scholarly journals Primary Hyperparathyroidism due to Parathyroid Adenoma Originated from Supernumerary Gland

2018 ◽  
Vol 2018 ◽  
pp. 1-4
Author(s):  
Fernando Mendoza-Moreno ◽  
Ángel Rodriguez-Pascual ◽  
María Rocío Díez-Gago ◽  
Marina Pérez-González ◽  
Laura Jiménez‐Alvárez ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Parathyroid Adenoma ◽  
Parathyroid Gland ◽  
Imaging Techniques ◽  
High Sensitivity ◽  
Parathyroid Glands ◽  
Parathyroid Surgery ◽  
Thyroid Lobe ◽  
The Impact ◽  
Supernumerary Gland

Introduction. The variability of the location of the parathyroid glands is directly related to the events that occur during embryonic development. The impact that an individual submits more than four parathyroid glands is close to 13%. However the presentation of a parathyroid adenoma in a supernumerary gland is an uncommon event. Case report. A 30-year-old man diagnosed with primary hyperparathyroidism with matching findings on ultrasonography and scintigraphy for parathyroid adenoma localization lower left regarding the thyroid gland. A cervicotomy explorer showed four orthotopic parathyroid glands. The biopsy of the inferior left gland was normal. No signs of adenoma were seen in the biopsy. Following mobilization of the ipsilateral thyroid lobe, fifth parathyroid gland was found increased significantly in size than proceeded to remove, confirming the diagnosis of adenoma. After the excision, the levels of serum calcium and parathyroid hormone were normalized. Conclusions. The presentation of a parathyroid adenoma in a supernumerary gland is a challenge for the surgeon. The high sensitivity having different imaging techniques has been a key to locate preoperatively the pathological parathyroid gland. Analytical or clinical persistence of primary hyperparathyroidism after parathyroid surgery can occur if the location of the adenoma is a supernumerary or ectopic gland location.

scholarly journals Parathyroid Adenoma - From Surgical to Biochemical Cure

2021 ◽  
Vol 10 (23) ◽  
pp. 1809-1814
Author(s):  
Rupa Mehta ◽  
Nitin M. Nagarkar ◽  
Satish S.S. ◽  
Ripu Daman Arora ◽  
Jyoti Ranjan Das
Keyword(s):  
Primary Hyperparathyroidism ◽  
Secondary Hyperparathyroidism ◽  
Parathyroid Adenoma ◽  
Parathyroid Gland ◽  
Neck Mass ◽  
The Body ◽  
Parathyroid Glands ◽  
Posterior Aspect ◽  
Biochemical Cure ◽  
High Index Of Suspicion

Parathyroid glands, minute endocrine glands, located in posterior aspect of thyroid glands secrete parathormone which plays an important role in maintaining calcium homeostasis in the body. The superior and inferior parathyroid glands originate from the 4th and 3rd branchial pouches respectively and migrate to occupy their normal positions in relation to the thyroid gland.1 Hyperparathyroidism is defined as hyper functioning of parathyroid gland and can be primary, secondary or tertiary. Primary hyperparathyroidism is due to parathyroid gland proliferative disorders which include parathyroid adenoma, parathyroid hyperplasia, parathyroid carcinoma or in association with other conditions in MEN syndrome. In more than 90 % patients, primary hyperparathyroidism is caused by a single parathyroid adenoma. Very rarely double parathyroid adenomas are seen. Secondary Hyperparathyroidism is caused in response to any chronic hypocalcaemic conditions like renal failure, gastrointestinal malabsorption, dietary rickets & drugs, like phenytoin, phenobarbital & laxative. Prolonged secondary hyperparathyroidism leads to tertiary hyperparathyroidism due to autonomous secretion. The clinical presentation of hyperparathyroidism is classically described as kidney stones, abdominal groans, painful bones, psychic moans, and fatigue overtones. In the initial course of the disease, the patients present with vague symptoms of fatigue, muscle and joint pain, frequent urination, nausea, constipation, and decreased appetite. If high index of suspicion is maintained, they can be conveniently diagnosed by routine blood tests which show increased calcium levels. However, in India still majority of people are diagnosed when they present with palpable neck mass, skeletal manifestations or deranged renal function. We hereby present 5 cases of parathyroid adenoma managed at our centre over a period of 2 years. P

scholarly journals The Current Role of Parathyroid Fine-Needle Biopsy (P-FNAB) with iPTH-Washout Concentration (iPTH-WC) in Primary Hyperparathyroidism: A Single Center Experience and Literature Review

