Concurrent Renal Chronic Kidney Disease-Metabolic Bone Disorder ( Renal Hyperparathyroidism ) and Noninvasive Benign

Synchronous or metachronous coexistence of two or more distinct pathological entities often raised problems about their pathogeny, diagnosis and best therapy, but occasionally epitomized new syndromes. Owing to their anatomical connexions and common embryological origin from the third pharyngeal pouch, the rare but possible association between lesions causing hyperparathyroidism i.e. adenoma, hyperplasia and thymoma can be explained. Our aim is to present an unusual case of Abstract


Introduction
Synchronous or metachronous coexistence of two or more distinct pathological entities often raised problems about their pathogeny, diagnosis and best therapy, but occasionally epitomized new syndromes.Owing to their anatomical connexions and common embryological origin from the third pharyngeal pouch, the rare but possible association between lesions causing hyperparathyroidism i.e. adenoma, hyperplasia and thymoma can be explained.Our aim is to present an unusual case of

Abstract
Common embryological origin of the inferior parathyroid glands and thy-mus can lead to rare concomitant lesions of these two glands.The authors reported a 59 year-female with confirmed chronic kidney disease-metabolic bone disorder (CKD-MBD) on hemodyalysis from 12 years whose extensive surgical exploration occasioned by total parathyrodectomy enabled discovery and complete removal of a retromanubrial nonmyasthenic thymoma.The clinical and pathological features of parathyroid nodular hyperplasia and noninvasive thymoma are discussed.The case presented here can be added to the few published observations describing an coinci-dental association between CKD-MBD (i.e renal hyperparathyroidism) and thymoma.coincidental association between CKD-MBD and nonmyasthenic thymoma.To our knowledge this is one of the first observations reported in literature.

Case report:
Sixtytwo patients who underwent surgical exploration of the neck for renal hyperparathyroidism between 1994-2012 were revised.Thirtyseven of these patients had a total parathyroidectomy ( 9 with autotransplantation). Excision of retromanubrial areolar fibrofatty tissue searching ectopic or supranumerary parathyroids was done in 19 cases revealing one nonmyasthenic thymoma, one thymic cyst and thymic cellular rests in 6 cases.A 59-year old female with a medical history of CKD-BMD, on hemodialysis from 12 years for an ESRD consecutive to a chronic glomerulonephritis of streptococcal origin is referred to our clinic by a nefrodialysis unit.She accused intense bone pains, persistent disturbing itching, generalized muscle weakness, depression and massive weight loss (15 kg in few months).Preoperative serum calcium was 2,2 mmol/l, and iPTH level was 1150 pg/ml.Ultrasound evidenced four parathyroid glands of 12-15 mm diameter and a normal thyroid.(Fig.1) The patient underwent a standard total parathyroidectomy without autotransplantation.The four unequally enlarged parathyroid glands weighting=300 mg showed nodular hyperplasia with a higher proportion of clear and vacuolised chief cells, no-table nuclear pleomorphism, rare oxyphyls and reduction of the normal fat.(Fig. 2,3), However, at the exploration of the retromanubrial space searching ectopic or supra-numerary glands, a round, well defined greyish mass of 20 mm 0 was identified, progressively mobilized and removed through cervical incision together with the surrounding connective tissues.The postoperative course was uneventful and the patient continues the hemodialy without any evidence of symptoms recurrence after 12 and 24 months followup.Laboratory usual tests revealed normal calcemia but raised iPTH and of course uremia and hypercreatinemia of renal HP.Selected investigations can be used only to look for detecting associated problems or tumor spread in thymoma: full blood count electrophoresis and anti-acetylcholinereceptors ( indicative for malignancy) Imaging resort to ultrasound and sestamibi scan in RHp and to chest X-ray, high unhanced contrast CT scan and MR scan for thymoma as Mari et al (1999) and Ceriani et al (2008) and the lesion may be sampled with a CT guided needle biopsy.A third of these tumors are discovered serendipitous due to chest radiography or CT for imaging of other conditions, for screening purpose or, as in our case, intraoperatively at surgery for any cervical or thoracic lesions.However the final

Conclusions
Coexistence of the main types of hyperparathyroidism and thymoma is probably coincidentally and in the lack of myasthenic features the diagnosis can be established only by chance, imaging methods or surgery on a neighboring organ.Although rare the operating surgeon must be aware of possible presence of such pathology.Concomitant exeresis of all hyperplastic parathyroids together with the thymic tumor will achieve cure of both lesions.
The authors declare that they have no competing interest All authors read and approved the final manuscrip Author's contribution: DMR-conceived the study and performed surgery, GM-performed surgery, G -expertise in pathology, DS -drafted the paper, corresponding author

Fig. 1 :
Fig. 1:Ultrasound Evidencing the Four Parathyroids and the Normal Thyroid