Hypercalcemia induced pancreatitis as a rare presentation of primary hyperparathyroidism

Abstract

Acute pancreatitis (AP) is an inflammatory process of the pancreas. It is a relatively common cause of acute upper abdominal pain and is potentially associated with high morbidity and mortality. Underlying hypercalcemia as a cause of AP is very rare. We present a case of a hypercalcemia-induced acute pancreatitis with an underlying parathyroid adenoma in an 81-year-old woman with no previous symptoms of hypercalcemia. The parathyroid adenoma was semi-urgently surgically resected with normalization of calcium-levels. This case report summarizes the causes of acute pancreatitis and hypercalcemia and its management.

Hypercalcemic Pancreatitis: A Rare Type of Acute Pancreatitis Caused by a Parathyroid Adenoma

“…PHPT is most commonly caused by a solitary parathyroid adenoma (85%-90%) [7,8] . Other less common causes include: Hyperplasia of the four parathyroids, parathyroid carcinoma, and multiple endocrine neoplasia type 1 and 2A [9,10] . Most patients with PHPT are asymptomatic and it is detected upon routine laboratory testing.…”

“…Clinical manifestations in patient with PHPT secondary to hypercalcemia include recurrent renal calculi, skeletal manifestations, nonspecific gastrointestinal symptoms, cardiovascular and neuromuscular disorders [2,3,11] . Acute pancreatitis is an inflammatory pancreatic process with high morbidity and mortality [9] . Alcohol and biliary tract stones are the most common causes [12] .…”

“…Although a clear physiopathological base could not be determined, proposed mechanisms of hypercalcemia induced acute pancreatitis include increased intrapancreatic activation of trypsinogen to trypsin causing pancreatic autodigestion, which leads to forming calcium deposits in the pancreatic ducts, followed by pancreatic duct obstruction. Also high cytosolic calcium can generate the activation of nuclear factor Kappa-B (NF-kB) leading to local and systemic inflammation [7,9,21] . In addition, a genetic risk factor has also been found in the setting of hypercalcemia; mutations in SPINK 1 (Kazal-type serine protease inhibitor type1), CFTR (cystic fibrosis transmembrane conductance regulator) and CASR (calcium receptor) genes were suggested as possible mechanisms [4,5] .…”

“…Within context of hypercalcemia, the diagnosis of PHPT is based on measuring PTH serum level which is increased [9] . The identification of the parathyroid adenoma as a further work up of PHPT in the preoperative setting is performed by imaging studies such as neck ultrasound, neck tomography or scintigraphy with sestamibi.…”

“…The identification of the parathyroid adenoma as a further work up of PHPT in the preoperative setting is performed by imaging studies such as neck ultrasound, neck tomography or scintigraphy with sestamibi. The later can also detect ectopic locations [5,9] .…”