Endocrine Abstracts

Introduction: Neuropsychiatric manifestations are well recognised in patients with primary hyperparathyroidism (PHP). Abnormal calcium channel physiology has been implicated in several pain disorders. The psychopathology emerges after prolonged subclinical hypercalcemia, but there is poor correlation with symptom severity. We report the complex management of two adolescents with PHP, secondary to parathyroid adenoma (no predisposing germline mutation identified), with persistent symptoms following successful parathyroidectomy.

Case Report: Case 1: 15-year-old boy, with a background of attention deficit hyperactivity disorder, Tourette’s syndrome and oppositional defiant disorder, who presented with paraesthesia and numbness. He had severe hypercalcaemia, requiring urgent parathyroidectomy and since maintained normal biochemistry. In the early post-operative period, he developed numbness in his arms, chest tightness, headaches and blurred vision. Investigations including bone profile, vitamin D, MRI brain and spine were normal. He continues to have lower limb pain and is now jointly managed with CAMHS and pain clinic. However, he described a significant improvement in symptoms after starting antidepressant (Fluoxetine) and ADHD medication (Lisdexamfetamine). Case 2: 15-year-old-girl presented with lethargy, low mood, bone pain, anorexia, weight loss, hair thinning and polydipsia. Blood tests, ultrasound and Tc-99m-sestamibi scans revealed a right lower parathyroid adenoma. She was started on Cinacalcet with no improvement in symptoms. Her biochemistry normalised following parathyroidectomy. However, post-operatively, her lethargy, bone pain, low mood, weight loss and poor appetite persisted for over 9 months. After a normal Rheumatology assessment, she is now followed up at the chronic fatigue clinic.

Discussion: We describe two adolescents with normal biochemistry following successful parathyroidectomy for PHP, secondary to parathyroid adenoma, that report ongoing symptoms – beyond the time within which resolution would be expected. Neuropsychiatric symptoms can be a presenting feature of hypercalcaemia; however, the mechanism remains poorly understood. Resolution is expected soon after parathyroidectomy and reports of persistent symptoms are rare. Could prolonged hypercalcaemia cause permanent neurological dysfunction? Further studies are needed to better understand the aetiology and post-operative course of neuropsychiatric symptoms due to PHP. A multidisciplinary approach is essential in managing the medical, surgical and mental health challenges this condition can present with.