Giant parathyroid adenomas constitute a rare clinical entity, particularly in the developed world. We report the case of a 53-year-old woman where the initial ultrasonography significantly underestimated the size of the lesion. The subsequent size and weight of the adenoma (7cm diameter, 27g) combined with the severity of the hypercalcaemia raised the suspicion for the presence of a parathyroid carcinoma. This was later disproven by the surgical and histological findings. Giant parathyroid adenomas are encountered infrequently among patients with primary hyperparathyroidism, and appear to have distinct clinical and biochemical features related to specific genomic alterations. Cross-sectional imaging is mandated in the investigation of parathyroid adenomas presenting with severe hypercalcaemia as ultrasonography alone can underestimate their size and extent. This is important since it can impact on preoperative preparation and planning as well as the consent process as a thoracic approach may prove necessary for certain cases. KEYWORDSParathyroid adenoma -Giant -Primary hyperparathyroidism -Surgery -Imaging -Consent Accepted 11 January 2015; published online XXX CORRESPONDENCE TO George Garas, E: g.garas@imperial.ac.uk Primary hyperparathyroidism (pHPT) is the third most common endocrine disorder and the leading cause of hypercalcaemia among ambulant patients. It primarily affects women with a female-to-male ratio of 4:1 and a peak incidence around the fifth decade of life.1 In the majority (80-85%) of cases, it results from a single parathyroid adenoma while parathyroid hyperplasia (15%) and carcinoma (<1%) represent rarer causes of pHPT. Giant parathyroid adenomas have variable definitions in the literature but the most commonly used is that for adenomas exceeding 3.5g in weight. 2,3Case HistoryA 53-year-old woman was referred to the endocrinology department for investigation and management of newly diagnosed hypercalcaemia. She reported suffering from fatigue as well as generalised bone and muscle pain over the preceding three months. Her past medical history included controlled hypertension. A 2-3cm left neck mass was palpable on cervical examination. The remainder of the physical examination was unremarkable. Laboratory evaluation was consistent with pHPT as she suffered from severe hypercalcaemia (adjusted serum calcium: 15.9mg/dl, normal range: 8.4-10.5mg/dl) associated with exceedingly high parathyroid hormone (PTH) levels measuring 4,038pg/ml (normal range: 10-65pg/ml). In view of the severe hypercalcaemia, the patient was admitted to hospital and started on intravenous fluids followed by a bisphosphonate infusion. Within two days of hospitalisation, the adjusted serum calcium had normalised.In order to investigate the pHPT, neck ultrasonography was initially performed. This revealed a lobular, well defined hypoechoic lesion situated behind the left lower pole of the thyroid gland and measuring 2.85cm in diameter (Fig 1). The severity of the hypercalcaemia made parathyroid carcinoma an important ...

SUMMARYWe report a case of severe eyelid oedema due to Graves' ophthalmopathy (GO). The aim was to present a case report and review of the literature about eyelid oedema due to GO. The case report includes a history of patient data and literature review. The patient was offered intravenous methylprednisolone and gave consent. A dosage of 500 mg intravenous methylprednisolone once weekly for 6 weeks, followed by 250 mg intravenous methylprednisolone once weekly for 6 weeks, with a total treatment period of 12 weeks was given. Up to day, minor improvement has been observed. Severe eyelid oedema due to GO is a rare manifestation of Graves' disease. In cases of active and moderate-to-severe disease, treatment with intravenous glucorticoids is recommended alone or with orbital radiotherapy, followed by rehabilitative surgery. DESCRIPTIONA 55-year-old woman presented to our department with disfiguring, marked upper and lower eyelid swelling, pruritus and intermittent diplopia during the previous 4 months. She was smoking 20-30 cigarettes/day. Physical examination revealed resting tachycardia (110 bpm), gross periorbital oedema, (figures 1 and 2) and slightly enlarged thyroid gland. Ophthalmic disease activity score was 5/7, with moderate severity. Thyroid-stimulating hormone was suppressed at 0.005 μIU/L (reference range 0.27-4.2). Free thyroxine and triiodothyronine levels were 2.39 ng/dL (reference range 0.7-2) and 3.23 ng/mL (reference range 0.8-2), respectively. TSH-receptor antibodies were elevated at 32 IU/L (normal values <1.75), anti-TPO were 66.4 IU/L (normal values <45), while antithyrogobulin antibodies were negative. Graves' disease (GD) was diagnosed and the patient was started on methimazole and propranolol and was subsequently admitted for intravenous glucocorticoid pulse therapy (500 mg intravenous methylprednisolone once weekly for 6 weeks, followed by 250 mg intravenous methylprednisolone once weekly for 6 weeks, with a total treatment period of 12 weeks). Up to day, minor improvement has been observed. Graves' orbitopathy (GO) is the commonest extrathyroidal manifestation of GD (50% of cases) and it is of autoimmune aetiology.

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One Sentence Summary: Dual sellar lesions are relatively uncommon. Asymptomatic Rathke's cleft cyst, a relatively common entity, in concurrence with a pituitary adenoma, should be considered in the differential diagnosis of two distinct pituitary lesions.