Endocrine Abstracts

We describe a case of a male who presented to a rheumatologist with hypercalceamia at the age of 22 in 1995. Investigations were incomplete and he was lost to follow up. He was referred to a general surgeon in 2002 as another blood test had showed hypercalcaemia of 2.8 mmol/l (2.2–2.6), parathyroid hormone 9.5 pmol/l (1.6–6.9). A spot urine calcium/creatinine excretion ratio was 0.014. It was felt he probably had primary hyperparathyroidism and he was managed conservatively but he then underwent surgical neck exploration at James Paget University Hospital in April 2004 following an episode of ureteric colic (presumed nephrolithiasis); histology did not show any parathyroid tissue. Calcium remained elevated post operatively.

He was referred to another centre in 2007 where an ultrasound, sestamibi scanning and CT scan did not show any evidence of parathyroid pathology. Subsequent venous sampling showed PTH 127 pmol/l in the midline inferior thyroidal vein. Further imaging was inconclusive but in 2009 he underwent a left hemithyroidectomy and thymectomy. Calcium remained elevated post operatively. He underwent further imaging including a contrast MRI scan in 2012 which suggested the possibility of a nodule in the upper mediastinum adjacent to the brachiocephalic artery. He was offered cinacalcet but declined. Bone densitometry was within normal limits. He was lost to follow up.

He then visited a clinic in Florida, USA where he had an operative procedure where some thyroid rest tissue was resected but no parathyroid gland identified. However, a sestamibi scan suggested uptake in the mediastinum. He was then referred to Hammersmith Hospital where a 4D CT scan showed a possible low mediastinal intrathymic ectopic parathyroid gland. Venous sampling showed a 10-fold concentration of PTH in the samples from the thymic vein. He has recently undergone an excision of the ectopic parathyroid gland via a thoracoscopic approach and we would hope to present the outcome of this.

In summary, we presented a patient with a history of primary hyperparathyroidism of over 20 years who had three unsuccessful operations. This was complicated by kidney stones, neurocognitive symptoms, lethargy and aches and pains.