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IJCRI 201 2;3(8):51 –56.
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Aswath et al. 51
CASE IN IMAGES
OPEN ACCESS
Pimary hyperparathyroidism as central giant cell
granuloma of the jaws: Pre­ and post­treatment pattern
of clinical and radiographic presentation
Nalini Aswath, Pravda Chidambaranathan
ABSTRACT
Introduction: The parathyroid glands regulate
serum calcium and phosphorous levels by its
secretion and maintenance, within physiological
limits, of its hormone parathormone (PTH).
Hyperparathyroidism is a metabolic disorder
resulting from excessive secretion of
parathyroid hormone. Hyper secretion might
occur either due to a primary pathology in the
glands (or) due to secondary causes. Central
giant cell lesions occur in jaw bones. Case
Report: A 20­year­old boy reported with
complaints of swelling in left maxilla. Intra
orally swelling extended from left upper canine
till left upper second premolar and caused
expansion of the cortical plates. Intra oral
radiograph and orthopantomograph showed a
poorly defined radiolucent lesion in between left
upper canine and left upper 1st premolar with
multiple cystic cavities in the region of the
symphysis, left body and right angle of
mandible. The radiographs of long bones showed
osteoporosis. Serum alkaline phosphatase level
was raised. Histopathology was reported as
central giant cell granuloma. Nuclear scan of
parathyroid showed a functioning parathyroid
adenoma. The swelling in left maxilla regressed
Nalini Aswath 1 , Pravda Chidambaranathan 2
Affiliations: 1
Professor & Head of Department-Sree Balaji
Dental College and Hospital, Chennai, Tamilnadu, India;
2
Reader-Sathyabama Dental College and Hospital,
Chennai Tamil Nadu, India.
Corresponding Author: Dr. Nalini Aswath, “Mathuram”, Plot
No:1 61 , #5, Murugu Nagar 5 th street, Velachery, Chennai,
Tamil Nadu, India - 600042; Ph: +91 -044-22591 51 9; Mob:
91 - 94441 -61 841 ; Fax: +91 -044-22460631 ; Email:
naliniaswath@gmail.com
Received: 20 December 2011
Accepted: 1 2 April 201 2
Published: 01 August 201 2
on its own after the adenoma of the
parathyroids was excised. Conclusion: Timely
diagnosis of parathyroid adenoma results in
total regression of intra oral swelling and
further progression of osteoporosis and
fractures of long bones can be prevented.
Keywords: Central giant cell granuloma, Brown
tumor, Hyperparathyroidism
*********
Aswath N, Chidambaranathan P. Pimary
hyperparathyroidism as central giant cell granuloma of
the jaws: Pre and post treatment pattern of clinical and
radiographic presentation. International Journal of
Case Reports and Images 2012;3(8):51–56.
*********
doi:10.5348/ijcri­2012­08­167­CII­14
INTRODUCTION
The parathyroid glands regulate serum calcium and
phosphorous levels by secretion and maintenance,
within physiological limits, of its hormone
parathormone (PTH). Secretion of PTH is mainly
controlled through interaction of calcium with calcium
sensitive receptors on the membrane of the parathyroid
cells. Hyperparathyroidism is a syndrome of
hypercalcemia resulting from excessive secretion of
parathyroid hormone. A case of central giant cell
granuloma in left maxilla due to adenoma of
parathyroid gland is presented.
CASE REPORT
A 20­year­old boy reported with complaints of
swelling in the left upper jaw (Figure 1). The swelling
IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 8, August 201 2. ISSN – [0976-31 98]

IJCRI 201 2;3(8):51 –56.
www.ijcasereportsandimages.com
Aswath et al. 52
was initially smaller six months ago and gradually
increased in size. It was asymptomatic since onset and
had not regressed in size at any time. There was no
history of discharge from the swelling. No history of
paresthesia or fever. The past medical history and
surgical histories were unremarkable. Patient was
moderately built, well nourished, calm and cooperative.
His growth appeared to be retarded to his
age. His vital signs were stable. A single left submandibular
lymph node was enlarged, palpable,
nontender, measuring 1 cm/1 cm in size, firm in
consistency and mobile.