Biomedicines ◽  
2022 ◽  
Vol 10 (1) ◽  
pp. 123
Author(s):  
Łukasz Obołończyk ◽  
Izabela Karwacka ◽  
Piotr Wiśniewski ◽  
Krzysztof Sworczak ◽  
Tomasz Osęka
Keyword(s):  
Primary Hyperparathyroidism ◽  
Parathyroid Gland ◽  
Clinical Symptoms ◽  
Imaging Techniques ◽  
Preoperative Assessment ◽  
Threshold Level ◽  
Shape Index ◽  
Fine Needle Biopsy ◽  
Parathyroid Glands ◽  
Safe Procedure

Introduction. Primary hyperparathyroidism (PHPT) is a condition characterized by disorders of calcium–phosphate metabolism and bone metabolism caused by pathological overproduction of parathyroid hormone (PTH). The diagnosis of overt PHPT is based on the presence of clinical symptoms and laboratory abnormalities typical of this condition: hypercalcemia, hypercalciuria and elevated iPTH levels. Imaging studies are not used for diagnostic purposes; they are performed to localize the parathyroid glands prior to potential surgical treatment. Technetium 99 m sestamibi scintigraphy (Tc99 m-MIBI) is the gold standard in the assessment of pathologically altered parathyroid glands. Other diagnostic options include cervical ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET). Parathyroid biopsy (P-FNAB) with iPTH washout concentration (iPTH-WC) assessment is still an underestimated method of preoperative parathyroid gland localization. Few studies have reported the utility of US-guided P-FNAB in preoperative assessment of parathyroid lesions. The aim of the study was to present our experience with 143 P-FNAB with iPTH-WC assessment. Material and methods. Laboratory results, US findings, P-FNAB complications and comparison with other imaging techniques were described and analyzed. Results. In 133 (93.0) patients, iPTH washout-to-serum ratio exceeded threshold level 0.5 and were classified as positive results. Median iPTH-WC in this group was 16,856 pg/mL, and the iPTH-WC to serum iPTH ratio was 158. There was no correlation between iPTH-WC and serum PTH, serum calcium, parathyroid gland volume and shape index. In the group of 46 operated patients, 44 demonstrated positive iPTH-WC results, which corresponds to a sensitivity of 95.6%. In Tc99-MIBI, radiotracer retention was found in 17 cases (in 24 MIBI performed), which corresponds to a sensitivity of 52.2%. P-FNAB did not cause any major side effects −92.5% of all patients had no or mild adverse events after this procedure. Conclusions. P-FNAB with iPTH-WC is a reliable method in parathyroid adenoma localization during PHPT. Its sensitivity for diagnosis of PHPT is much higher than that of Tc99-MIBI, and in some situations, P-FNAB with iPTH-WC may even replace that method. Furthermore, cost-effectiveness of iPTH-WC is at least similar to that of Tc99-MIBI. Complications of P-FNAB are mild and we can describe this method as a safe procedure.

scholarly journals SUN-473 Primary Hyperparathyroidism and Papillary Thyroid Carcinoma, Association or Coincidence?

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Nitish Singh Nandu ◽  
Janice L Gilden
Keyword(s):  
Papillary Thyroid Carcinoma ◽  
Thyroid Gland ◽  
Primary Hyperparathyroidism ◽  
Thyroid Carcinoma ◽  
Parathyroid Adenoma ◽  
Parathyroid Gland ◽  
Total Serum ◽  
Papillary Thyroid ◽  
Thyroid Lobe ◽  
The Right

