Breaks, bends and holes

A 14 year old boy presented with lower limb deformities and bone pain since 8 months. He was severely wasted, stunted with tachypnea, pallor, genu-valgum, widened wrists and rachitic rosary. Workup revealed end-stage-renal-disease with metabolic acidosis, anaemia, hypocalcemia and secondary hyperparathyroidism. Scannogram of both lower limbs showed evidence of rickets, fractures and a lytic lesion in the lower end of the right femur suggestive of osteitis-fibrosa-cystica (OFC). The case depicts how one should evaluate a lytic bony lesion taking into consideration the complete clinical and biochemical picture and that OFC is not uncommon in adolescence in the presence of unchecked hyperparathyroidism. The child was treated with iron therapy, oral bicarbonate, oral vitamin D, erythropoietin and advised renal replacement therapy