Hyperparathyroidism Clinically Mimicking Multiple Myeloma: A Case Report

Case Report

Hyperparathyroidism Clinically Mimicking Multiple Myeloma: A Case Report

Deepak Goel ^1*
Jyoti Kotwal ²
Sabina Langer ³
Pallavi Prakhar ⁴

1Senior Resident, Department of Haematology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India.

2Senior Consultant and Head, Department of Haematology, Sir Ganga Rama Hospital, Rajinder Nagar, New Delhi, India.

3Senior Consultant and Vice chairperson, Department of Haematology, Sir Ganga Rama Hospital, Rajinder Nagar, New Delhi, India.

4Associate Consultant, Department of Haematology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India.

*Corresponding Author: Deepak Goel, Senior Resident, Department of Haematology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India.

Citation: Goel D, Kotwal J, Langer S, Prakhar P. (2025). Hyperparathyroidism Clinically Mimicking Multiple Myeloma: A Case Report, International Journal of Biomedical and Clinical Research, BioRes Scientia Publishers. 4(5):1-3. DOI: 10.59657/2997-6103.brs.25.094

Copyright: © 2025 Deepak Goel, this is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: September 16, 2025 | Accepted: October 30, 2025 | Published: November 05, 2025

Abstract

Brown tumor is rare manifestation associated with hyperparathyroidism that may simulate metastatic bone disease or multiple myeloma and pose difficulty in differential diagnosis. Here, we report a case which was clinically suspected as multiple myeloma on basis of anemia, hypercalcemia and multiple lytic bone lesions but classical bone marrow features of osteotitis fibrosa cystic led to suspicion of hyperparathyroidism and helped to reach the final diagnosis. Hence, hypercalcemia and lytic bone lesions on imaging are not always due to malignant pathology but metabolic bone disease should also be considered in differential diagnosis.

Keywords: hypercalcemia; lytic bone lesions; hyperparathyroidm; multiple myeloma

Introduction

Two most common differential in patients with lytic bone lesion are metastatic bone tumor and multiple myeloma. Brown tumor is a rare benign condition (2 percent cases in patients with hyperparathyroidism) which may simulate malignancy and pose difficulty in differential diagnosis [1]. We describe a case of Primary hyperparathyroidism clinically mimicking multiple myeloma.

Case Presentation

A case of 36-year-old female who was referred from orthopedics department of clinical hematology with complaint of back pain, anemia (8.2 gm/dl), hypercalcemia (11.1 mg/dl) and multiple lytic lesions in pelvic and sacral bone on X-ray (Figure 1). Renal function test and liver function test were normal except markedly elevated serum alkaline phosphatase (593 U/L). Bone marrow was done to rule out multiple myeloma.

Figure 1: Digital X ray showing multiple lytic lesions in Ileum, pubic rami and right femur bone.

Bone marrow aspirate showed prominence of osteoblasts which is not normal findings at this age with 3% plasma cells. All other hemopoietic elements were in normal range. Bone marrow biopsy showed a hypocellular marrow with narrowing of marrow spaces with fibrosis and new cement lining with mineralization of trabeculae (osteosclerosis). Also, these areas show excess osteoid rimming around the bony trabeculae (like osteomalacia) (Figure 2,). Rest areas show normal cellularity with thinned out trabeculae with paratrabecular fibrosis and increased osteoclastic activity (Figure 3). Focal areas show cyst formation, hemosiderin laden macrophages and metastatic calcification. Reticulin Stain: Grade 2-3 fibrosis. So, features of bone marrow were consistent with osteotitis fibrosa cystica secondary to hyperparathyroidism due to any cause.

Figure 2: Osteoblastic rimming around bony trabeculae. (H&E x 1000).

Figure 3: Microscopic examination of the right iliac bone biopsy showing high number of osteoclasts (arrows) (H&E x 100).

In view of this bone marrow features patients was called to hematology lab and extensively valued. Patient gave history of loose motion for 2 years, weight loss and severe bone pains. Her investigation reports showed normal renal function test with paradox of high serum calcium levels but low vitamin D3. Hence, parathyroid hormone level was advised which came out to be 1046 pg/ml (Normal range: 10-65 pg/mL). Patient was then referred to endocrinologist. USG neck was done which showed 5 x 12.9 mm hypodense lobulated space occupying lesion along inferior pole of right lobe of thyroid. Tc99m labeled parathyroid scan showed hyperfunctioning parathyroid tissue-adenoma. Surgical excision of the parathyroid adenoma was done. It was reported as parathyroid adenoma on histopathology. After normalization of serum parathyroid hormone level, the bony lesion resolved. The patient is now symptom free.