Abstract Background: The Parathyroid glands originate from the Pharyngeal pouches, Inferior from the third and superior from the fourth. Rarely these glands migrate to the thyroid gland, isthmus or thymus and become ectopic. Primary Hyperparathyroidism (PHPT) is a common cause of hypercalcemia in ambulatory patients. It is also more frequent in women and increases with age. Its treatment is often surgical removal of the affected parathyroid gland. We present a case of an ectopic parathyroid adenoma hidden within the thyroid lobe, treated by thyroid lobectomy ultimately leading to the diagnosis and management of Papillary thyroid carcinoma. Case report: A 73-Year-old female with DM, HTN, hyperlipidemia, osteoporosis was referred to the Endocrine clinic for a history of fractures to the right upper and lower extremities after trivial falls, She was subsequently evaluated for metabolic bone disease, noted to have a PTH 78 (n=14-64 pg/ml) with a total serum calcium 9.7 (n=8.6-10.4 mg/dl), 25-OH Vit-D 14 (n=30-100 ng/ml), urinary calcium to creatinine ratio 20 (n=10-320 mg/g). The parathyroid scan showed persistent activity in the area of the inferior margin right thyroid lobe, suggesting a parathyroid adenoma. She had a parathyroidectomy and during the procedure, the parathyroid gland was unable to be visualized. Hence the Right inferior thyroid lobe was removed. The pathology also showed papillary thyroid carcinoma and the patient had a total thyroidectomy. Discussion: The relationship between PHPT and Papillary thyroid carcinoma still remains unclear. Our patient demonstrated a rare circumstance, wherein the presence of a parathyroid adenoma within the thyroid gland has led to early diagnosis and timely treatment of papillary thyroid carcinoma. Few authors reported thyroid malignancy as the most prevalent cancer among patients with PHPT as the primary disorder. While others report concurrence as a coincidental pathology. Nevertheless, we emphasize the importance of surveillance for thyroid pathology in patients with PHPT that can provide better overall patient outcomes. References: 1. Vargas-Ortega, G., et al. (2018). “Symptomatic Primary Hyperparathyroidism as a Risk Factor for Differentiated Thyroid Cancer %J Journal of Thyroid Research.” 2018: 6. 2. Miccoli, P., et al. (2006). “Incidental thyroid carcinoma in a large series of consecutive patients operated on for benign thyroid disease.” ANZ J Surg 76(3): 123-126. 3. Bentrem, D. J., et al. (2002). “Is preoperative investigation of the thyroid justified in patients undergoing parathyroidectomy for hyperparathyroidism?” Thyroid 12(12): 1109-1112.

scholarly journals Primary Hyperparathyroidism due to Parathyroid adenoma presenting as recurrent acute pancreatitis

2017 ◽  
Vol 8 (1) ◽  
pp. 98-100
Author(s):  
Tarun J George ◽  
Pughazhendhi Thangavelu ◽  
S Zahir Hussain ◽  
MP Kumaran ◽  
Kini Ratnakar ◽  
...  
Keyword(s):  
Acute Pancreatitis ◽  
Primary Hyperparathyroidism ◽  
Parathyroid Adenoma ◽  
Elevated Serum ◽  
Surgical Excision ◽  
Medical Sciences ◽  
Thyroid Lobe ◽  
Recurrent Acute Pancreatitis ◽  
Hypoechoic Nodule ◽  
Left Thyroid Lobe

Primary hyperparathyroidism (PHPT) due to parathyroid adenoma presenting as recurrent acute pancreatitis is a rare entity. A 17-year-old male presented with recurrent attacks of pancreatitis and was found to have elevated serum calcium and Parathyroid hormone levels, 11.9mg/dL (8.5-10.2 mg/dL) and 396 pg/ml (10-65pg/ml) respectively. USG neck showed a 1.1 x 0.9 cm hypoechoic nodule in the superior aspect of left thyroid lobe. Parathyroid scintigraphy findings were consistent with parathyroid adenoma. After recovery of pancreatitis, surgical excision of the adenoma was done and the histopathological findings confirmed parathyroid adenoma. There were no further recurrence of pancreatitis following the excision.Asian Journal of Medical Sciences Vol.8(1) 2017 98-100

scholarly journals Night Sweats as the Presenting Symptom of Primary Hyperparathyroidism

