Facial Deformity in a Patient with Chronic Secondary Hyperparathyroidism

### Case Answer A 44-year-old woman with ESKD treated with hemodialysis for >10 years presented with facial swelling, bone pain, and drifting of teeth leading to dysphagia and dysarthria (Figure 1). Past medical history includes chronic schizophrenia complicated by episodes of acute psychoses. Over the years, the patient had difficulty adhering to her treatment regimen. She regularly skipped hemodialysis sessions and was noncompliant with dietary and medical therapy (including phosphate binders), resulting in long-lasting uncontrolled hyperparathyroidism. Laboratory findings confirmed an extremely elevated parathyroid hormone (2150 ng/L, reference range 85–295 ng/L), a normal serum calcium (2.25 mmol/L, …