Endocrine Abstracts

We present the case of a 50 year old with primary hyperparathyroidism and 2 unsuccessful surgeries. Initially presenting in 2012 we question whether further surgical attempts to cure her should be made.

She was found to have hypercalcaemia since 2009 with levels 2.60–2.80 mmol/l with PTH 21.9–28.9 pmol/l, vitamin D 9 nmol/l, ACE 37.8 iu/L, normal protein electrophoresis, creatinine 84 umol/l, phosphate 1.06 mmol/l, TSH 0.86 mU/l, Hb 142 g/l, and CCR of 0.027 confirming primary hyperparathyroidism. USS renal tract shows no calculi or calcinosis. DEXA showed osteopenia with T score –1.0 at the femoral neck. She was given vitamin D and felt should receive surgical treatment given her young age.

Imaging with SESTAMIBI showed increased uptake in the anterior mediastinum and right midpole but MRI demonstrated no obvious lesion. She had neck exploration in summer 2014 finding no convincing adenoma and histologically normal parathyroid tissue. She remained hypercalcaemic and repeat imaging in December 2014 showed concordance at the right midpole but subsequent exploration was difficult due to scarring. Histology showed benign reactive lymph nodes, fat and no parathyroid tissue.

She was admitted with a DVT in September 2015 and found to have worsening hypercalcamia and was symptomatic on the ward with levels over 3 mmol/l. She was given iv hydration and bisphosphonate. Other medical history includes 2 previous DVTs and hypertension. She is currently taking candesartan, atenolol, lercanidipine and rivoroxaban. There is no family history of hypercalcaemia or thromboembolism. She is Pakistani, tee total and a nonsmoker.

She is currently well with no symptoms and serum calcium of around 2.60 mmol/l. She is aware that the condition will cause her bone density to decline and she risks symptomatic hypercalcaemia again without treatment but not keen for surgery. How shall we proceed?