Non-adherence to medical
therapy in patients with
end-stage kidney disease (ESKD) can lead to severe metabolic derangements rarely seen in the current medical era. Such complications may take the form of
secondary hyperparathyroidism (HPT) leading to rare manifestations of bone
mineral disease, and profound
vitamin C deficiency from poor nutrition combined with removal of water-soluble
vitamins during dialysis. Secondary HPT causes
renal osteodystrophy which can lead to diffuse enlargement of the facial skeleton and morphological changes suggestive of leontiasis ossea. We report a 36-year-old, non-adherent woman on chronic dialysis for over 10 years who developed progressive, diffuse facial bone enlargement in the context of years of extreme HPT and newly diagnosed severe
vitamin C deficiency. Imaging revealed diffuse
hypertrophy of the maxillary and mandibular bones. Histopathology showed extensive fibro-osseous proliferation without evidence of Brown
tumor, suggestive of uremic leontiasis ossea. In this report, we discuss the orofacial manifestations of secondary HPT and the possible potentiating role of
vitamin C deficiency on the development of
renal osteodystrophy through altered
vitamin D metabolism. Non-adherent patients on chronic dialysis should be evaluated for
vitamin C deficiency, and the development of uremic leontiasis ossea should be considered when such patients present with distortion of facial features in the context of severe secondary HPT.