Endocrine Abstracts

Background: Primary hyperparathyroidism (PHPT) is usually a mild or asymptomatic condition; however, severe or “florid” cases can lead to life-threatening metabolic disturbances and multi-organ dysfunction. We present a rare instance of extreme PHPT characterised by profound hypercalcemia that was resistant to maximal medical treatment, complicated by bilateral nephrocalcinosis and acute kidney injury (AKI).

Case: A healthy woman in her 30s presented with nausea, vomiting, and general weakness, prompting biochemical analyses that revealed critical hypercalcemia (corrected calcium level of 4.99 mmol/l), significantly elevated parathyroid hormone (PTH) at 107 pmol/l, hypomagnesemia, hypophosphatemia, and acute kidney injury (creatinine level of 179 μmol/l). Imaging studies, including neck ultrasound and MIBI scan, identified a 3.5-cm mixed solid-cystic vascular lesion posterior to the left thyroid lobe, suggestive of a parathyroid adenoma, in addition to a smaller nodule on the right. Renal ultrasound indicated bilateral nephrocalcinosis with cortical calcifications. Despite comprehensive medical management—including intravenous fluids, pamidronate, cinacalcet, magnesium and phosphate supplementation, and vitamin D repletion—persistent hypercalcemia above 3.7 mmol/l led to signs of end-organ damage. Consequently, an urgent inpatient parathyroidectomy was performed, during which a well-defined vascular mass was excised. Histopathological examination confirmed a benign parathyroid adenoma with no evidence of capsular or vascular invasion.

Outcome: Postoperatively, calcium levels were normalised within 48 hs. Transient hypocalcaemia was effectively managed with oral calcium and vitamin D supplementation. Renal function showed improvement, and the patient was discharged with a plan for outpatient endocrine follow-up.

Conclusion: This case underscores the severe complications associated with florid primary hyperparathyroidism (PHPT) in a young adult, the limitations of medical therapy in cases of profound hypercalcemia, and the critical importance of early surgical intervention. A multidisciplinary approach is essential to prevent irreversible renal damage and optimise patient outcomes.