Background: Primary hyperparathyroidism (PHPT), caused by increased parathyroid hormone (PTH) secretion, leads to generalised disorder of bone metabolism characterised with hypercalcaemia and hypophosphatemia. Causes of PHPT include solitary parathyroid adenoma (80%), primary parathyroid hyperplasia (1015%), and parathyroid carcinoma (12%). Other rare cause is double parathyroid adenomas (DPA) with frequency <12%, which can be sporadic or familial. DPA should be considered for persistent or recurrent PHTP cases.
Case report: A 45-year-old female patient with type 2 diabetes was admitted with weakness, fatigue, and generalized bone pain. She had a history nephrolithaisis five times in the last 2 years. In laboratory examination, serum calcium level was 12.3 mg/dl (8.810.6), phosphorus level was 2.9 mg/dl (2.45.1), albumin level was 4.1 g/dl (3.55.3), PTH level was 237 pg/ml (1288), alkaline phosphatase was 99 IU/l (60105 IU/l), 25-OH vitamin D level was 6.4 ng/ml (2030 ng/ml), 24-h urine calcium was 483 mg/day, creatinine clearance was 75 ml/min, and prolactin level was 26 ng/ml (526 ng/ml). I.v. saline and furosemide treatment was administered. Bone densitometry measurement was showed osteoporosis. Neck ultrasound imaging revealed no abnormality in the thyroid gland with bilateral smooth, ovoid, hypoechoic lesion considered parathyroid adenomas at inferior contiguity of thyroid gland in size of 15×11×8 mm on the right and 18×12×7 mm on the left side. Tc99m-MIBI scan detected parathyroid adenoma in the lower part of the left thyroid lobe consistent with radioactivity uptake, while in the lower part of the right thyroid was suspicious. PTH level from fine needle aspiration material of parathyroid washout was measured 2097 pg/ml from the right side and 1989 pg/ml from left side. Hence, bilateral minimally invasive parathyroidectomy was intended to be performed, but the surgeon saw a third adenoma at retrosternal location by using intraoperative ultrasonography (US), all were removed and pathology report was consistent with parathyroid adenoma.
Conclusion: Intraoperative parathyroid evaluation by US plays an important role preventing patient from unnecessary surgery.