Image Diagnosis: Disappearing Digits: Metabolic Bone Disease in End-Stage Renal Disease

A 32-year-old man with end-stage renal disease on hemodialysis since 2009 presented with reports of a “disappearing finger nail.” He denied bone pain and muscle weakness but confirmed dry skin and pruritus. He was noncompliant with his prescribed cinacalcet and sevelamer. On examination, he was noted to have loss of lunula in the left index finger with shortening of the distal phalanx (Figure 1). Laboratory test results showed a phosphorus level of 7.0 mg/dL and an intact parathyroid (PTH) level of 2380 pg/mL. Radiographic imaging of his hands showed severe generalized bone resorption (the left hand is shown in Figure 2). His PTH scan showed retention of Tc-99m methoxyisobutylisonitrile in the left lower pole and right upper pole, which was discordant with Tc-99m pertechnetate uptake. The scan findings were consistent with nodular PTH hyperplasia, and he was referred for parathyroidectomy