Endocrine Abstracts

A 83-year-old lady presented to hospital with a one week history of malaise, dyspnoea and chest pain. Her admission bloods revealed a markedly elevated calcium of 4.16 mmol/l. Further investigations revealed a PTH of >5000 ng/l. Clinically the patient had poor dentition which had developed over the past 3 years and a history of episodic abdominal pain and constipation. For investigation of primary hyperparathyroidism, she had an ultrasound neck, which revealed an enlarged 8 cm left parathyroid gland. She was initially managed with intravenous bisphosphonate, i.v. fluids and i.v. furosemide, once intravascularly volume replete. As part of her initial workup, she underwent a CT pulmonary angiogram. This revealed acute subsegmental pulmonary emboli, a cystic pancreatic lesion, sequelae of previous pancreatitis, nephrolithiasis and possible medullary sponge kidney. Swift surgical referral was sought because of concern of possible parathyroid carcinoma. Once her calcium was optimised and the patient was medically fit, a minimally invasive parathyroidectomy was carried out. Surgical dissection included a sliver of the left thyroid lobe to ensure clear surgical margins with the aforementioned suspicion of a parathyroid carcinoma. The high risk of hungry bones was anticipated and the patient was given vitamin D by intramuscular injection pre operatively and a bed was booked in the high dependency unit post operatively to facilitate an arterial line and frequent close monitoring of ioinsed calcium levels. Fortunately the patient only required four intravenous infusions of calcium. Within five days of her surgery the patient was discharged. The histology revealed a parathyroid adenoma with no suspicious or mitotic features. This case acts a reminder that although primary hyperparathyroidism is often considered a benign entity, life-threatening hypercalcaemia can develop and requires urgent management. It highlights the multi-systemic sequelae that can occur with chronic hypercalcemia and reminds us that parathyroid carcinoma although rare, must always be considered when markedly elevated levels of parathyroid hormone and hypercalcaemia are encountered.