Image Quiz
A Lytic Lesion of the Metacarpal in a Twenty-eight-Year-Old Woman1
A twenty-eight-year-old woman who had been in purdah (no skin exposed in public except the hands and face) since she was thirteen years old presented with a 4 × 3-cm painful mass in the region of the fourth metacarpal of the right hand without redness or warmth (Fig. 1). Her hand movement was extremely restricted. Radiographs revealed an expansile lytic lesion of the fourth metacarpal (Fig. 2) as well as subperiosteal bone resorption of the phalanges. Laboratory evaluation showed a serum level of calcium of 8.3 mg/dL (2.07 mmol/L) (normal, 8.5 to 10.2 mg/dL [2.12 to 2.54 mmol/L]), phosphate of 2.9 mg/dL (0.94 mmol/L) (normal, 2.5 to 4.5 mg/dL [0.81 to 1.45 mmol/L]), and alkaline phosphatase of 834 IU/L (normal, 50 to 140 IU/L); a urinary calcium of 87 mg/24 h (2.2 mmol/d) (normal, 80 to 320 mg/24 h [2.0 to 8.0 mmol/d]); and urinary phosphate of 276 mg/24 h (0.276 g/24 h or 9 mmol/d) (normal, 250 to 1000 mg/24 h [0.25 to 1.0 g/24 h or 8 to 32 mmol/d]). The results of liver and kidney function tests were normal. The serum intact parathyroid hormone level was 777 pg/mL (780 ng/L) (normal, 10 to 72 pg/mL [10 to 70 ng/L]), while the 25-hydroxycalciferol level was 5 ng/mL (normal, 10 to 60 ng/mL). Dual x-ray absorptiometry showed a substantial reduction in bone mineral density (a Z score of −3.0 in the lumbar spine). A skeletal survey revealed a few other lytic lesions in the pubis. A technetium bone scan revealed increased uptake in the fourth metacarpal, the right pubic ramus, the calvaria, the mandible, and the sternoclavicular and costochondral junctions. She was not taking any medication and had no history of steatorrhea. She described very little ingestion of food that was rich in vitamin D. The patient had had weakness and a lack of energy on walking, especially on climbing stairs, for the last year.
Fig. 1 |
Fig.1 Photograph of the lesion at presentation.
For larger view, click on image |
Fig. 2 |
Fig. 2 Radiograph of the right hand at presentation.
For larger view, click on image |
The expansile lesion of the fourth metacarpal was curetted, and histologic examination was performed.
Fig. 3-A |
Fig. 3-B |
For larger view, click on image |
|
