Endocrine Abstracts

Primary hyperparathyroidism causing symptomatic hypercalcaemia is often encountered in clinical practice. However, hyperparathyroid crisis is a rare and potentially fatal presentation of primary hyperparathyroidism characterised by profoundly symptomatic hypercalcaemia, altered mental status, and cardiac and renal dysfunction. Recognising the need for rapidly controlling hypercalcaemia with aggressive medical therapy and definitive management with early parathyroidectomy are necessary to reduce morbidity and mortality. A 89-year-old man presenting with six weeks history of lethargy, polyuria, polydipsia, confusion and acute kidney injury was found to have raised serum calcium of 3.5 mmo/l (2.10-2.58), suppressed serum phosphate and highest parathyroid hormone (PTH) level of 178.2 pmol/l (1.6-6.9). An ultrasound neck revealed 3.5 cm hypoechoic likely parathyroid neoplasm in the right inferior thyroid pole. He was aggressively treated with intravenous fluids, cinacalcet and intravenous bisphosphonates. Due to refractory symptomatic hypercalcaemia, suspected parathyroid carcinoma and need for withholding anticoagulant, calcitonin was used as a bridging therapy allowing safe and early parathyroidectomy on 14th day of admission. An enlarged superior parathyroid located posterior to recurrent laryngeal nerve and adherent to surrounding structures was removed successfully under local anaesthesia. It resulted in complete resolution of hypercalcaemia and associated symptoms and electrolyte abnormalities. His PTH reduced to 1.2 pmol/l on 3rd and calcium to 1.94 mmol/l on 5th day post-surgery, the later treated with oral calcium and alfacalcidiol. On histopathologic examination, the parathyroid specimen showed multiple fragments with an encapsulated zone of proliferation, compressed normal parathyroid tissue focally in the peripheral regions and no evidence of complete capsular transgression or vascular invasion. These features are suggestive of parathyroid adenoma; immunohistochemical examination is pending. Our case demonstrates challenges of managing hyperparathyroid crisis. Aggressive control of hypercalcaemia, with multiple therapeutic agents, and definitive management with early parathyroidectomy after optimising patient’s condition are crucial for a successful outcome.