We present a 20-year-old lady who was known to have MEN-1 and had previously been treated for hyperparathyroidism at a different hospital in 2003 with excision of right upper and lower and left lower parathyroid glands and left thyroid lobectomy, resulting in normalisation of adjusted calcium (adjCa) levels.
She presented to our department with persistently elevated adjusted calcium levels (adjCa 2.69 mmol/l) along with raised parathyroid hormone (PTH 16 pmol/l) and low total vitamin D levels (14.2 nmol/l). She was also roughly 8 weeks pregnant at this stage. Correction of her vitamin D deficiency did not improve her biochemistry and in July 2010 she was now 15 weeks pregnant with adjCa 2.86 mmol/l, PTH 10.6 pmol/l and total vitamin D 139 nmol/l. An ultrasound of her neck demonstrated a normal right thyroid lobe and no masses and a foetal anatomy scan was normal other than a possibility of a hyper echoic bowel.
After discussion with the radiology department she had an MRI of her neck and thorax which demonstrated a solitary parathyroid adenoma in the lower pole of the right lobe of the thyroid, likely to be an ectopic PTH adenoma. A focussed neck ultrasound confirmed a uniformly echo poor lesion measuring 16 mm×7 mm with blood flow within it. Fluid aspirated from the nodule under ultrasound guidance had elevated PTH levels (280 pmol/l) consistent with an ectopic PTH adenoma. The lesion was excised during her second trimester and post-operatively her biochemistry normalised (adjCa 2.39 mmol/l, PTH<0.3 pmol/l).
This case illustrates the need for long term monitoring and follow up of MEN patients. It was complicated further by pregnancy, and careful choice of imaging enabled prompt diagnosis and treatment to minimise foetal complications of hypercalcaemia.