International Journal of Advanced and Integrated Medical Sciences

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Hypercalcemia due to Parathyroid Adenoma:A Delayed Diagnosis
  IJAIMS
CASE REPORT
Hypercalcemia due to Parathyroid Adenoma:A Delayed Diagnosis
1Vinish K Agarwal, 2Kartikeya Purohit, 3SS Bist, 4Mamta Goyal
1Assistant Professor, 2Senior Resident, 3Head, 4AssociateProfessor
1-3Department of ENT, Himalayan Institute of Medical SciencesSwami Rama Himalayan University, Dehradun, Uttarakhand, India
4Department of Radiodiagnosis, Himalayan Institute of MedicalSciences, Swami Rama Himalayan University, DehradunUttarakhand, India
Corresponding Author:
Vinish K Agarwal, Assistant ProfessorDepartment of ENT, Himalayan Institute of Medical SciencesSwami Rama Himalayan University, Dehradun, UttarakhandIndia,
e-mail: vinish143agra@yahoo.co.in
10.5005/jp-journals-10050-10075
 
ABSTRACT
Hypercalcemia is a serious health problem occurring due topathology of many organ systems including thyroid, parathyroid,kidney, and bone. Hypercalcemia due to parathyroid is usuallya delayed diagnosis as parathyroid adenoma is usually discoveredduring surgery of thyroid gland disease. We present a caseof hypercalcemia due to parathyroid adenoma, who underwenttotal thyroidectomy with right inferior parathyroidectomy. Weconclude that a patient with features suggestive of hypercalcemiashould be suspected to have parathyroid adenoma andevery effort has to be made to diagnose parathyroid adenomaas this is a surgically resectable medical problem.
Keywords: Hypercalcemia, Parathyroid adenoma, Parathyroidectomy, Thyroidectomy.
How to cite this article: Agarwal VK, Purohit K, Bist SS,Goyal M. Hypercalcemia due to Parathyroid Adenoma: ADelayed Diagnosis. Int J Adv Integ Med Sci 2017;2(1):51-52.
Source of Support: Nil
Conflicts of Interest: None
 
 

INTRODUCTION

Primary hyperparathyroidism (PHPT) is an uncommondisease with an incidence between 1 in 1,000 and 1 in 200.1It is caused by different pathologic lesions of the parathyroidglands.2 Usually, patients with PHPT are symptomatic;however, a small group of patients who do not exhibitany biochemical or clinical manifestations of the diseaseare thought to have "subclinical" hyperparathyroidismbecause of the enlargement of the parathyroid glands.2The most common cause of PHPT is solitary parathyroidadenoma (approximately 85%).3 Parathyroid adenomais usually discovered during surgery of thyroid glanddisease or as an incidental finding on ultrasonographyof the neck.2

 
CASE REPORT

A 53-year-old woman, a known case of diabetes mellitussince 10 years, presented to the outpatient clinic withcomplaint of swelling on the right side lower aspect ofneck since 4 years duration (Fig. 1). On examination ofthe neck, there was a single oval-shaped approximately3 × 2 cm swelling, 2 cm above the sternal end of rightclavicle. The overlying skin color was normal, overlyingskin temperature was normal, firm in consistency,mobile, nontender, moved with deglutition, and didnot move with protrusion of tongue. Ultrasonographyneck showed well-defined hypoechoic lesion measuringapproximately 11 × 7 mm seen near inferior poleof right lobe of thyroid along with multinodular goiter(MNG). Fine-needle aspiration cytology revealedhyperplastic nodule on lower pole of thyroid glandwith MNG. Blood investigations of patient were asfollows: Euthyroid (free triiodothyronine - 2.08 pg/mL,free thyroxine - 1.30 ng/dL, thyroid stimulatinghormone - 2.21 µIU/mL), serum calcium - 13.9 mg/dL,and parathyroid hormone - 188 pg/mL. Technetium99m tetrofosmin dual-phase parathyroid scintigraphywas suggestive of right superior parathyroid adenoma(Fig. 2). Contrast-enhanced computed tomography neckshowed multiple nodules in bilateral thyroid lobe witha small lesion at the inferior pole of right thyroid lobe(Fig. 3). The patient underwent total thyroidectomy withright inferior parathyroidectomy. During the procedure,right inferior parathyroid gland appeared enlarged andadherent to the inferior pole of right thyroid lobe (Fig. 4).Postoperatively, patient had hypocalcemia, which wastreated conservatively. The patient was also managedfor diabetes mellitus by intravenous insulin therapy.Histopathology came out as MNG with parathyroidadenoma.

DISCUSSION

We present a case of parathyroid adenoma of rightinferior parathyroid as a cause of PHPT in associationwith a MNG. Multinodular goiter is the most commonendocrine disorder affecting 500 to 600 million peopleworldwide.4 In India, about 54 million people havegoiter and the number at risk is estimated to be about167 million with an annual incidence of 0.1 to 1.5%.5Primary hyperparathyroidism has become an asymptomaticdisease in the Western world, whereas in India,PHPT is still an uncommonly diagnosed, overtly symptomaticdisease of "bones, stones, abdominal groans,and psychic moans" due to the fact that screening of thehealthy population for hypercalcemia is not a routinepractice. The treatment of choice for PHPT is surgicalremoval of the hyperfunctioning tissue. Hungry bonesyndrome is common in the postoperative period. Thedisease-related mortality rate is 7.4%, recurrence 4.16%,and persistent disease 2.17%.6

International Journal of Advanced & Integrated Medical Sciences, January-March, Vol 2, 201751

Vinish K Agarwal et al

Hypercalcemia due to Parathyroid Adenoma: A Delayed Diagnosis
Fig. 1: Anterior neck swelling on right side

Hypercalcemia due to Parathyroid Adenoma: A Delayed Diagnosis
Fig. 3: Axial contrast-enhanced computed tomography scan -lesion of 1.17 × 0.62 cm at the inferior pole of right lobe thyroid

CONCLUSION

All patients with features suggestive of hypercalcemiashould be suspected to have parathyroid adenoma andevery effort to be made to diagnose parathyroid adenomaas this is a surgically resectable medical problem.

 
Hypercalcemia due to Parathyroid Adenoma: A Delayed Diagnosis
Fig. 2: Red line showing increased uptake in right parathyroidon nuclear scan

Hypercalcemia due to Parathyroid Adenoma: A Delayed Diagnosis
Fig. 4: Thyroid lobe being removed with exposed enlarged rightinferior parathyroid gland

REFERENCES
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  2. Marchesi M, Biffoni M, Benedetti RN, Campana FP.Incidental parathyroid adenomas with normocalcaemiadiscovered during thyroid operations: report of three cases.Surg Today 2001 Mar;31(11):996-998.
  3. Chan, JK. Tumors of the thyroid and parathyroid glands.Part B: the parathyroid gland. In: Fletcher CD, editor.Diagnostic histopathology of tumors. 4th ed. Philadelphia:Saunders Elsevier; 2013. p. 1273-1293.
  4. Day TA, Chu A, Hoang K. Multinodular goiter. OtolaryngolClin North Am 2003;36(1):35-54.
  5. Hurley DL, Gharib H. Evaluation and management ofmultinodular goiter. Otolaryngol Clin North Am 1996Aug;29(4):527-540.
  6. Pradeep PV,. Jayashree B, Mishra A, Mishra SK. Systematicreview of primary hyperparathyroidism in India: the past,present, and the future trends. Int J Endocrinol 2011 Mar;2011:7.

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