Endocrine Abstracts

Background: The presentation of primary hyperparathyroidism has changed radically over 30 years. Indeed, currently, asymptomatic forms which represented around a quarter are now estimated at 80% of cases.

Case description: We report the case of a 57-year-old women, postmenopausal for 10 years, who presented following a fall from height with a triple pathological fracture (the left humeral head and the two upper ends of the femurs). Surgical treatment was indicated but rejected in the face of severe osteoporosis (Tscore a -6.3 at the cortical bone level). The pre-therapeutic assessment of bisphosphonates revealed severe hypercalcemia (>3 mmol/l). The diagnosis of primary hyperparathyroidism was confirmed with a PTH level >5000 pg/ml on a left parathyroid macroadenoma, mixed solido-cystic with a long axis of 44 mm. Morphological exploration revealed multiple brown tumors, and multiple bilateral renal micro- and macro-lithiasis with right hydronephrosis. The patient underwent a successful parathyroid adenectomy (post-operative PTH had PTH at 11 pg/ml). The histological study is in favor of benignity.

Discussion: The revelation of primary hyperparathyroidism by a fracture is rare. Brown tumors can be completely asymptomatic, manifest as bone pain or even pathological fractures. Histologically they correspond to an area of osteoclastic hyper-resorption containing hypervascular inflammatory connective tissue, giant cells, and hemosiderin deposits. The classic sites of involvement are the facial bones, ribs, pelvis, femur, other long bones and rarely the vertebrae. Primary hyperparathyroidism is most often related to a benign parathyroid adenoma. However, the existence of a polymorphic and more pronounced symptomatology due to severe hypercalcemia, with bone and renal manifestations; as well as other digestive, cardiovascular and psychological signs, should point towards parathyroid carcinoma

Conclusion: Serious skeletal manifestations of primary hyperparathyroidism (fibrocystic osteitis, brown tumors, pathological fractures) are rare. Any medical practitioner must consider the diagnosis of primary hyperparathyroidism at the stage of bone pain before complications set in.