The patient’s vital signs on the day of admission revealed a blood pressure of 150/70 mmHg, heart rate 110 bpm, respiration rate 20 times per minute. From physical examination, a diastolic murmur was noted at cardiac apex. A chest X-ray demonstrated mild cardiomegaly. Review of Angiogenesis inhibitor serial chest radiographs

revealed progressive cardiac enlargement. An electrocardiogram showed LVH, tall-T wave in V1-4 leads. Laboratory data showed serum calcium 9.2 Inhibitors,research,lifescience,medical mg/dL (normal 8.5-10.5 mg/dL), serum phosphate 9.4 mg/dL (normal 2.7-4.5 mg/dL), serum blood urea nitrogen 135.7 mg/dL (normal 5-23 mg/dL), serum creatinine 13.5 mg/dL (normal 0.4-1.2 mg/dL), serum potassium 6.7 mg/dL (normal 3.5-5.5 mg/dL), immuno-reactive parathyroid hormone (iPTH) 2959 pg/mL (normal 10-65 pg/mL). The echocardiogram Inhibitors,research,lifescience,medical showed extensive myocardial calcification, severe mitral stenosis with a mitral valve area of 0.99 cm2 by planimetry and mean pressure gradient 24.3 mmHg. The mitral valve was severely calcified (Fig. 1). The aortic valve was thickened and had mild calcification. The left ventricular ejection fraction was estimated to be 61% and diastolic dysfunction showed as an impaired relaxation pattern. Coronary computed tomography (CT)

showed severe calcification of the coronary artery and left ventricular myocardium and an increased calcium score in the coronary artery (Fig. 2). A follow-up coronary angiography was performed, and revealed remnant RCA stenosis, and left anterior Inhibitors,research,lifescience,medical descending artery with 50% stenosis. We suspected ‘porcelain heart’ cardiomyopathy secondary to hyperparathyroidism of ESRD. The patient started a phosphate restricted diet. A thyroid sonogram showed enlarged parathyroid glands (right lower Inhibitors,research,lifescience,medical lobe 2.2 cm size, left lower lobe 1 cm size) and the patient underwent surgical parathyroidectomy. Microscopic

analysis of the parathyroid tissue showed diffuse hyperplasia of chief cells (Fig. 3). Post-operation laboratory data showed serum calcium 8.2 mg/dL (normal 8.5-10.5 mg/dL), serum phosphate 3.6 mg/dL (normal 2.7-4.5 mg/dL), iPTH 357 pg/mL (normal 10-65 Inhibitors,research,lifescience,medical pg/mL). After surgery, test results have shown improvement of Calcium, Phosphate, and iPTH levels (Fig. 4). However, the patient’s cardiac symptoms remained. In the future, we will consider mitral valve Rutecarpine replacement. Fig. 1 Changes of transthoracic echocardiography. The echocardiogram on parasternal long axis view shows moderate LVH in 2007 (A). Follow up echocardiogram shows extensive myocardial calcification (arrowhead) and severe mitral stenosis with a mitral valve calcification … Fig. 2 Cardiac CT (A-D) and peripheral CT (E and F) shows extensive calcification. Cardiac CT shows severe mitral valve calcification (arrow) and myocardial calcification (arrowhead, A), diffuse calcification of LAD coronary artery (B), LCX coronary artery (C) … Fig. 3 Microscopic findings. Histology exam shows parathyroid tissue with diffuse hyperplasia of chief cells (A: H&E stain, × 100; B: H&E stain, × 200). Fig.