Endocrine Abstracts

Introduction: Celiac disease (CD) is gluten sensitive enteropathy with a wide spectrum of severity. Iron deficiency, growth retardation, shortness, delayed puberty can be seen. Osteomalacia and hypocalcemia are results of malabsorbtion of vitamin D and calcium which may cause secondary hyperparathyroidism. In untreated cases for a long period, tertiary hyperparathyroidism can also be seen due to autonomy of parathyroid glands with chronic stimulation. There are some cases of primary hyperparathyroidism accompanying CD. We report a case of CD presenting with severe hypercalcemia of a parathyroid adenoma.

Case report: A 14-year-old girl admitted to our department for delayed puberty and growth retardation. She was 125 cm tall and 28.5 kg; under the 3rd percentile. Her wrist graphy was consistent with 7–8 years. Laboratory examination revealed iron deficiency anemia, low 25OH vitamin D level (7 ng/ml), high parathyroid hormone level (PTH) (955 pg/ml), hypercalcemia (13.4 mg/dl), hypogonadotropic hypogonadism (FSH: 0.29 mIU/ml, LH: 0.1 mIU/ml, estradiol: 5.32 pg/ml), low levels of GH (6.67 ng/ml) and IGF1 (26.2 ng/ml; 111–551). Endoscopic biopsy was compatible with total villous atrophy, crypt hyperplasia, intraepitelial lymphocyte infiltration, edema, lymphocyte and plasma cell infiltration of lamina propria. Endomysium antibody was positive. Gluten free diet was started. Her neck ultrasound and parathyroid scintigraphy demonstrated a parathyroid adenoma. She underwent parathyroidectomy. Her calcium became 8.8 mg/dl and PTH 12.3 pg/ml. After 4 months of gluten free diet she is now 132 cm tall and weighed 34 kg. She is in stage Tanner 2, her axillary and pubic hair had began to grow up.

Conclusion: Tertiary hyperparathyroidism may arise in patients with longstanding undiagnosed CD. It has been suggested that autonomous four gland hyperplasia or tertiary hyperparathyroidism may progress to adenoma formation and that this should be termed ‘quaternary hyperparathyroidism’. There should be more studies to explain the relationship between CD and hyperparathyroidism.