Background: Primary Hyperparathyroidism is mainly produced by an adenoma and it is mostly a benign condition. Most of the patients are asymptomatic. We present a case of ectopic parathyroid cyst presenting with this condition.
Case: A 76 yr female presented with new onset confusion, abdominal pain, vomiting, diarrhoea and dehydration. She was currently being treated for a urinary tract infection. Investigations showed acute kidney injury with creatinine 381 umol/L (4590), eGFR 11(>60). Corrected calcium was 4.2 mmol/L (2.22.6), PTH 241 pmol/L (26.5), 25-OH Vitamin D 76.1 nmol/L (>50). Chest X-ray showed a prominent mediastinum and CT scan of chest revealed a 75×30 mm cyst in the anterior mediastinum, probably in the thymus, with normal lungs and no lymphadenopathy. She was treated with intravenous fluids, antibiotics and bisphosphonate. Her calcium and renal functions improved. Ultrasound neck was normal, 99 TCM SESTAMBI Parathyroid scintigraphy showed ectopic foci in the mediastinum which corresponded to the anterior mediastinal mass. DEXA scan was normal. The mass was excised surgically, histology revealed a parathyroid cyst. Post-operatively her PTH level and calcium levels returned to normal and she is now asymptomatic.
Discussion: Parathyroid crisis is a very rare but a life threatening manifestation of primary hyperparathyroidism in which patients develop severe hypercalcemia with signs and symptoms of multiple organ dysfunction and has mortality approaching 100% in non-operable cases and 20% in cases in which parathyroidectomy is performed. This condition should be suspected in acutely ill patients with profound dehydration, gastrointestinal manifestations, urinary symptoms, altered mental state or cardiac arrhythmias. This report also illustrates how prompt and appropriate management provides the best outcome for the patient. In our case, presence of ectopic parathyroid cyst posed an additional diagnostic challenge.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.