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A207-A207
Author(s):  
Vanessa Williams ◽  
Hadoun Jabri ◽  
Michael G Jakoby
Keyword(s):  
Primary Hyperparathyroidism ◽  
Parathyroid Adenoma ◽  
Serum Calcium ◽  
Vasomotor Symptoms ◽  
Temperature Threshold ◽  
Hot Flushes ◽  
Parathyroid Surgery ◽  
Intact Pth ◽  
Patient Reported ◽  
Night Sweats

Abstract Background: Approximately 25–40% of patients report night sweats in the previous month during appointments with their primary care clinicians. The differential diagnosis for night sweats is broad, with hyperthyroidism, carcinoid syndrome, pheochromocytoma, medullary thyroid carcinoma, insulinoma, and acromegaly as established endocrine causes. We present a case of primary hyperparathyroidism (PHPT) in which the patient’s chief complaint was night sweats and resolution occurred after parathyroidectomy. Case. A 39-year-old female reported one-year of daily night sweats that required changes of clothes and bedding. She denied excessive daytime sweating, frequent palpitations, tremors, nightmares, rashes, fevers, chills, cough, headaches, dizziness, abdominal pain, diarrhea, disrupted menses, or unintentional weight loss. Vital signs and examination were unremarkable. Hypercalcemia (11.0 mg/dL, 8.6–10.3) was noted and confirmed by additional serum calcium measurements. Intact PTH ranged from 27–33 pg/mL (12–88), and 24 h urine calcium (258 mg) excluded familial hypocalciuric hypercalcemia (FHH). Parathyroid scintigraphy and neck ultrasound identified a left neck mass, and the patient underwent successful resection of a left inferior parathyroid adenoma. Hypercalcemia and night sweats initially resolved after surgery, but the patient returned six weeks later with recurrence of night sweats. Reevaluation was notable for serum calcium 10.4 mg/dL, phosphorus 2.4 mg/dL (2.5–5.0), and intact PTH 104 pg/mL. A right superior parathyroid adenoma was identified on repeat parathyroidectomy, and the patient experienced durable resolution of night sweats and hypercalcemia following her second parathyroid surgery. She was screened for multiple endocrine neoplasia type 1 (MEN1) due to multiple parathyroid tumors, though no known pathogenic menin gene variants were identified. Conclusions: A title/abstract search in PubMed linking “hyperparathyroidism” and “hypercalcemia” to “night sweats,” “sleep hyperhidrosis,” “sweating,” “hot flashes,” “hot flushes,” “diaphoresis” and “vasomotor symptoms” yielded only one relevant case of a postmenopausal woman with hot flushes unresponsive to hormone replacement that resolved after parathyroidectomy for PHPT. Hypercalcemia is known to affect central nervous system function. It is possible that in rare cases hypercalcemia alters function of the medial preoptic area, lowering the temperature threshold above which peripheral vasodilatation and perspiration occur to dissipate heat. The patient’s predisposition to only night sweats is unclear, though unlike the first patient reported with PHPT and sweating, our patient is premenopausal. This case indicates that vasomotor symptoms may occur with PHPT and resolve after successful parathyroid surgery.

scholarly journals Indocyanine Green Fluorescence Angiography Can Guide Intraoperative Localization During Parathyroid Surgery

2019 ◽  
pp. 145749691987758
Author(s):  
G. Di Meo ◽  
I. Karampinis ◽  
A. Gerken ◽  
A. Lammert ◽  
S. Pellicani ◽  
...  
Keyword(s):  
Indocyanine Green ◽  
Indocyanine Green Angiography ◽  
Revisional Surgery ◽  
High Sensitivity ◽  
Parathyroid Glands ◽  
Fluorescence Angiography ◽  
Parathyroid Surgery ◽  
Indocyanine Green Fluorescence ◽  
Postoperative Hypoparathyroidism ◽  
Intraoperative Localization

