Endocrine Abstracts

Primary hyperparathyroidism (P-HPT) is one of the most common of all endocrine disorders. 80 to 85% of cases are due to parathyroid adenomas while hyperplasia accounts for 10% to 15% and carcinoma less than 1%, of cases.¹ Its very rare for parathyroid adenoma to present with clinically severe hypercalcaemia or a ‘parathyroid crisis’. There are some existing case reports.^2,3 We report a case of a 67 year old woman who presented with severe irritability and drowsiness. Her conscious level was so persistently reduced she required intensive care unit admission. Investigations showed a calcium of 5.98 mmol/l (2.20–26.60 mmol/l) with a PTH of level 214.1 pmol/l (1.6–6.9 pmol/l). She was also biochemically severe dehydrated deranged kidney functions, urea=22.2 mmol/l.creatinine=212 umol/l. Her only past medical history was mild hypercalcaemia. The working diagnosis was initially malignant parathyroid cancer after excluding other common causes of hypercalcaemia. She was managed in the intensive care unit by aggressive IV fluid resuscitation (4–8 litres /24 hours). Pamidronate and oral Cinacalcet were used as adjuncts. She was discharged home after normalisation of her calcium to 2.12 mmol/l on Cinacalcet therapy with her further follow up with her scan and surgical excision. Imaging on NM SCAN Spect CT showed an avid 19 mm parathyroid nodule in the right lower position and she underwent surgical resection within a week of her initial presentation. Her PTH rapidly normalised post-operatively. Unfortunately, due to pre-operative vitamin D deficiency she developed mild post-operative hypocalcaemia. Histology showed an adenoma with no atypical features. She was subsequently discharged on calcium replacement and vitamin D. We present an unusual case of very severe primary hyperparathyroidism secondary to a parathyroid adenoma with the highest calcium this authors seen requiring critical care support for its early management.

References

1. DeLellis RA, Mazzaglia P, Mangray S. Primary hyperparathyroidism: a current perspective.

2. S. Tahim, J. Saunders, and P. Sinha. A Parathyroid Adenoma: Benign Disease Presenting with Hyperparathyroid Crisis.

3. Georges CG, Guthoff M, Wehrmann M, Teichmann R, Gröne E, Artunc F, Risler T, Friedrich B, Müssig K. Hypercalcaemic crisis and acute renal failure due to primary hyperparathyroidism.

4. Marienhagen K, Due J, Hanssen TA, Svartberg J. Surviving extreme hypercalcaemia–a case report and review of the literature.

5. Nishimura K, Nozawa M, Hara T, Sonoda T, Oka T. A case of primary hyperparathyroidism associated with marked hypercalcemic crisis.