Objective: The aim of this article is to acknowledge coexistence of primary hyperparathyroidism, Cushings syndrome in a patient with previous history thyrotoxicosis treated with radioiodine. The presentation may be another variant of multiple endocrinal neoplasias.
Is there a role of previous radioiodine therapy?
Case report: A 67-year-old lady with past history of thyrotoxicosis treated with radioiodine. Now hypothyroid on thyroxine replacement presented with tiredness, generalised aches & pains and hypercalcaemia. No family history of endocrine disorder.
Investigation: Ca 2.76 mmol/l with raised PTH 15.6 pmol/l, normal renal function confirmed diagnosis of primary hyperparathyroidism.
Dexa scan showed osteoporosis.
Renal ultrasound and CT scan: renal stone and 5.2×6.1 cm right adrenal tumour and 1×1.4 cm left adrenal tumour.
3×24 h urinary cortisol levels were 394, 240 & 248 (10147 nmol/l) found to be raised.
Low and high dexamethasone suppression test failed to suppress cortisol which confirms Cushings syndrome.
ACTH <5 ng/l.
Gonadotrophins, oestrogen, testosterone, GH, IGF, prolactin, aldosterone rennin ratio and 24 urinary catecholamines were normal.
She had right adrenalectomy which cured her Cushings syndrome and currently she is on replacement steroids waiting for recovery of other adrenal gland. Now she is waiting for parathyroid surgery.
Conclusion: MEN type 1 is characterized by benign tumours of parathyroid, pituitary, islet cell of pancreas. Cushings syndrome from adrenocortical adenoma is extremely rare in MEN type 1. Occurrence of Cushings syndrome with thyrotoxicosis or hyperparathyroidism is recognized before. Our case with all the 3 endocrine disorders with non functioning adenoma of left adrenal gland may be unusual variant of multiple endocrine disorders. Previous treatment of hyperthyroidism with radioactive treatment is recognized as a cause of parathyroid adenoma as in our patient. Should the thyrotoxic patients treated with radioiodine be kept under regular surveillance so that hyperparathyroidism could be diagnosed early?