Discussion

Primary HPT (PHPT) is an endocrinopathic condition characterized by hypesecretion of parathyroid hormone (PTH), which may be caused by an adenoma (solitary or multiple), idiopathic hyperplasia, or a parathyroid carcinoma. Secondary HPT is characterized by hypocalcemia or Vitamin D deficiency acting as a stimulus of excessive PTH production. Chronic renal failure is the main cause of secondary HPT. Tertiary HPT is caused by the development of autonomous parathyroid hyperplasia after long - standing secondary HPT, most often in patients with renal failure. Most cases of PHPT (80% - 85%) are caused by a solitary adenoma, 15% to 20% are due to a parathyroid gland hyperplasia, and less than 0.5% are caused by parathyroid carcinoma [2,3]. Primary bone lesion (brown tumor). Skeltal involvement in hyperparathyroidism occur due to high rate of osteoclastic bone resorption and is accompanied by a cellular repair process that results in the accumulation of fibrous stroma and connective tissue cells along with multinucleated giant cells and occur more frequent in the carcinomas or secondary hyperparathyroidism than PHP [4,5]. Multiple lytic bone lesion is seen in all three condition- hyperparathyroidism, metastatic bone tumor and multiple myeloma (MM). But PHP more commonly involve cortical bones and bones distal to elbow, knee joint and facial skeletal (particularly mandible) while metastatic bone tumor and MM more commonly involve cancellous bone i.e., axial skeletal [5,6]. Hypercalcemia can occur in all three conditions. In our case multiple lytic bone lesion with hypercalcemia led to clinical suspicion of multiple myeloma but classical bone marrow biopsy features of hyperparathyroidism led to diagnosis of Primary hyperparathyroidism.

Conclusion

Our case report highlights the significance of high degree of suspicion and awareness that is required for reaching right diagnosis in a case presenting lytic bone lesion along with hypercalcemia. Lytic bone lesions together on imaging together with hypercalcemia are not always due to malignant pathology but metabolic bone disease should also be considered in differential diagnosis.

Declarations

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

References

Ullah, E., Ahmad, M., Ali, S. A., Redhu, N. (2012). Primary hyperparathyroidism having multiple Brown tumors mimicking malignancy. Indian Journal of Endocrinology and Metabolism, 16(6):1040-1042.
Publisher | Google Scholor
Khan, A., Samtani, S., Varma, V. M., Frost, A., Cohen, J. (1994). Preoperative parathyroid localization: prospective evaluation of technetium 99m sestamibi. Otolaryngology-Head and Neck Surgery, 111(4):467-472.
Publisher | Google Scholor
Owens, B. B. (2009). A review of primary hyperparathyroidism. Journal of Infusion Nursing, 32(2):87-92.
Publisher | Google Scholor
Doshi, S., Vadi, A., Mahajan, A., Nagpal, T. (2012). Primary hyperparathyroidism with rare presentation as multiple brown tumours. Clinics and Practice, 2(2):e48.
Publisher | Google Scholor
Huang, R., Zhuang, R., Liu, Y., Li, T., Huang, J. (2015). Unusual presentation of primary hyperparathyroidism: report of three cases. BMC Medical Imaging, 15(1):23.
Publisher | Google Scholor
Su, A. W., Chen, C. F., Huang, C. K., Chen, P. C. H., Chen, W. M., et al. (2010). Primary hyperparathyroidism with brown tumor mimicking metastatic bone malignancy. Journal of the Chinese Medical Association, 73(3):177-180.
Publisher | Google Scholor

Delia Teresa Sponza

"Journal of BioMed Research and Reports has created a diverse portfolio in peer review process and provides a wide range scientific and medical novel papers to the scientists. This journal publishes high-quality, peer-reviewed content across all levels of professional development and corporate research and development."

Fatema Tashrifwala

I would like to thank the editorial team for their timely responses and consideration in the publication of my paper. They have been very helpful and accommodating, Lastly, being an open access journal, the published work is freely available and accessible to readers at no cost to them. I would encourage other authors to publish their research in BioRes Scientia. I am happy to be a part of BioRes Scientia Publishers.

Dr Nikhil Vitthal Dayama

I would like to thank the editorial team for their timely and prompt responses and consideration in the publication of my case report. Being an open access journal, it will be great help for the readers to learn the new things without any cost. I would encourage the authors to publish their research in BioRes Scientia and I am happy to be part of this journal.

Boubacar Ahy Diatta

I warmly thank the editorial team for the excellent work they do for continuing medical education in Dermatology. I was able to discover with joy their professionalist, their support and above all appreciate their social generosity on the access to the magazines which is free. This allows an update of scientific knowledge to the entire scientific community. I gladly recommend authors for publication in this journal.

Professor Rajko Igic

The editor of JBRR helped me during the whole process, mainly to eliminate some typographical and other errors. It hastened this publication to be published quickly. Although it is a short text, I believe that the content is important for all medical and other scientific disciplines because eventual addition of the iC citations to citation of the paper would lead to proper assessment of the author's contribution.

Dr Tewodros kassahun Tarekegn

I am thrilled to have had the opportunity to publish my research article in this prestigious journal. The entire process of peer review and publication support provided by the editorial office was exceptional, and it fortified my belief in the quality of my research study. The rigorous peer review process ensured that only the highest quality research was published, and the feedback from the reviewers was extremely helpful. I appreciate the journal's commitment to open access publication, enabling my research to reach a wider audience. The easy-to-use online platform streamlined the submission, peer review, and publication process, and I would confidently recommend this journal to any author looking for efficient, rigorous, and high-quality peer-reviewed publication.

