Pathological Case of the Month

This 12-year-old girl had normal growth and development until age 5 years, when lethargy, nausea, vomiting, and pallor due to anemia developed. She had the features of uremia, with foul breath and facial edema. Laboratory values were as follows: serum calcium, 1.47 mmol/L; serum potassium, 5.9 mmol/L; and blood urea nitrogen, 71 mmol/L. Extensive nephrocalcinosis was evident on abdominal roentgenograms. The patient's height was 107 cm at age 5 years and failed to increase during the next 7 years (Fig 1). After 6 months of hemodialysis, the patient underwent a bilateral renal transplant. After a minor fall, a transverse fracture of the right femur at the level of the lesser trochanter (Fig 2) occurred. She was immobilized in a hip-spica cast, and her serum calcium level increased to 3.3 mmol/L. Her parathyroid hormone level was 11 mmol/L (in the normal range). A parathyroidectomy was performed in which three parathyroid glands