CASE 133

By: Dr. Nizar Al-Nakshabandi MD, FRCPC

HISTORY: 29-year-old complaining of bilateral hip pain.

What are your findings?

What is the differential diagnosis?

What are the causes?

FINDINGS:

AP radiograph of the right hand [A] demonstrates a lytic lesion of the distal metadiaphysis of the radius with evidence of subperiosteal reabsorption of the radial aspect of the proximal and middle phalanges of the second and third digits.

AP radiograph of the pelvis demonstrates bilateral femoral neck fractures likely to be insufficiency fractures. Although the hip joint remains congruent, there is superior migration of the femora bilaterally. Diffuse osteopenia of the pelvic bone is seen. Subchondral resorption of the symphysis pubis is noted.

Lateral radiograph of the lumbosacral spine demonstrates the classical rugger jersey spine appearance with evidence of prominent sub endplate increased density at multiple contiguous levels producing the alternating sclerotic lucent sclerotic appearance.

DIFFERENTIAL DIAGNOSIS:

Hyperparathyroidism whether its primary, secondary or tertiary. Appearances in the spine could be associated with Paget’s disease or osteopetrosis. However, the combination of findings is most likely due to hyperparathyroidism. Particularly given the Brown tumor in the distal radius, subperiosteal resorption on the radial aspect of the phalanges. Subchondral resorption at the symphysis pubis with bilateral insufficiency fractures from severe osteomalacia.

DIAGNOSIS:

Secondary hyperparathyroidism with insufficiency fractures.

PEARLS AND DISCUSSION:

Secondary hyperparathyroidism is associated with osseous sclerosis of renal osteodystrophy and osteomalacia vitamin D deficiency. It is usually caused by chronic hypocalcemia with renal osteodystrophy being the most common cause.

With rugger jersey spine sclerotic bands are caused by the accumulation of excess osteoid in the superior and inferior endplates which reflects increased volume when compared to the normal bone.

FURTHER READING:

1.      Wittenberg A. The rugger jersey spine sign. Radiology. 2004;230 (2): 491-2. 

2.      Clark PB, Perrier ND, Morton KA. Detection of an intrathymic parathyroid adenoma using single-photon emission CT 99mTc sestamibi scintigraphy and CT. AJR Am J Roentgenol. 2005;184 (3): S16-8.

3.      Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Mosby Inc. (2003) ISBN:0323023282.