Background and Aims: Intraoperative localization of pathologic parathyroid glands is of major importance for the hyperparathyroidism treatment. Based on the small size and the anatomic variability, the localization can be very challenging. The current practice is to compare preoperative ultrasonography with Technetium-99m sestamibi scintigraphy (MIBI) and plan the resection accordingly. In this study, we implemented indocyanine green angiography for the intraoperative localization of parathyroid glands. Materials and Methods: This is a retrospective analysis of 37 patients with primary, secondary, or tertiary hyperparathyroidism who were operated using indocyanine green angiography for the intraoperative localization of pathological parathyroid glands. An indocyanine green solution of 2.5 mg was were intravenously administered for parathyroid gland visualization. Different fluorescence scores were correlated with changes in postoperative parathyroid hormone levels. Results: Patients were divided into two groups depending on the presence of uniglandular or multiglandular disease. Sixty-four lesions were resected, and the final histopathologic analysis confirmed the parathyroid origin in 62 of them (96.8%). None of the patients with uniglandular disease developed postoperative hypoparathyroidism, whereas three patients in the multiglandular group developed temporary hypoparathyroidism symptoms. Indocyanine green imaging had higher sensitivity for the intraoperative detection of parathyroid glands compared with ultrasonography and MIBI ( p < 0.001). Conclusion: Indocyanine green angiography indicated high sensitivity for the intraoperative identification of pathologic parathyroid glands leading to a resection rate of 95.16%. The modality was useful, especially in cases of revisional surgery or ectopic parathyroid glands. Randomized trials have already proven the value of indocyanine green imaging in predicting postoperative hypocalcemia. Our results support the regular use of this method during parathyroid surgery.

scholarly journals Rare Case of Severe Hypercalcemia Secondary to Atypical Sestamibi Negative Parathyroid Cystic Adenoma

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A266-A267
Author(s):  
Timur Gusov ◽  
John Chen Liu ◽  
Sowjanya Naha ◽  
F N U Marium ◽  
Joseph Theressa Nehu Parimi ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Parathyroid Adenoma ◽  
Parathyroid Gland ◽  
Severe Hypercalcemia ◽  
Parathyroid Adenomas ◽  
Sestamibi Scan ◽  
Serum Pth ◽  
The Right ◽  
99Mtc Sestamibi ◽  
Cystic Adenoma

Abstract Primary hyperparathyroidism (PHPT) is defined as excessive secretion of parathyroid hormone (PTH) originating from the parathyroid gland. The most common cause is a single parathyroid adenoma which is typically solid. Cystic parathyroid adenomas (CPA) are the cause of about 1–2% of cases of primary hyperparathyroidism. It is known that cystic parathyroid adenomas are a result of degeneration of an existing parathyroid adenoma. SestaMIBI is an imaging study based on uptake of radioactive technetium99 and used to localize parathyroid adenomas. We describe an unusual case of severe hypercalcemia secondary to 99mTc sestaMIBI negative atypical parathyroid cystic adenoma. A 56-year-old male presented to our facility with nausea and vomiting. His past medical history included hypertension and hepatitis C with no history of fractures or kidney disease. Physical examination was normal. Upon admission the patient was afebrile with blood pressure of 170/120 mmHg and heart rate of 62 bpm. Chemistry showed Calcium of 14.5 mg/dL (8.6–10.2mg/dL), phosphorus 2.2 (2.7–4.5) mh/dL, magnesium 1.8 (1.7–2.6)mg/dL, intact PTH of 375 (15–65) pg/mL, PTH-related peptide &lt;2.0 pmol/L(&lt;2 pmol/L), 25-OH vitamin D of 19 ng/ml (30–80), Creatinine 1.22 (0.7–1.2)mg/dL, alkaline phosphatase 95 (40–129) units/L. He was started on aggressive hydration, calcitonin 4 units/kg, 4 mg of IV Zolendroninc acid. Neck sonogram revealed a large, complex, predominantly anechoic lesion with solid vascular components and thick internal septations in the inferior and medial aspect of the right thyroid lobe measuring 3 x 2 x 5.5 cm. Findings were confirmed with CT of the neck. Since Sestamibi scan (planar and SPECT/CT) did not show uptake in parathyroid glands, the cyst was thought to be of thyroid origin. Fine needle aspiration was not able to detect cellular material, but PTH was &gt;100 pg/ml on the FNA sample. Otolaryngology service was consulted for parathyroidectomy. During the surgical treatment, the right upper parathyroid gland was removed with no changes in serum PTH. Next, the cystic lesion was removed with normalization of serum PTH (from 218 pg/ml to 35.2 pg/ml respectively). Intraoperative frozen section analysis was read as a cystic parathyroid adenoma. The final pathology report revealed cystic parathyroid tissue favoring parathyroid adenoma with focal atypia. Hypercalcemia resolved. Conclusions: Atypical cystic parathyroid adenomas are a rare cause of PHPT. 90% of parathyroid cysts are nonfunctional. Above mention is a case of a patient presenting with hypercalcemic crisis secondary to cystic parathyroid adenoma, which posed a diagnostic challenge as both neck ultrasound and 99mTc sestaMIBI scan were inconclusive. These findings should trigger suspicion for functional parathyroid lesions. Cystic components should be evaluated for PTH levels and if significantly elevated should be treated as a parathyroid adenoma.

