FRACS Orthopaedic Exams
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. Her hand movement was extremely restricted. 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 steatorrhoea. 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.
1. What is the diagnosis?
2. How will you treat this lesion?
3. What else will you do for this lady?