Extra oral examination revealed a solitary swelling ,
with well defined margins, measuring 3 cm/3 cm in
diameter in the region of the left maxilla (Figure 2). It
was irregular in shape, with a smooth surface extending
anteriorly till nasolabial fold, posteriorly till the lateral
margin of the eye, superiorly till the infra orbital
margin, and inferiorly in line with angle of the mouth. It
was nontender, hard in consistency. The skin over the
swelling appeared normal. There was no local rise in
temperature. The swelling was not mobile and it was
fixed to the underlying structure.
Intra oral examination (Figure 3) revealed a swelling
extending from left upper central incisor to left upper
second premolar. There was expansion of the buccal
and palatal cortical plates. Margins were well defined. It
was firm to hard in consistency, nontender. Mucosa
over the swelling was normal. It measured 1.5 cm/2 cm
in diameter. The left upper canine and first premolar
were decayed and the vitality test showed a delayed
response.
Based on the history and clinical findings a provisional
diagnosis of adenomatoid odontogenic tumor and a
differential diagnosis of central giant cell granuloma,
ameloblastoma, fibro­osseous lesion were given.
Intra oral radiographs (Figure 4). Showed the
presence of a poorly defined radiolucent lesion in
between the left upper canine and left upper 1st
premolar with divergence of roots of left upper 1st
premolar. Orthopantomograph (Figure 5) showed the
presence of a poorly defined radiolucent lesion in
between the left upper canine and left upper 1st
premolar with divergence of the roots of the left upper
1st premolar and well defined cystic cavities in the
region of symphysis, left body and right angle of
mandible. Radiographs of long bones, chest, skull and
ultrasonography of abdomen were done. Radiographs of
long bones (Figure 6) were suggestive of osteoporosis.
No significant findings were revealed in
ultrasonography of abdomen.
Biochemical investigations revealed the following:
Serum calcium: 9.4 mg%, Serum phosphorus: 3.1 mg%,
serum alkaline phosphatise: ­2559 mg/mL.
Incisional biopsy was done and histopathological
examination showed presence of mature bundles of
connective tissue with plump fibroblasts, interspersed
with numerous multinucleated giant cells. Overlying
epithelium appeared hyperplastic, with few bundles of
blood vessels. The lesion was suggestive of central giant
cell granuloma (Figure 7).
Thereafter the patient was referred to an
endocrinologist to rule out hyperparathyroidism. After
general examination of the patient by the
endocrinologist, serum parathyroid estimation was
done and was found to be elevated. Nuclear study of the
parathyroid glands (Figure 8) was done with Tc­99m
MIBI injected intravenously and it showed the presence
of a functioning parathyroid lesion in the region of the
lower pole of the left lobe of thyroid. An incisional
biopsy was taken from the left. Inferior parathyroid
gland which was suggestive of parathyroid adenoma.
The tumor was surgically excised and post­operatively
the patient was treated with IV calcium and calcium
supplements, and multivitamin tablets.
The patient was periodically reviewed there­after at
an interval of three months. The serum calcium,
alkaline phosphatase, serum phosphorus returned to
their normal limits.
The central giant cell granuloma in the region of the
left maxilla regressed on its own (Figure 9, 10).
Intraoral radiographs, Occlusal X­ray (Figure 11),
OPG (Figure 12), were taken which showed
disappearance of the previous lesion. The multiple
cystic cavities that were noticed in the mandible too
disappeared.
Figure 1: Photograph of face shows swelling in the left maxilla.
IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 8, August 201 2. ISSN – [0976-31 98]

IJCRI 201 2;3(8):51 –56.
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Aswath et al. 53
Figure 4: Intraoral radiograph shows poorly defined
radiolucent lesion between canine and second premolar and
divergence of root of first premolar.
Figure 2: Facial profile shows swelling in the left maxilla.
Figure 5: Orthopantomogram shows poorly defined
radiolucent lesion between canine and second premolar in left
maxilla and well defined cystic cavities in symphysis at left
body and right angle of mandible.
Figure 3: Intraoral photograph shows swelling in alveolar
mucosa extending from the central incisor to second
premolar.
DISCUSSION
Hyperparathyroidism is a metabolic bone disease.
Primary Hyperparathyroidism is a disease, in which the
parathyroid gland secretes excessive quantities of
parathormone (PTH), due to increased activity of the
gland due to (1) hyperplasia of the gland, (2) adenoma
of the gland, (3) functional carcinoma of the
parathyroid. Secondary hyperparathyroidism is
secondary to chronic renal failure, rickets and
osteomalacia [1].
