Endocrine Abstracts

Background: Recurrenthyperparathyroidism following total parathyroidectomy with autotransplantation in patients with end-stage renal disease who are on hemodialysis is not an uncommon condition and can be due to hyperplastic autografted tissue, remnant parathyroid tissues in the neck or in the presence of ectopic and/or supernumerary parathyroid glands.

Case report: We report the case of a 66-year-old patient with a history of chronic kidney disease on hemodialysis since 2012, surgical hypothyroidism (she underwent total thyroidectomy in 2017 for non-toxic multinodular goiter) and tertiary hyperparathyroidism for which she underwent total parathyroidectomy with autograft transplantation into the left sternocleidomastoid muscle in 2017, who referred to our clinic with a progressive swelling on the left side of the neck over the last few months. The clinical examination was unremarkable except for a soft, non-tender, mobile left-sided cervical mass of approximately 3×1.5 cm. Biochemical evaluation revealed normal corrected serum calcium (9.3 mg/dl, n=8.5-10.2) and serum phosphorus (3.6 mg/dl, n=2.5-4.5) levels and the intact PTH level was significantly increased (915.3 pg/ml, n=15-65) demonstrating secondary hyperparathyroidism. The bone turnover markers were elevated: crosslaps=2.8 ng/ml (n=0.33-0.78), osteocalcin=463.6 ng/ml (n=15-46); alkaline phosphatase was 119 IU/l (n=38-105) and serum 25 OHD was 17.9 ng/ml (n=20-100). Her thyroid function revealed subclinical hypothyroidism; ATPO, ATG and calcitonin were within normal ranges. Neck ultrasound showed a hypoechoic nodular mass of 2.85/1.48 cm in the left thyroidectomy bed. Fine needle aspiration of the neck mass was performed; the level of PTH in the aspiration needle wash-out fluid was over 5000 pg/ml. We recommended treatment with Paricalcitol at a dose of 5 mg three times a week during hemodialysis sessions. Cinacalcet was not available as a therapeutic option. A three months follow-up revealed an iPTH level of 1515 pg/ml.

Conclusions: We presented a patient with end-stage renal disease and secondary hyperparathyroidism at 6 years after the total parathyroidectomy with autograft transplantation for tertiary hyperparathyroidism. Considering the refractory hyperparathyroidism on the pharmacological treatment available in this case, surgical reintervention to remove the hyperfunctioning parathyroid tissue is necessary.