scholarly journals Re-explorative Parathyroid Surgery for Persistent and Recurrent Primary Hyperparathyroidism

2011 ◽  
Vol 3 (3) ◽  
pp. 107-111 ◽  
Author(s):  
Karolina Afors ◽  
Rachel L O'Connell ◽  
Martin H Thomas
Keyword(s):  
Primary Hyperparathyroidism ◽  
Imaging Techniques ◽  
Parathyroid Tissue ◽  
Parathyroid Surgery ◽  
Redo Surgery ◽  
Normal Gland ◽  
Primary Surgery ◽  
High Calcium ◽  
Targeted Approach

ABSTRACT Primary hyperparathyroidism (HPT) is treated by parathyroidectomy. Excision of abnormal parathyroid tissue is curative in the majority of cases. Postoperative persistent or recurrent HPT has been reported up to 30%. The purpose of this study was to evaluate the role of imaging techniques and determine the efficacy of reexplorative surgery. A total of 306 patients underwent parathyroidectomy between 2000 and 2009. Twelve patients (3.9%) were not cured. Two patients declined further treatment, the other 10 patients underwent further investigation and surgery. Imaging and results of redo surgery together with associated complications were evaluated. All 10 patients were investigated with sestamibi, which accurately localized aberrant parathyroid tissue in three cases and ultrasound scans which also localized three cases. CT was useful in one of the three cases for which it was used. PET and MRI were not helpful. Twelve glands were resected, six adenomas, five hyperplastic and one normal gland. Nine of the 10 reoperated patients became normocalcemic. Complications included a bilateral recurrent laryngeal paresis. In total, 317 operations were performed and 303 of 306 (99%) patients were cured. Redo surgery for HPT is challenging and carries higher risks than primary surgery. Sestamibi and ultrasound scans are the most helpful imaging modalities. When there is concordance a targeted approach may be considered, otherwise a more extensive dissection is required. Redo parathyroid surgery should be considered, even if scans are unhelpful, for patients who are symptomatic or young or have a persistently high calcium level.

scholarly journals SAT-349 Cinacalcet Resistant Tertiary Hyperparathyroidism with One Large Parathyroid Gland

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Bayan Chaker ◽  
Hussam Alim ◽  
Wael Taha
Keyword(s):  
Hospital Stay ◽  
Parathyroid Adenoma ◽  
Parathyroid Gland ◽  
Calcium Level ◽  
Parathyroid Glands ◽  
Incomplete Resection ◽  
Lower Pole ◽  
Tertiary Hyperparathyroidism ◽  
The Right ◽  
Inferior Parathyroid Gland

