Magnetic resonance imaging of the spine reveals diffuse bone-marrow infiltration and fracture of the third thoracic vertebra, causing cord compression (arrow). (B) Light microscopy shows multiple multinucleated giant cells (black arrows), stromal cells, and hemosiderin deposits (white arrow). Hematoxylin and eosin stain. Original magnification, ×40.

The patient underwent urgent spinal decompression, combining laminectomy and osteosynthesis. Surgical exploration revealed a heterogeneous mass with bloody and fleshy components. Blood cultures and microbiologic testing of the surgical sample were negative. Histopathologic examination showed numerous, multinucleated giant cells (Figure 1B, black arrows) with hemosiderin deposits (Figure 1B, white arrow), consistent with a brown tumor. Total-body bone scintigraphy showed disseminated increased uptake involving the axial skeleton. The patient fully recovered from paraparesis a few weeks after surgery. He received a deceased-donor kidney transplant 8 months later, after which iPTH levels returned to normal.

Discussion

A brown tumor is a focal osteolytic lesion caused by high bone turnover due to uncontrolled and long-standing hyperparathyroidism (1⇓–3). It is composed of collections of osteoclasts intermixed with fibrous tissue and poorly mineralized woven bone. It is characterized by the presence of numerous giant cells and hemosiderin deposits that cause the reddish-brown color (2). It predominantly affects the mandibula, clavicles, long bones, pelvis, and ribs (1⇓–3). Spinal involvement is rare (2). The lesion is seen as single or multiple well-demarcated radiolucent zones (geodes), without invasion of adjacent tissues. A brown tumor is asymptomatic unless there is adjacent structure compression or pathologic fracture (3). It should be distinguished from malignant bone lesions, spondylodiscitis, and spondyloarthropathy due to β2-microglobulin amyloidosis (4). The final diagnosis is made after histopathologic examination, coupled with the clinical and laboratory history of severe hyperparathyroidism (3). Correction of the underlying hyperparathyroidism usually leads to tumor regression (1⇓–3). Resection of the brown tumor is required only in those who do not respond to medical therapy or in patients with severe pain or neurologic deficits (1⇓–3).

Teaching Points

  • A brown tumor is a rare complication of severe hyperparathyroidism, which should be considered in patients with ESKD presenting with an osteolytic bone lesion.

  • Histologic examination is characterized by the presence of numerous giant cells and hemosiderin deposits.

  • The brown tumor is managed by correcting the underlying hyperparathyroidism.

Disclosures

L. Labriola reports receiving personal fees from Amgen, Fresenius, and Vifor, outside the submitted work. All remaining authors have nothing to disclose.

Funding

None.

Acknowledgments

Informed consent was obtained from the patient.

Author Contributions

L. Labriola reviewed and edited the manuscript; and C. Maalouly and B. Vô wrote the original draft.

Footnotes

  • C.M. and B.V. contributed equally to this work.

  • Received May 26, 2020.
  • Accepted June 30, 2020.
  • Copyright © 2020 by the American Society of Nephrology

References

  1. ↵
    1. Can Ö,
    2. Boynueğri B,
    3. Gökçe AM,
    4. Özdemir E,
    5. Ferhatoğlu F,
    6. Canbakan M,
    7. Şahin GM,
    8. Titiz MI,
    9. Apaydın S
    : Brown tumors: A case report and review of the literature. Case Rep Nephrol Dial 6: 46–52, 2016
    OpenUrl
  2. ↵
    1. Duval-Sabatier A,
    2. Gondouin B,
    3. Bouvier C,
    4. Bataille S,
    5. Berland Y,
    6. Brunet P
    : Brown tumor: Still an old disease? Kidney Int 80: 1110, 2011
    OpenUrlPubMed
  3. ↵
    1. Di Daniele N,
    2. Condò S,
    3. Ferrannini M,
    4. Bertoli M,
    5. Rovella V,
    6. Di Renzo L,
    7. De Lorenzo A
    : Brown tumour in a patient with secondary hyperparathyroidism resistant to medical therapy: Case report on successful treatment after subtotal parathyroidectomy. Int J Endocrinol 2009: 827652, 2009
    OpenUrlPubMed
  4. ↵
    1. Labriola L,
    2. Jadoul M
    : Dialysis-related amyloidosis: Is it gone or should it be? Semin Dial 30: 193–196, 2017
    OpenUrl
View Abstract
PreviousNext
Back to top

In this issue

Kidney360: 1 (12)
Kidney360
Vol. 1, Issue 12
31 Dec 2020
  • Table of Contents
  • Table of Contents (PDF)
  • Cover (PDF)
  • About the Cover
  • Index by author
View Selected Citations (0)
Print
Download PDF
Sign up for Alerts
Email Article

Thank you for your interest in spreading the word on American Society of Nephrology.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Back Pain and Lower Extremity Sensory Loss in an ESKD Patient
(Your Name) has sent you a message from American Society of Nephrology
(Your Name) thought you would like to see the American Society of Nephrology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Back Pain and Lower Extremity Sensory Loss in an ESKD Patient
Christian Maalouly, Bernard Vô, Laura Labriola
Kidney360 Dec 2020, 1 (12) 1466-1467; DOI: 10.34067/KID.0003322020

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Request Permissions
Share
Back Pain and Lower Extremity Sensory Loss in an ESKD Patient
Christian Maalouly, Bernard Vô, Laura Labriola
Kidney360 Dec 2020, 1 (12) 1466-1467; DOI: 10.34067/KID.0003322020
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Case Description
    • Discussion
    • Teaching Points
    • Disclosures
    • Funding
    • Acknowledgments
    • Author Contributions
    • Footnotes
    • References
  • Figures & Data Supps
  • Info & Metrics
  • View PDF

More in this TOC Section

  • Persistent Isolated Hematuria in a Japanese Woman
  • Purple Urine in a Patient with Refractory Hypotension
  • Acute Kidney Injury in a Patient following Percutaneous Kidney Biopsy
Show more Clinical Images in Nephrology and Dialysis

Cited By...

  • No citing articles found.
  • Google Scholar

Similar Articles

Related Articles

  • No related articles found.
  • Google Scholar

Keywords

  • dialysis
  • back pain
  • brown tumor
  • end stage kidney disease
  • hemodialysis
  • hyperparathyroidism
  • lower extremity

Articles

  • Current Issue
  • Early Access
  • Subject Collections
  • Article Archive
  • ASN Meeting Abstracts

Information for Authors

  • Submit a Manuscript
  • Author Resources
  • ASN Journal Policies
  • Reuse/Reprint Policy

About

  • Kidney360
  • ASN
  • ASN Journals
  • ASN Kidney News

Journal Information

  • About Kidney360
  • Kidney360 Email Alerts
  • Kidney360 Podcasts
  • Kidney360 RSS Feeds
  • Editorial Board

More Information

  • Advertise
  • ASN Podcasts
  • ASN Publications
  • Become an ASN Member
  • Disqus Code of Conduct
  • Disqus Information
  • Feedback
  • Follow on Twitter
  • Subscribe to JASN and CJASN

© 2021 American Society of Nephrology

Online ISSN - 2641-7650

Powered by HighWire