Endocrine Abstracts

Introduction

Parathyroid crisis (PC) is a very rare yet fatal clinical condition which mandates urgent intervention. We present a case of parathyroid crisis with severe symptomatic hypercalcemia and multi-organ involvement.

Case description

A 63-year-old male presented with three days of generalized fatigue, abdominal pain and vomiting. Review of systems revealed constipation and symptoms suggestive of depression over the past 6 months. Vital signs were notable for tachycardia with a heart rate of 120 beats/minute. On physical examination, the patient was in mild distress and looked dehydrated. Laboratory investigations revealed hypercalcemia with a total calcium of 19.9 mg/dl, ionized calcium of 1.83 mmol/l, phosphorus of 3.2 mg/dl, creatinine of 2.7 mg/dl. Hypercalcemia workup revealed a PTH level of 2472 pg/ml and a normal urine calcium, vitamin D level and serum protein electrophoresis. Acute kidney injury, depression and gastrointestinal symptoms were explained by severe hypercalcemia. He was promptly treated with aggression fluid resuscitation, pamidronate and calcitonin. A Technetium 99m sestamibi scan demonstrated two large bilateral parathyroid masses which correlated with the findings on the ultrasound. The patient underwent bilateral parathyroidectomy and left thyroid lobectomy as the left sided mass was adherent to the thyroid gland. Parathyroid carcinoma was ruled out on biopsy and was consistent with hyperplastic parathyroid tissue. The PTH level decreased to 125 pg/ml intraoperatively and subsequently normalized. Post-operatively the patient developed hungry bone syndrome requiring IV calcium therapy and large-dose vitamin D supplementation.

Discussion

PC is a rare phenomenon where PHPT manifests as a hypercalcemic crisis (serum calcium > 14 mg/dl and multi-organ involvement) requiring urgent therapeutic intervention to prevent life-threatening complications from severely elevated calcium levels. PHPT can be due to parathyroid hyperplasia, adenoma or carcinoma. It is difficult to distinguish the etiology of PHPT clinically but when PTH levels are greater than 5 times the upper limit of normal, it usually suggests parathyroid carcinoma. However, in our case, the inordinate levels of PTH were due to parathyroid hyperplasia. Imaging modalities are helpful in localizing the disease but cannot assess malignancy potential and fine needle aspiration cytology (FNAC) is contraindicated due to the risk of seeding. Hence, early surgery is the ultimate diagnostic and curative modality.