Abstract Tertiary hyperparathyroidism is thought to develop after long term secondary hyperparathyroidism, such as CKD on dialysis. In This case, all parathyroid glands are significantly enlarged. We report a case of an 84-year-old female with a past medical history of ESRD on HD and recurrent nephrolithiasis who was found to have an enlarged multinodular goiter with the dominant mass in the lower pole of the right gland measuring about 4.7 cm on thyroid ultrasound. Blood work was done which showed elevated intact PTH levels at 2720 pg/mL (12–88). Her calcium level was normal at that time at 10.5 mg/dL (8.6–10.8) with an albumin of 4.2 g/dL (3.5–5.7), and a phosphorus of 5.7 mg/dL (2.5–4.5). Patient had a DEXA scan which showed severe osteoporosis in the lumbar spine, left hip, and right forearm. Patient had increased PTH levels despite being on Cinacalcet. She had a nuclear medicine parathyroid scan with SPECT CT which showed increased uptake along the right inferior thyroid concerning for a large right lower parathyroid adenoma or functional thyroid nodule. FNA of the nodule was done and showed colloid nodule but PTH wash showed elevated PTH at 7634 pg/mL. She was referred for right lower parathyroidectomy and Cinacalcet was discontinued prior to surgery. She had right and left inferior parathyroidectomy and 4 gland exploration. Pathology showed the right inferior parathyroid gland to be markedly hyper-cellular, weighing 36 grams consistent with hyperplasia and the left inferior parathyroid gland to be slightly hyper-cellular parathyroid gland consistent with hyperplasia. No evidence of malignancy was noted on pathology. Prior to surgery her calcium level of 10.6 mg/dL which went down to 9.6 mg/dL post-operatively. Patient then developed severe hypocalcemia and hungry bone syndrome following the surgery requiring a calcium drip for 3 days post-operatively. Was changed to oral calcium but required large amounts of calcium gluconate and calcitriol supplementation and an extended hospital stay of 13 days. However, throughout the hospital stay, PTH levels continued trending back up to 239 which may represent either increased activity from remaining parathyroid glands or residual parathyroid adenoma with incomplete resection. Post-operative US neck showed Post-surgical collection in the lower pole of the right gland measuring 4.8 cm compatible with recent resection. In conclusion, tertiary hyperparathyroidism can develop due to one enlarged parathyroid gland or an adenoma, which can be resistant to cinacalcet.

scholarly journals Persistent primary hyperparathyroidism: an uncommon location for an ectopic gland - Case report and review

2012 ◽  
Vol 56 (6) ◽  
pp. 393-403 ◽  
Author(s):  
Sofia Gouveia ◽  
Dírcea Rodrigues ◽  
Luísa Barros ◽  
Cristina Ribeiro ◽  
Anabela Albuquerque ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Parathyroid Gland ◽  
Median Sternotomy ◽  
Parathyroid Glands ◽  
Aortopulmonary Window ◽  
Genetic Syndromes ◽  
Subtotal Parathyroidectomy ◽  
Common Causes ◽  
Ectopic Parathyroid ◽  
99Mtc Sestamibi

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that mainly affects middle-aged women. Patients are usually asymptomatic. The disease might be ascribable to hyperplasia, carcinoma, and single or multiple adenomas. PHPT may be sporadic or familial, the latter comprising multiple endocrine neoplasia type 1 or 2A, familial benign hypocalciuria hypercalcemia, and hyperparathyroidism-jaw tumor syndrome. The most common causes for persistent PHPT are multiglandular disease, and missed abnormal ectopic or orthotopic parathyroid glands. Imaging localization studies should precede a new surgical intervention. Ectopic parathyroid glands are rarely located at the aortopulmonary window. For diagnosis confirmation, 99mTc-sestamibi SPECT/CT seems to be an advantageous test. Another possibility is to perform 99mTc-sestamibi followed by thoracic CT or MRI. Parathyroidectomy may be performed by means of median sternotomy, thoracotomy, or video-assisted thoracoscopy. We describe a case of persistent primary hyperparathyroidism due to the presence of an ectopic parathyroid gland found at the aortopulmonary window. As the investigation necessary to clarify the etiology of recurrent nephrolithiasis proceeded, the diagnosis of PHPT was determined. The patient underwent subtotal parathyroidectomy; nevertheless, PHPT persisted. Genetic syndromes that could account for this condition were excluded. Imaging studies available at that time were not able to locate abnormal glands; moreover, the patient refused to undergo surgical exploration. Later, the patient underwent 99mTc-sestamibi SPECT/CT, which revealed a parathyroid gland at the aortopulmonary window.

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