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A 5½12 year old boy presented with fever, limb pain, polydipsia, and polyuria for 18 months, and respiratory distress for two weeks. His weight and length were below the 5th centile and he had multiple enlarged lymph nodes and hepatosplenomegaly. He was tachypnoeic with retractions, and had bilateral scattered crepitations. A chest x ray showed a dense homogeneous opacity on the left and right hilar prominence, with healed rib fractures. There was cupping and fraying at the ends of long bones, with osteopenia and pencil thinning of cortex. Serum calcium was 2.6 mmol/l, phosphorus 1.48 mmol/l, and alkaline phosphatase 3790 U/l. A presumptive diagnosis of disseminated tuberculosis, rickets, and scurvy was made and he was started on appropriate therapy.
Within a month, he presented with a pathological fracture in the left tibia and worsening respiratory distress. He was emaciated, oxygen dependent, and hypertensive (BP 130/110 mm Hg). Serum calcium was 3.3 mmol/l and phosphorus 0.77 mmol/l. Figure 1 shows chest x ray; limb x rays showed osteopenia, bone resorption, and calcification of the radial artery. Ultrasound of the neck showed right parathyroid adenoma (fig 2); serum intact parathormone level was 122.7 pmol/l. A 3×3 cm parathyroid adenoma was excised surgically and comprised of clear and chief cells. Postoperatively, he required ventilatory support for 40 days. Radiologically, his lung shadows initially worsened and then partially cleared. He has been on follow up for a year and has remained normocalcaemic. Chest x ray shows partial clearing (fig 3).
Primary hyperparathyroidism is rare in children.1 Solitary adenomas account for the majority of such cases.2 Metastatic calcification is rare in primary hyperparathyroidism.3–5 With lung involvement, the x rays have often been interpreted as pneumonia, interstitial fibrosis, or atelectasis.3,5 Metastatic calcification of the lung has not been reported in children.