Challenging investigations in the diagnostic workup: a clinical perspective

Louise Apperley; Ramya Gokul; Nagabhushan Seshadri; Nick Airey; Neil Houghton; Samantha Goh; Renuka Ramakrishnan

doi:10.1530/endoabs.111.P132

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Endocrine Abstracts (2025) 111 P132 | DOI: 10.1530/endoabs.111.P132

BSPED2025 Poster Presentations Miscellaneous/Other 2 (9 abstracts)

Challenging investigations in the diagnostic workup: a clinical perspective

Louise Apperley ¹ , Ramya Gokul ¹ , Nagabhushan Seshadri ² , Nick Airey ² , Neil Houghton ² , Samantha Goh ¹ & Renuka Ramakrishnan ¹

Author affiliations

¹Alder Hey Children’s Hospital, Liverpool, United Kingdom; ²Royal Liverpool University Hospital, Liverpool, United Kingdom

Introduction: Secondary hyperparathyroidism is commonly seen in adults, but less often reported in paediatric patients, with chronic kidney disease, which leads to tertiary hyperparathyroidism following a renal transplant. It is thought to be secondary to parathyroid hyperplasia or downregulation of the calcium-sensing or vitamin D receptors. Increased age, phosphate and parathyroid hormone (PTH) levels pre-transplant are risk factors for persistent hyperparathyroidism. This leads to hypercalcaemia, hypophosphatemia, reduced graft function and growth concerns and therefore needs appropriate investigation and management.

Case Report: A 10-year-old boy with a background of a renal transplant secondary to bilateral renal dysplasia, autism spectrum disorder (ASD) and nasogastric feeding was admitted with hypercalcaemia due to hyperparathyroidism (Table1). The patient was treated with hyperhydration and low calcium diet. Neck ultrasound showed no parathyroid masses, and renal ultrasound showed no nephrocalcinosis. On stopping intravenous fluids and restarting standard diet his calcium increased again. Cinacalcet was commenced and increased in increments (Table1). The possibility of a parathyroid adenoma needed investigating. Magnetic Resonance Imagining and a Sestamibi scan were considered but were not ideal imaging modalities due to lower sensitivities and long imaging time under general anaesthetic (GA) due to his neurodivergence. An 18F Choline Positron Emission Tomography-Computed Tomography (PET-CT) was performed under GA. The scan clearly highlighted bilateral parathyroid hyperplasia. A multidisciplinary team have advised removal of all four parathyroid glands with auto transplantation.

Table 1: Biochemistry trend and medication changes
	Corrected Calcium (2.15- 2.74) mmol/l	PTH (1.1-6.9) pmol/l)	Phosphate (0.97-1.94) mmol/l	Vitamin D (>50nmol/l)	Urea (2.3-6.4) mmol/l	Creatinine	u.Ca/create (0-0.60) mm/mm Cr
At diagnosis	3.04	16.4	1.05	91	6.6	68	1.08
On Cinacalcet	2.36	13.5	1.19	98	7.6	76	x

Conclusion: 18F Choline PET-CT is a specialised scan with high sensitivity in detecting parathyroid adenomas. It is only available in our local adult hospital, which was challenging to organise in our patient, but very successful in identifying the lesions. It is important to diagnose tertiary hyperparathyroidism in these patients by using high sensitivity modalities such as Choline PET-CT and initiate appropriate management to optimise bone biochemistry, graft function, bone health and growth.