A case report: Giant cystic parathyroid adenoma presenting with parathyroid crisis after Vitamin D replacement

Abstract

BackgroundParathyroid adenoma with cystic degeneration is a rare cause of primary hyperparathyroidism. The clinical and biochemical presentation may mimic parathyroid carcinoma.Case presentationWe report the case of a 55 year old lady, who had longstanding history of depression and acid peptic disease. Serum calcium eight months prior to presentation was slightly high, but she was never worked up. She was found to be Vitamin D deficient while being investigated for generalized body aches. A month after she was replaced with Vitamin D, she presented to us with parathyroid crisis. Her corrected serum calcium was 23.0 mg/dL. She had severe gastrointestinal symptoms and acute kidney injury. She had unexplained consistent hypokalemia until surgery. Neck ultrasound and CT scan revealed giant parathyroid cyst extending into the mediastinum. After initial medical management for parathyroid crisis, parathyroid cystic adenoma was surgically excised. Her serum calcium, intact parathyroid hormone, creatinine and potassium levels normalized after surgery.ConclusionThis case of parathyroid crisis, with very high serum calcium and parathyroid hormone levels, is a rare presentation of parathyroid adenoma with cystic degeneration. This case also highlights that Vitamin D replacement may unmask subclinical hyperparathyroidism. Consistent hypokalemia until surgery merits research into its association with hypercalcemia.

Determining primary from secondary hyperparathyroidism: A review of current management

“…Primary hyperparathyroidism results from a defect in proliferation leading to hypercellularity of one or more glands but also a defect in the negative feedback system [13]. Mean preoperative PTH levels of 180 pg/mL is common in pHPT while levels greater than 700 pg/mL indicate parathyroid carcinoma [3]. Only sixteen cases of parathyroid adenoma larger than 30 grams have been documented as of 2011.…”

“…Tumors larger than two to five grams are deemed giant parathyroid adenomas based on the local definitions [11,14]. One to two percent of patients with pHPT present with parathyroid crisis, a life-threatening condition in which severely elevated calcium levels lead to multiorgan failure [3].…”

“…bony destruction and elevated serum calcium with its resultant sequelae [3,4]. Primary and secondary hyperparathyroidism may occur in patients with parathyroid adenoma and chronic renal disease, as we intend to discuss fully, and can muddle the diagnosis of the former [5][6][7].…”

Efficacy of Vitamin D Supplementation After Bariatric Operation: Letter to the Editor

“…I think that this study is based in a very small population, without any power analysis data given. The authors do not also reveal the possible problems with unmasking subclinical parathyroid glands adenomas with intensive vitamin D supplementation [2]. The rate of these problems and the rate of preoperative secondary hyperparathyroidism could not possibly be revealed with such a small group of patients [3].…”

Hypercalcemic Crisis Secondary to A Parathyroid Hormone-Secreting, Intrathymic, Cystic, Parathyroid Adenoma

“…PHPT is commonly caused by a single parathyroid adenoma (75 to 85%), parathyroid gland hyperplasia (10 to 20%), multiple adenomas (4 to 5%), and rarely carcinoma (1%) (1,3). Functional parathyroid cysts have also been reported as a cause of PHPT, with most commonly located in the cervical region (4). Parathyroidectomy is the treatment of choice in most cases of symptomatic PHPT to preserve renal function, prevent bone resorption and fractures, and improve quality of life.…”