Resolution of “salt and pepper” appearance of the skull with vitamin D therapy
A 27-year-old male patient, presented with the complaint of pain in legs and difficulty while walking for past 4 months. He also complained of pain and stiffness in the lower back for the same time. Patient could walk only with support for the past 1 month. There was no history of any trauma to the back. No history suggestive of bladder involvement, no positive or negative sensory symptoms. Patient was on antidepressant medication for the last few years and housebound for the past few months. Patient's examination revealed no features suggestive of spinal cord involvement; however, power in both lower limbs was grade four out of five in the proximal and distal muscles. No features suggestive of sensory involvement were seen. His systemic examination was unremarkable.\nInvestigations revealed hemoglobin 14.9 g/dl, total leucocyte count 6800/μl, platelets 212,000/μl, blood urea 20 mg/dl, serum creatinine 0.73 mg/dl, serum sodium 142 mEq/l, serum potassium 3.4 mEq/l, serum chloride 108 mEq/l, serum calcium 9.5 mg/dl, serum phosphorus 2.7 mg/dl, serum alkaline phosphate 2347 U/L, serum albumin 5.1 g/dl. Urine examination was unremarkable. Plasma parathyroid hormone (PTH) was 754.0 pg/ml and serum 25-hydroxyvitamin D3 (25[OH] D3) was 4.60 (normal > 20). His X-ray skull showed salt and pepper appearance [], X-ray pelvis showed loosers zones with marked subperiosteal resorption in the region of pubic rami [], X-ray hand showed resorption of the terminal phalanges with the presence of a cortical cyst in the metacarpal []. X-ray lumbosacral spine showed osteoporotic changes with central collapse of lumbar vertebrae and biconvex disc spaces []. His computerized tomography (CT) neck with contrast was normal, sestamibi scan showed diffuse uptake in the bones, with no evidence of parathyroid adenoma discernible in the parathyroid scan.\nA diagnosis of vitamin D deficiency with a secondary hyperparathyroidism with normocalcemia was made. He was given vitamin D and calcium supplementation and his general condition improved over the next few months. Power in musculature improved with resolution of pain. His serum showed PTH levels, after 9 months, of 59.0 pg/ml and calcium 8.9 mg/dl. X-rays skull, hand and pelvis showed remarkable improvement with resolution of salt and pepper appearance, regression of osteopenic changes and cortical cyst in a span of 11 months [Figures –].