Hyperparathyroid crisis is a rare manifestation of parathyroid disease. We present the case of a 53-year-old gentleman with a review of the current literature. He presented in acute renal failure with epigastric pain and vomiting. His serum-corrected calcium (CCa2+) was raised at 5.2 mmol/L, in addition to a massively raised parathyroid hormone (PTH) level (3957 ng/L). Ultrasound studies of the neck revealed a 2 cm well-defined mass inferoposterior to right thyroid lobe. CT scans of the neck showed a normal mediastinum and confirmed no associated lymphadenopathy. Having undergone medical resuscitation for 9 days, a neck exploration revealed a cystic mass, which was excised. Histological investigations revealed a 9.25 g, cystic parathyroid adenoma with no features of malignancy. His PTH and CCa2+ returned to normal postoperatively. This suspicious presentation of benign disease, including a marked elevation in PTH, highlights the challenges facing the endocrine surgeon in dealing with parathyroid disease.

1 The work contained in this paper formed part of a thesis which was accepted by the University of Durham for the degree of Ph.D. from the British Drug Houses, Ltd. An analysis of doucil [Hilditch and Wheaton, 1925] is very similar to that of permutit in 1923 [Higgins and O'Callaghan, 1925].

An 8-year-old intact male Briard was presented with a non-painful bilateral diffuse swelling of mandible and maxilla. The teeth were mobile. The jaws felt like rubber. Radiographic examination revealed generalized osteopenia. Ultrasound showed prominent parathyroid glands. The plasma parathyroid hormone concentration was extremely high, the serum 25-hydroxy-vitamin D (25-OH Vit D) was low, and the serum ionized calcium remained within the reference range. As the dog had been fed an unbalanced homemade diet for many years, rubber jaw, osteomalacia and secondary hyperparathyroidism due to dietary calcium and vitamin D deficiency were diagnosed. Dietary correction resulted in clinical improvement and normalization of the plasma parathyroid hormone concentration within 4 months. However, although the 25-OH Vit D was clearly raised, it still did not reach reference values, which was due to lack of owner compliance, as the owner had changed the patient's diet over time. SAMENVATTINGEen acht jaar oude, mannelijk intacte briard werd aangeboden met een niet-pijnlijke diffuse zwelling van de manibula en maxilla. De tanden stonden los. De kaken voelden aan als rubber. Radiografisch onderzoek toonde een algemene osteopenie. Ultrasonografie liet een prominente zwelling van de bijschildklieren zien. De plasma parathyroïd hormoonconcentratie was extreem hoog, de serum 25-hydroxy-vitamin D (25-OH Vit D) concentratie was laag en het serumgeïoniseerd calcium bleef binnen de referentiewaarden. Aangezien de hond ook reeds vele jaren een nietuitgebalanceerd huishouddieet als voeder kreeg, werd de diagnose van rubber jaw, osteomalacie en secundaire hyperparathyroïdie ten gevolge van een diëtair calcium-en vitamine D-tekort gesteld. Na vier maanden resulteerde de correctie van het dieet in een klinische verbetering en een normalisatie van de plasma parathyroïd hormoonconcentratie. Hoewel de serum 25-OH Vit D-waarde reeds een duidelijke stijging vertoonde, werden de referentiewaarden niet bereikt. Dit kwam omdat de eigenaar het dieet van de patiënt na verloop van tijd veranderde.

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