Persistent knee pain in a patient with systemic lupus erythematosus

• Autor(a) principal: Vieira,Miguel Bigotte
• Data de Publicação: 2018
• Outros Autores: Dias,Joana Monteiro, Romeu,José Carlos, Pereira,Marta, Abreu,Cristina Pinto de
• Tipo de documento: Relatório
• Idioma: eng
• Título da fonte: Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos)
• Texto Completo: http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692018000400008
• topic: Chronic kidney disease-mineral and bone disorder; hyperparathyroidism; brown tumor

The evaluation of chronic kidney disease-mineral and bone disorder (CKD-MBD) is based on clinical, laboratory, radiology and histological data. However, these data may not always be entirely concordant, leading to significant doubt over therapeutic options. We present a challenging CKD-MBD case report. A 26-year-old female patient presented a past medical history of systemic erythematosus lupus and end-stage renal disease. She had been on hemodialysis and transited to peritoneal dialysis due to multiple vascular access failure. Medication included calcium carbonate, cholecalciferol, calcitriol, and cinacalcet but adherence to medication was low, leading to PTH values often higher than 1000 pg/mL. She presented right knee pain for two months. Radiology exams revealed iliac, femoral and tibial osteolytic lesions. A bone biopsy was performed, detecting disperse multinucleated giant cells compatible with brown tumors. However, poor therapeutic adherence did not allow persistent control of hyperparathyroidism, with PTH levels often >1000 pg/mL, and parathyroidectomy was considered. A tetracycline-labeled bone biopsy showed high turnover bone disease in the past, evolving to low-bone turnover/adynamic bone disease. This led to the decision of optimizing medical treatment and avoiding parathyroidectomy. Significant clinical improvement was observed with knee pain resolution and transient reduction of PTH to stage 5 chronic kidney disease reference levels. Four years later an imagiological re-evaluation was performed, revealing bilateral tibial, femoral and iliac enlarged bone lesions, and bone scintigraphy confirmed hypermetabolic lesions. She was then submitted to subtotal parathyroidectomy and subsequently to deceased-donor renal transplantation. This case report shows the importance of closely following CKD-MBD patients, even in asymptomatic patients. Treatment decision should not solely include bone histology criteria. Repeated evaluations at different time points of clinical, laboratory, and radiology data might be particularly useful