Severe hypercalcaemia presenting with acute abdominal pain: learning from two cases of primary hyperparathyroidism

Helen Couch; Benjamin Fisher; Emile Hendriks; Sandra Walton-Betancourth; Ajay Thankamony

doi:10.1530/endoabs.111.P140

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Endocrine Abstracts (2025) 111 P140 | DOI: 10.1530/endoabs.111.P140

BSPED2025 Poster Presentations Miscellaneous/Other 3 (8 abstracts)

Severe hypercalcaemia presenting with acute abdominal pain: learning from two cases of primary hyperparathyroidism

Helen Couch , Benjamin Fisher , Emile Hendriks , Sandra Walton-Betancourth & Ajay Thankamony

Author affiliations

Cambridge University Hospital, Cambridge, United Kingdom

Background: Primary hyperparathyroidism (PHPT) is rare in children, with an estimated incidence of 2–5 per 100,000. Hypercalcaemia presents with non-specific symptoms, often resulting in delayed diagnosis. Children typically manifest more severe biochemical and clinical features than adults, including nephrocalcinosis and marked skeletal involvement at presentation.

Aim: To describe the presentation, clinical features, management, and outcomes of two paediatric cases of PHPT.

Clinical cases: Both cases presented to the emergency department with a short history of acute abdominal pain. Blood tests revealed marked hypercalcaemia and elevated parathyroid hormone levels (Table 1). Ultrasound imaging identified solitary parathyroid enlargement in both cases. Case 1 received furosemide and hyperhydration with good effect, whereas Case 2 had concurrent acute kidney injury and hyperhydration-resistant hypercalcaemia. She therefore received pamidronate reducing serum calcium to 3.10 mmol/l. Both underwent parathyroidectomy with histological confirmation of adenoma. Post-operatively, Case 1 achieved normocalcaemia. Case 2 developed symptomatic hypocalcaemia with a fall in PTH levels (1.17 pmol/l), managed with oral calcium supplementation. Case 2’s chronic knee pain and headaches resolved post-operatively. Multiple endocrine neoplasia gene panels were negative.

Table 1. Clinical and biochemical case comparison
Parameter	Case 1	Case 2
Sex, Age	Female, 12 years	Female, 14 years
Presenting complaints	48 hours of abdominal pain, polyuria, polydipsia, lethargy	6 hours of abdominal pain
Medical history	Constipation, learning difficulties	Chronic headache, knee pain
Adjusted Calcium (2.25–2.69 mmol/l)	3.44	3.94
Parathyroid Hormone (1.95–8.49 pmol/l)	23.11	79.18
25OH Vitamin D (>50 nmol/l)	36.0	30.2
Urinary Calcium 24h (2.50–7.50 mmol/24h)	-	14.54
Serum Creatinine (35–65 umol/l)	39	91
Parathyroid ultrasound	Right superior node enlarged (11 × 5 × 7 mm)	Left superior node enlarged (22 ×6 × 12 mm)
Acute management	Hyperhydration, furosemide	Hyperhydration, pamidronate
Parathyroidectomy timing	Day 4	Day 10
Post-operative adjusted calcium ( mmol/l)	2.16	1.84
Post-operative course	Uncomplicated	Hungry bone syndrome

Conclusion: PHPT, though rare in children, often presents with acute abdominal pain. Early recognition, multidisciplinary care, and definitive parathyroidectomy are essential to prevent long-term complications. Clinicians should remain vigilant for hungry bone syndrome post-operatively. These cases prompted the development of a local paediatric hypercalcaemia guideline.