Primary Hyperparathyroidism Masquerading as Acute Pancreatitis

Abstract

Acute pancreatitis as an initial manifestation of primary hyperparathyroidism (PHPT) is a rare occurrence and timely diagnosis of PHPT is crucial in preventing repeat attack of pancreatitis. The study aimed at evaluating the clinico-radiological profile of patients admitted with acute pancreatitis as the index presentation of PHPT and to determine the factors associated with development of severe pancreatitis. This series included retrospective analysis of medical records of 30 patients admitted with acute pancreatitis as initial manifestation of PHPT. Additionally, we analyzed the data of another 30 patients admitted with PHPT but without any evidence of pancreatitis, to serve as control group. The mean age of the subjects was 44.9±13.9 years with male to female ratio of 1.30. The mean serum calcium level was 12.24±2.79 mg/dl and five (16.6%) patients had normocalcemia at time of presentation. Presence of nephrolithiasis was significantly associated with severe pancreatitis. One patient had refractory hypercalcemia associated with renal failure and was successfully managed with denosumab. Patients with PHPT associated with acute pancreatitis had significantly higher calcium levels and lower frequency of skeletal involvement as compared to PHPT patients without pancreatitis. PHPT masquerading as acute pancreatitis is rare and high index of suspicion is required to diagnose this condition especially in the presence of normocalcemia at presentation. Patients with PHPT associated pancreatitis had male preponderance, higher calcium levels, and lower frequency of skeletal involvement as compared to PHPT patients without pancreatitis.

Turning Points in Cross-Disciplinary Perspective of Primary Hyperparathyroidism and Pancreas Involvements: Hypercalcemia-Induced Pancreatitis, MEN1 Gene-Related Tumors, and Insulin Resistance

“…This was a retrospective study on 30 patients admitted for acute pancreatitis caused by primary hyperparathyroidism as the first clinical element compared with 30 individuals diagnosed with the same parathyroid condition but without any pancreas involvement. Arora et al [ 30 ] identified a higher rate of nephrolithiasis within the first group (having an average age at pancreatitis diagnosis of 44.9 ± 13.9 years and a male-to-female ratio of 1.3), a lower rate of bone complications (as prior mentioned data [ 27 ]), and higher serum calcium versus controls. Of note, one patient posed an additional severity due to overlapping pancreatitis and chronic kidney failure, one of the renal complications of longstanding uncontrolled hypercalcemia [ 30 ].…”

“…Arora et al [ 30 ] identified a higher rate of nephrolithiasis within the first group (having an average age at pancreatitis diagnosis of 44.9 ± 13.9 years and a male-to-female ratio of 1.3), a lower rate of bone complications (as prior mentioned data [ 27 ]), and higher serum calcium versus controls. Of note, one patient posed an additional severity due to overlapping pancreatitis and chronic kidney failure, one of the renal complications of longstanding uncontrolled hypercalcemia [ 30 ].…”

“…Seven studies were retrospective [20,[27][28][29][30]32], one was prospective [26], and another was a registry-based cohort [31], for a total of 1375 individuals. The sample size in cohorts primarily confirmed with acute or chronic pancreatitis was 67 [26] of 100 persons [20], while within the studies firstly addressing subjects with primary hyperparathyroidism, there were 35 patients (of note, this was the single study on the pediatric population) [29], 30 persons (compared with 30 hyperparathyroidism-free controls) [30], and 51 individuals [27], for, respectively, larger cohorts of 242 [32], 386 (particularly gestational hyperparathyroidism) [31], and 464 [28] (Table 1).…”

“…In short, according to our methods, we identified nine studies to address the presence of pancreatitis in primary hyperparathyroidism, having as a starting point a population confirmed with parathyroid NETs ( n = 7) or different types of pancreatitis ( n = 2) [ 20 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. Seven studies were retrospective [ 20 , 27 , 28 , 29 , 30 , 32 ], one was prospective [ 26 ], and another was a registry-based cohort [ 31 ], for a total of 1375 individuals.…”

“…In short, according to our methods, we identified nine studies to address the presence of pancreatitis in primary hyperparathyroidism, having as a starting point a population confirmed with parathyroid NETs ( n = 7) or different types of pancreatitis ( n = 2) [ 20 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. Seven studies were retrospective [ 20 , 27 , 28 , 29 , 30 , 32 ], one was prospective [ 26 ], and another was a registry-based cohort [ 31 ], for a total of 1375 individuals. The sample size in cohorts primarily confirmed with acute or chronic pancreatitis was 67 [ 26 ] of 100 persons [ 20 ], while within the studies firstly addressing subjects with primary hyperparathyroidism, there were 35 patients (of note, this was the single study on the pediatric population) [ 29 ], 30 persons (compared with 30 hyperparathyroidism-free controls) [ 30 ], and 51 individuals [ 27 ], for, respectively, larger cohorts of 242 [ 32 ], 386 (particularly gestational hyperparathyroidism) [ 31 ], and 464 [ 28 ] ( Table 1 ).…”