A CASE OF PARATHYROID CRISIS SECONDARY TO BENIGN PARATHYROID ADENOMA

Abstract

INTRODUCTION
Hypercalcaemic parathyroid crisis is a rare and potentially fatal complication of primary hyperparathyroidism (PHPT) in which patients develop severe symptoms and signs of hypercalcemia.

CASE
67-year-old lady presented to Accident and Emergency with increasing generalized lethargy, vomiting and severe epigastric discomfort for 1 week. She had significant history of osteoporosis with T12 compression fracture and multinodular goiter. At admission, she looked lethargic and clinically dehydrated. There was no palpable neck lump, goiter or cervical lymphadenopathy. Her corrected calcium on admission was markedly raised at 4.1 mmol/l. Other biochemistries revealed significantly elevated intact PTH 189 [1.3-7.6 pmol/l] and serum alkaline phosphatase 618 [32-103 IU/l]. Her urea, creatinine, thyroid functions were normal. She was started on aggressive intravenous hydration with 0.9% sodium chloride followed by subcutaneous calcitonin and iv pamidronate. Technetium-99 sestamibi scan showed hyperfunctioning parathyroid tissue at the region of lower lobe of left thyroid. There was a prompt decrease in her calcium and parathyroid hormone level immediately after removal of a 5 cm left inferior parathyroid tumor. Histology revealed benign parathyroid adenoma.

CONCLUSION
Parathyroid crisis is a syndrome characterized by a serum calcium level usually greater than 3.5 mmol/l resulting from marked elevation of PTH with multiple organ dysfunction and profound dehydration. 3% of PHPT patients present with parathyroid crisis in which 88% are caused by parathyroid adenoma. It is important to institute multimodality treatment to lower serum calcium before early parathyroidectomy.