Figure 6: Radiographs of long bones shows reduced density of
bones suggestive of osteoporosis.
Hyperparathyroidism is a relatively rare disease which
is three times more common in women than men. It
usually occurs in middle age, but might occur
occasionally in children or in later life. Clinically, pathologic
IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 8, August 201 2. ISSN – [0976-31 98]

IJCRI 201 2;3(8):51 –56.
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Aswath et al. 54
Figure 7: Photomicrograph shows connective tissue with
plump fibroblasts, multinucleated giant cells and blood
vessels (H & E, X400).
Figure 9: Postoperative photograph shows disappearance of
swelling in the region of the left maxilla.
Figure 8: Nuclear scan shows functioning parathyroid lesion
in the region of the lower pole of the left lobe of thyroid.
fractures may be the first symptom of the disease,
although bone pain and joint stiffness are frequently
heard early symptoms. Urinary tract stone is also a
significant early finding [2].
Intraorally, the first sign of the disease may be a
giant cell tumor (Brown tumor) or a cyst of the jaw.
Brown tumor represents a giant cell reparative reaction.
The loss of phosphorous and calcium results in
generalized osteoporosis with attempts to repair the
bone by new bone formation. The new bone may be
resorbed and the resorption may lead to pseudocyst
formation. Then the proliferation of granulation tissue
from the cystic cavity occurs. As the area of bone
resorption undergoes replacement by fibrous tissue,
hemorrhage may occur. Small multinucleated giant cells
may appear in an attempt to remove the blood.
Hemosiderin in blood gives the lesion a brown color.
Malocclusion caused due to sudden drifting of teeth
may be the first sign of the disease [3­7, 8, 11, 12­14].
Radiographs show the presence of small or large
sharply defined radiolucencies suggestive of cysts in the
Figure 10: Postoperative intraoral view shows regression of
intra­oral swelling.
maxilla or mandible. Some lesions show the classical
ground glass appearance. The lamina dura around the
teeth may be partially lost. Multifocal involvement of
other bones in the body might also be seen [8, 11, 12].
The serum calcium is raised as high as 12 to 20 mg per
100 mL, while the serum phosphorus is lowered to 2 mg
or less per 100 mL. If bone lesions are present serum
alkaline phosphatase and serum parathormone levels
IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 8, August 201 2. ISSN – [0976-31 98]

IJCRI 201 2;3(8):51 –56.
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Aswath et al. 55
regress if the pathology in the parathyroid gland is
corrected.
*********
Figure 11: Postoperative intraoral occlusal and periapical
radiographs showing disappearance of the radiolucent lesion
between canine and second premolar.
Author Contributions
Nalini Aswath – Substantial contributions to conception
and design, Acquisition of data, Analysis and
interpretation of data, Drafting the article, Revising it
critically for important intellectual content, Final
approval of the version to be published
Pravda Chidambaranathan – Analysis and
interpretation of data, Revising it critically for
important intellectual content, Final approval of the
version to be published
Guarantor
The corresponding author is the guarantor of
submission.
Conflict of Interest
Authors declare no conflict of interest.
Copyright
© Nalini Aswath et al. 2012; This article is distributed
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License which permits unrestricted use, distribution
and reproduction in any means provided the original
authors and original publisher are properly credited.
(Please see www.ijcasereportsandimages.com
/copyright­policy.php for more information.)
Figure 12: Postoperative orthopantomogram shows
disappearance of radiolucent lesion in the left maxilla,
symphysis, left body and right angle of mandible.
are usually, raised, and urinary output of calcium is
considerably increased [11, 12]. Histologically,
multinucleated osteoclast like giant cells bone lesions
show lying in hemorrhagic fibrous tissue. Deposits of
hemosiderin may be seen. Multiple cystic cavities are
noted [5, 6].
CONCLUSION
To conclude hyperparathyroidism is a metabolic
bone disorder that might occur either due to
hypertrophy (or) adenoma of the parathyroid gland,
that manifests intraorally as a central gint cell
granuloma. Timely diagnosis, and treatment of the
parathyroid lesion, results in total regression of the
intraoral lesion on its own [10]. Further progression of
osteoporosis and pathological fractures can also be
prevented. Therefore if any case of central giant cell
granuloma involving the jaw bones is reported, it is
mandatory to rule out hyperparathyroidism. There is no
need to surgically excise the lesion as the lesion will
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