"A Midlife Crisis" Parathyroid Crisis Secondary to Parathyroid Adenoma

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 199-223-Disorders of Bone & Calcium Homeostasis: Case Reports
Clinical
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-203
Mohamad Hosam Horani*1, Omar Salim2, Khalid Salim2, Joseph Abdo3 and Gautam Chore4
1Alsham Endocrinology, Chandler, AZ, 2Midwestern University, AZ, 3Mercy Gilbert Hospital, Gilbert, AZ, 4Desert Kidney, Phoenix, AZ
Introduction: Hypercalcemic crisisis a serious and potentially life-threatening complication of markedly increased serum calcium concentrations most commonly due to severe primary sporadic hyperparathyroidism (HPT).

Case Study: A 50 year old female with PMHx of HTN and GERD presented to ED complaining of lethargy, HA, and balance problems. She was found to be severely hypercalcemic at 26.1 mg/dL (nl: 8.4-10.2) and in acute renal failure with a creatinine of 1.8 mg/dL (nl: .6-1.2) and albumin of 3.5 g/dL (nl: 3.5-5.5). She was aggressively hydrated and given furosemide, calcitonin, and pamidronate. Her calcium did not improve, so she underwent hemodialysis. PTH level was 2,090 pg/mL (nl: 230-630). The patient received a CT / thyroid US revealing left sided parathyroid and thyroid nodules. Surgery consult performed a neck exploration with left inferior parathyroidectomy and left thyroid lobectomy. Pathology reveals a parathyroid adenoma and adenomatous and hyperplastic nodularity of thyroid with no evidence of malignancy.

Postoperatively, the patient recovers, but noted with worsening nonoliguric acute renal failure with creatinine of 4.7 mg/dL. Calcium had improved drastically, and actually found low at 7 mg/dL. Patient was started on calcium supplements. PTH levels improved and normalized. Repeat TSH / Free T4 were unremarkable. Patient was later discharged after a 13 day hospital course.

Discussion: The prevalence of PHPT is approximately 1:1000, most commonly manifested as an asymptomatic disease. Acute PHPT is rare and can precipitate a parathyroid crisis, characterized by life-threatening hypercalcemia that can cause muscle weakness, headache, neurological symptoms, and renal failure as described in the patient.It should be suspected in acutely ill patients complaining of muscular weakness, gastrointestinal and cerebral symptoms.

Elective parathyroidectomy is the most appropriate treatment for PHPT.  Despite emergency parathyroidectomies to treat hypercalcaemic crisis, mortality rates remain high

Conclusion: The hypercalcemic crisis of hyperparathyroidism due to a parathyroid adenoma is a rare endocrine emergency that is fatal without surgical intervention. Despite emergency parathyroidectomies, mortality rates remain high. Even postoperatively, the danger of a rapid decline of serum calcium contributes to complications. Making a definite diagnosis and performing an early parathyroidectomy within 48 hours are then required, especially in patients exhibiting poor medical response.

Nothing to Disclose: MHH, OS, KS, JA, GC

*Please take note of The Endocrine Society's News Embargo Policy at http://www.endo-society.org/endo2013/media.cfm