Persistent Primary Hyperparathyroidism Secondary to an Ectopic Mediastinal Adenoma in a Young Adult: A Case Report

Karl Homer; Rebecca Alba

doi:10.15605/jafes.038.02.16

Authors

Karl Homer Chinese General Hospital and Medical Center, Manila, Philippines https://orcid.org/0000-0002-3394-8573
Rebecca Alba Chinese General Hospital and Medical Center, Manila, Philippines https://orcid.org/0000-0003-2191-8518

DOI:

https://doi.org/10.15605/jafes.038.02.16

Keywords:

hyperparathyroidism, reoperation, hypercalcemia, ectopic parathyroid adenoma

Abstract

Primary hyperparathyroidism commonly affects elderly women. When present in the young population, it is usually asymptomatic, most frequently due to a parathyroid adenoma and the definitive management is surgical excision.
Uncommonly, 5-10% of patients fail to achieve long-term cure after initial parathyroidectomy and 6-16% of them is due to
an ectopic parathyroid adenoma that will require focused diagnostic and surgical approaches.

We report a 21-year-old male who had bilateral thigh pain. Work-up revealed bilateral femoral fractures, brown tumors on the arms and multiple lytic lesions on the skull. Serum studies showed hypercalcemia (1.83 mmol/L), elevated parathyroid hormone [(PTH) 2025.10 pg/mL], elevated alkaline phosphatase (830 U/L), normal phosphorus (0.92 mmol/L) and low vitamin D levels (18.50 ng/mL). Bone densitometry showed osteoporotic findings. Sestamibi scan showed uptake on the left superior mediastinal region consistent with an ectopic parathyroid adenoma. Vitamin D supplementation was started pre-operatively. Patient underwent parathyroidectomy with neck exploration; however, the pathologic adenoma was not visualized and PTH levels remained elevated post-operatively. Chest computed tomography with intravenous contrast was performed revealing a mediastinal location of the adenoma. A repeat parathyroidectomy was done, with successful identification of the adenoma resulting in a significant drop in PTH and calcium levels. Patient experienced hungry bone syndrome post-operatively and was managed with calcium and magnesium supplementation. A high index of suspicion for an ectopic adenoma is warranted for patients presenting with hypercalcemia and secondary osteoporosis if there is persistent PTH elevation after initial surgical intervention. Adequate follow-up and monitoring is also needed starting immediately in the post-operative period to manage possible complications such as hungry bone syndrome.

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Author Biographies

Karl Homer, Chinese General Hospital and Medical Center, Manila, Philippines

Section of Endocrinology, Diabetes and Metabolism

Rebecca Alba, Chinese General Hospital and Medical Center, Manila, Philippines

Section of Endocrinology, Diabetes and Metabolism

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