Pseudoclubbing with Tumoral Calcinosis and Acro-Osteolysis

Introduction: Secondary hyperparathyroidism frequently complicates chronic kidney disease (CKD) and end stage renal disease (ESRD) which can evolve into tertiary hyperparathyroidism due to prolonged parathyroid gland stimulation. This progression significantly impacts bone metabolism and overall health. We report a case of a 28-year-old male patient with severe long-standing secondary and tertiary hyperparathyroidism and ESRD, presenting with pseudoclubbing of the fingers and thumbs. Case Description: Patient is a 28 year old man with a history of end stage renal disease secondary to bilateral congenital renal hypoplasia. He started peritoneal dialysis at the age of 6 months old and received a diseased donor kidney transplant at 6 years old with delayed graft rejection requiring him to start home hemodialysis at age of 25. Patient was unfortunately non-compliant with home hemodialysis treatments which resulted in poor clearance and severe tertiary hyperparathyroidism. Despite being on maximum dose of cinacalcet, phosphorous binder, and calcitriol, patient’s parathyroid hormone was greater than 2000. He started developing pseudoclubbing of the right second digit due to distal bone erosion and third digit due to soft tissue calcinosis as well as in his two thumbs. He ultimately agreed to parathyroidectomy and transfer to in center hemodialysis to improve compliance. His parathyroid hormone is now within normal limits and pseudoclubbing has not progressed. As highlighted in this case, it is unusual to have 2 separate etiologies leading to the same physical finding in a patient. Discussion: This case underscores the complexity of managing severe secondary/tertiary hyperparathyroidism in ESRD patients. Pseudoclubbing, although rare, requires meticulous clinical attention and intervention. A multidisciplinary approach involving nephrologists, endocrinologists, and surgeons is crucial for optimizing outcomes. Continuous monitoring of labs, individualized treatment plans, and proactive management of complications are vital for improving quality of life and prognosis in patients with advanced renal disease and associated endocrine disorders. Further research is needed to explore optimal management practices for patients with similar presentations, including rare manifestations like pseudoclubbing.