Endocrine Abstracts

Background: Primary hyperparathyroidism (PHPT) is often only mildly sympthomatic¹. Nevertheless, some patients are diagnosed late and severe complications such as osteitis fibrosa cystica can develop.

Case Presentation: A 32 years old female was hospitalized due to pain in the left femoral region after falling from standing height. Radiological investigations revealed left femoral pathologic fracture and bone malignancy was suspected. Further radiologic investigations revealed lytic bone lesions in 7th cervical vertebra, multiple ribs, the left scapula and the left tibia. Thyroid ultrasound showed intermediate malignancy risk (TIRADS 4A) thyroid nodules in both lobes. Cytologic evaluation from fine needle aspiration of the left lobe’s nodule showed cells with signs of follicular neoplasia. Later the serum calcium (Ca) and parathyroid hormone (PTH) levels were ordered and both were markedly elevated. Patient was hospitalized in the endocrinology ward and laboratory tests were repeated, revealing a serum PTH level 835.37 pg/ml (15.00-68.00), Ca 3.94 mmol/l (2.15-2.50), phosphorus 0.47 mmol/l (0.81-1.45). Repeated thyroid ultrasound failed to visualize a parathyroid (PT) adenoma. PT scintigraphy was inconclusive, but suspected increased uptake in the right lower PT gland. Selective thyroid vein sampling was performed and demonstrated elevated PTH levels in the right middle thyroid vein. The decision to perform a total thyroidectomy was made. Intraoperative serum PTH was ordered and showed substantial drop once the thyroid was excised. Pathohistological evaluation revealed 2 intrathyroidal PT adenomas with no thyroid nodules present. After surgery the patient developed right sided Horner’s syndrome, presumably due to iatrogenic damage of the cervical ganglia.

Conclusions: The case illustrates the importance of serum Ca and PTH screening in the population and in patients with skeletal and renal pathologies, as untreated PHPT can cause severe health consequences.

Reference

1. Bilezikian JP et al. Primary hyperparathyroidism. Nat Rev Dis Primers. 2016;2:16033. Published 2016 May 19. doi:10.1038/nrdp.2016.33