Although rare, secondary hyperparathyroidism (SHPT) can lead to skeletal damage, such as when patients go without treatment for chronic kidney disease and its complications. In Oxford Medical Case Reports, Abhilash Koratala, MD, of University of Florida Health, and Vikrampal Bhatti, MD, of University of Florida Physicians Nephrology, both in Gainesville, Florida, discussed the case of a 28-year-old Hispanic man who recently immigrated to the United States. The patient had not received medical care for some time and presented with nausea, vomiting, epigastric pain, and nose bleeds. Lab results prompted initiation of renal replacement therapy, and his uremic symptoms improved.

The patient received a work up for acute kidney injury that ruled out autoimmune and glomerular influences. However, upon lab testing, his serum parathyroid hormone (PTH) level was astonishingly high at 3904 pg/mL and accompanied by a serum calcium level of 9.5 mg/dL and a serum phosphate level of 10.8 mg/dL. Vitamin D was 20 ng/mL. 

When the patient later divulged shoulder and hand pain, clinicians ordered X-rays, which revealed bilateral acro-osteolysis with resorption of the distal phalangeal tufts, Dr Koratala and Dr Bhatti stated. In addition, X-rays of the right shoulder showed resorption of the distal end of the clavicle and mild focal subchondral cystic change along the posterior lateral humeral head. X-rays of the skull showed abnormal bony mineralization along the calvarium. These skeletal findings are all consequences of SHPT, according to the authors. Managing SHPT according to guidelines may prevent such damage. 

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1. Koratala A and Bhatti V. Skeletal findings in secondary hyperparathyroidism. Oxf Med Case Reports (2017): omw097. doi: 10.1093/omcr/omw097