Hyperparathyroidism x ray

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Overview

X-ray is helpful in diagnosis of hyperparathyroidism. Finding in primary hyperparathyroidism includes subperiosteal bone resorption, endoosteal bone resorption, subchondral resorption, subligamentous resorption, intracortical resorption, osteopenia, brown tumors, salt and pepper sign in the skull (pepper pot skull), and chondrocalcinosis. X-ray is the preferred imaging for diagnosis of secondary hyperparathyroidism as majority of findings are radiological. Findings in secondary and tertiary hyperparathyroidism are often associated with the osteosclerosis of renal osteodystrophy, and the osteomalacia of vitamin D deficiency and includes subperiosteal bone resorption,subchondral resorption, subligamentous resorption, severe osteopenia, osteosclerosis, brown tumor, amyloid deposition, soft tissue and vascular calcification, superior and inferior rib notching, and osteonecrosis.

X Ray

Primary hyperparathyroidism

Finding in primary hyperparathyroidism includes:^[1]

Subperiosteal bone resorption
- Classically affects the radial aspects of the proximal and middle phalanges of the index and middle fingers
- Medial aspect of tibia, femur, humerus
- Phalangeal tuft erosion (acro-osteolysis)
- Lamina dura around teeth (floating teeth)
Endoosteal bone resorption
- Widening of medullary cavity
- Thinning of the inner cortex
Subchondral resorption
- Lateral end of the clavicles
- Symphysis pubis
- Sacroiliac joints
Subligamentous resorption
- Ischial tuberosity
- Humeral tuberosity
- Trochanters
- Inferior surface of calcaneus
- Inferior margin of lateral clavicle
Intracortical resorption: cigar/oval-shaped or tunnel-shaped radiolucency in the cortex
Osteopenia
Brown tumors
Salt and pepper sign in the skull (pepper pot skull)
Chondrocalcinosis

Secondary and tertiary hyperparathyroidism

X-ray is the preferred imaging for diagnosis of secondary hyperparathyroidism as majority of findings are radiological. ^[2] Findings in secondary and tertiary hyperparathyroidism are often associated with the osteosclerosis of renal osteodystrophy, and the osteomalacia of vitamin D deficiency:

Subperiosteal bone resorption
- Radial aspect of middle phalanges of index and long fingers are involved.
Subchondral resorption
- Hands, hips, shoulders, patellofemoral and sacroiliac joints are involved.
- Hands are involves in the ulnar side.
- Distal interphalangeal and metacarpophalangeal joints are involved.
- Subchondral resorption is very severe. It may lead to bony collapse.
Subligamentous resorption
- Retrocalcaneal bursa and insertion of planter aponeurosis may be involved.
Severe osteopenia, may be complicated by pathologic fractures
Osteosclerosis, e.g. rugger-jersey spine
Brown tumor
Amyloid deposition
- May be manifested as lytic bone lesion on radiograph
Soft tissue and vascular calcification
Superior and inferior rib notching
Osteonecrosis may be often observed in patients in whom steroid is administered for prevention of renal transplant rejection.

Subperiosteal bone resorption – Source:Radiopedia

Brown tumors – Source:Case courtesy of A.Prof Frank Gaillard, Radiopedia

Normal skull compared to Salt & pepper appearance of skull – Source:Radiopedia

Acro-osteolytis, terminal tufts erosion – Source:Case courtesy of Dr Andrew Dixon, Radiopedia

References

↑ Lachungpa T, Sarawagi R, Chakkalakkoombil SV, Jayamohan AE (2014). “Imaging features of primary hyperparathyroidism”. BMJ Case Rep. 2014. doi:10.1136/bcr-2013-203521. PMC 3962932. PMID 24614783.
↑ Tigges S, Nance EP, Carpenter WA, Erb R (1995). “Renal osteodystrophy: imaging findings that mimic those of other diseases”. AJR Am J Roentgenol. 165 (1): 143–8. doi:10.2214/ajr.165.1.7785573. PMID 7785573.

[pmid24614783-1] Lachungpa T, Sarawagi R, Chakkalakkoombil SV, Jayamohan AE (2014). “Imaging features of primary hyperparathyroidism”. BMJ Case Rep. 2014. doi:10.1136/bcr-2013-203521. PMC 3962932. PMID 24614783.

[pmid7785573-2] Tigges S, Nance EP, Carpenter WA, Erb R (1995). “Renal osteodystrophy: imaging findings that mimic those of other diseases”. AJR Am J Roentgenol. 165 (1): 143–8. doi:10.2214/ajr.165.1.7785573. PMID 7785573.

[1]

[2]