Endocrine Abstracts

We report a case surviving hyperparathyroid crisis, with the second highest serum calcium concentration ever reported.

A 45-year-old female with type 2 diabetes and mixed hyperlipidaemia was admitted with extreme lethargy, dehydration and drowsiness. Serum corrected calcium was 6.49 mmol/l (2.2–2.6 mmol/l), phosphate 1.79 mmol/l, intact parathyroid hormone (PTH) 1059 pg/ml (15–65 pg/ml), creatinine 124 μmol/l and urea 16.0 mmol/l.

Two weeks earlier she sustained right scaphoid fracture following a fall. Primary hyperparathyroidism (PHPT) was diagnosed 5 months earlier when her corrected serum calcium was 3.4 mmol/l and PTH 342 pg/ml. A diagnosis of Paget’s disease was made at the same time. She was awaiting elective parathyroidectomy.

She was treated with intravenous fluids, furosemide, pamidronate, calcitonin and hydrocortisone. Calcium gradually declined to 2.84 mmol/l by day5. Despite attaining normalised serum calcium she remained drowsy, and therefore underwent emergency parathyroidectomy. Tc-99-m-sestamibi scan suggested single parathyroid adenoma. Successful parathyroidectomy was confirmed by >50% reduction of PTH at 15 min during intra-operative PTH sampling (1772 pg/ml at 0 min, 229 pg/ml at 15 min). She received intraoperative intravenous calcium infusion after removal of adenoma, which continued for 24 h post-operatively. She recovered fully, with drowsiness resolving within 24 h. Histology was consistent with parathyroid adenoma. Her calcium supplements were stopped one month later as her serum calcium remained normal.

Hypercalcaemic crisis caused by PHPT is rare but life-threatening. Emergency parathyroidectomy, after initial resuscitation is essential for reversal of drowsiness/coma. Intraoperative intravenous calcium is necessary to allow gradual and controlled decline of serum calcium to avoid fatal cardiac complications. Intraoperative PTH measurement facilitates minimally invasive parathyroidectomy without the need for bilateral neck exploration.

Paget’s disease, which is reported in association with PHPT, may have contributed to the hypercalcaemic crisis in our patient.