Francis Okello Ooko

I was impressed by your author-centred approach whereby you maintained constant and timely communication with us from the time we submitted the manuscript to acceptance, each time providing critical suggestions to improve the manuscript. In addition, we are encouraged by the thoroughness of your editorial team in checking the originality and overall, quality of the work. Which I believe is very encouraging to other researchers and authors who wish to publish their work in your journals. The published work and the information imparted is freely available and accessible to a wide spectrum of readers at no cost to them. I would encourage other authors to publish their research in BioRes Scientia. I am happy to be a part of BioRes Scientia Publishers.

Dr Nidhi Sapolia

I would like to thank the editorial team of their timely response and guidance in the publication of my case report. They have been extremely helpful at all stages. Being an open access journal, it is of great help for the readers to learn new experiences in different fields, I would highly recommend this journal to authors for high quality peer-reviewed publications.

Dwight L Mckee MD CNS ABIHM

I am very impressed by the high quality of the papers published by the International Journal of Clinical and Molecular Oncology. The editors of this journal are a pleasure to work with, as they are highly responsive even to numerous last minute changes in the manuscript that I recently published with them, and the changes are made on-line the same day they are received. I highly recommend this journal to anyone working in the oncology field, and also value it as a source of cutting edge information in the field.

Kyaw Swar Thet

I would like to thank the editorial team for the opportunity to publish our case report in this prestigious journal. I am very impressed by their timely and efficient handling of the submission, peer review, and publication processes. As residents of a developing, low-income country, we greatly appreciate the discount on submission charges. I hope that as an open access journal, it will facilitate easy access for readers to update their scientific knowledge. I highly recommend this journal for high-quality, peer-reviewed publications. I express my sincere gratitude to the editorial team for their excellent work.

Michel Farah

I would like to thank the editorial team for their quick response and support. The publication support and editorial office were excellent and very helpful. I am happy to have my research article published in this prestigious journal. Our previous case report published in this journal was very successful and viewed by many physicians worldwide.

Kristina Dimitrijevic

I am very positively surprised by thе International Journal of Biomedical and Clinical Research, as well as by the review process itself, which is carried out in a high-quality, timely and professional manner. I am glad that my articles are part of this journal.

Hamid Kasim

I had the pleasure of working with your esteemed journal. I testify that the peer review process was effective and quick, the support from the editorial office is very professional, respectful and friendly and the quality of the review is objective and accurate. I am grateful for the opportunity to work with International Journal of Biomedical & Clinical Research and looking forward for more future cooperation.

Ochala Ejura J

The interaction with the Journal of Women Health Care and Gynaecology has been seamless. I wish to express my profound appreciation to your expert editorial team for the timely response and support. The feedbacks from the peer review process was of great help. Thank you for the discount and opportunity to publish in your reputable journal. I believe that being an Open access journal, it will enable readers easy access to to update their knowledge. I would recommend BioRes Scientia publishers and look forward to more collaborations.

Fernando M Clara

I would like to thank the Journal of Clinical Cardiology and Cardiology Research for the opportunity to publish our work. We greatly appreciate the professionalism demonstrated throughout the editorial process. The rapid peer review, along with the high-quality graphic design, streamlined the process and significantly improved the final presentation of our manuscript. The Journal’s support for scientific dissemination is a meaningful incentive for ongoing research. We commend your editorial efforts and extend our best wishes for the Journal's continued success.

Dr Stylianos Sergios Chatziioannou

Journal of BioMed Research and Reports process was constructive and timely, ensuring that the scientific rigor of the manuscript was upheld. Communication with the editorial office was smooth and supportive throughout, making the overall publication experience very positive. I appreciate the efforts of the editorial team in maintaining high-quality standards, and I am confident that the journal will continue to grow in impact and recognition.

Dr C Zeroual

I am pleased to have worked with the Journal of Brain Research and Neurology. The editorial team was responsive and supportive throughout the process, and the peer review was handled efficiently. I appreciate the opportunity to contribute to this journal and look forward to future collaborations

Mohammadreza Kashefi Baher

I am pleased to have published my research in Dentistry and Oral Health Care. The peer review process was efficient and respectful, and I appreciated the timely communication and support from the editorial team. The journal maintains a professional standard and provides an accessible platform for sharing scientific work. I am grateful for the opportunity and look forward to contributing again in the future.

Cidalia De Fatima Cabral De Frias

I would like to thank the editorial team of International Journal of Biomedical and Clinical Research for their prompt and timely responses during the review process of my article. I had the opportunity to share with the academic community my understanding of the process of caring for a person at the end of life. I recommend the publication of research in the area of palliative care in this prestigious journal.

Roxana Maria Hoza

The peer review process at Hematology Research and Blood Disorders is fair and constructive. The editorial office provides excellent support and timely communication. The journal maintains high quality and is a trusted platform for hematology research.

Dr Hamid Kasim

I was very pleased to collaborate with your esteemed Journal of BioMed Research and Reports, and I also thank the editorial board and the reviewers who enriched my article with their very helpful comments, resulting in a beautiful and elegant presentation. I hope our collaboration will continue in the future, With my respect and best wishes for your continued success.