Primary Hyperparathyroidism is known to present with protean manifestations leading to misdiagnosis in the initial stages of the disease. In the developing world, most of the cases are detected late when they manifest with severe symptomatic metabolic bone disease or renal stones. Distal Renal Tubular Acidosis is a rare complication of primary hyperparathyroidism and should be looked for, in cases presenting with nephrolithiasis. Nuclear scintigraphy accurately localizes the tumor in most of the cases and plays a major role in localizing ectopic parathyroid gland adenoma. High index of suspicion, diligent preoperative preparation and expert surgical management can yield good results with minimum residual morbidity. We present our experience of 45 symptomatic cases of primary hyperparathyroidism encountered over the past decade with special emphasis on their unusual manifestations.