Metastatic calcification from secondary hyperparathyroidism

A 48-year-old man who had end-stage renal disease of 9 years presented with a 5-month history of painful left toe. The patient was on dialysis for 9 years. On physical exam, multiple masses were found on his back (Fig. 1A), right forearm (Fig. 1B) and knee, which had started to grow since 7 years ago. Chest computed tomography (Fig. 1C) showed extensive calcifications (yellow arrows) and destruction of ribs (green arrows). A plain radiograph of the right forearm (Fig. 1D) showed vascular calcification (red arrow) and phymatoid calcification (yellow arrow). Laboratory studies showed an intact parathyroid hormone level of >2000 pg per milliliter (reference range, 10 to 65), a serum calcium level of 2.81 mmol per liter (reference range, 2.12 to 2.52) and a phosphate level of 2.78 mmol per liter (reference range, 0.85 to 1.51). He received pain relief therapy and underwent parathyroidectomy. At a follow-up visit 2 months later, the parathyroid hormone level had returned to a normal level, and the masses had visibly regressed.