A 56-year-old male with hypercalcemia and osteoporosis

T. Puls, Mvr. M. Ramael, H. Van Steelandt, E. Krznaric, T. Maes and Mr. M. Ramael


Primary hyperparathyroidism affects 22 per 100,000 peo­ple per year with a mean age onset of 56 years. Parathy­roid adenomas account for 80 to 85% of cases of primary hyperparathyroidism. The median weight of parathroid adenoma is 600 mg. In 5% of resected parathyroid adeno­mas the weight is more than 3500 mg and these are des­ignated as giant parathyroid adenomas.


Case Description

A 56-year-old male patient was referred with com­plaints of anorexia, weight loss of 7 kg and fatigue since 7 months. Antecedents of nefrolithiasis were noted. The blood pressure, heart rate and ECG were normal. A blood analysis revealed hypercalcemia (3.11 mmol/l), Phosphor (0.67 mmol/l) and a high PTH level (333.6 ng/l). All other hormonal parameters including prolactin, LH, FSH, testos­teron, cortisol, TSH, FT4, calcitonin and metanefrines were normal as well as the Vitamine D level and creatinin. BMC investigation in the L2–L4 region disclosed a T score of – 1.3 SD indicating osteoporosis.



An ultrasound investigation of thyroid and parathyroids was normal. The parathyroid scintigraphy with single photon emitted tomography (SPECT)/CT demonstrated a preferential MIBI-tracer accumulation after technetium substraction infero-posterior to the right lobe of the thy­roid. Surgical exploration revealed a tumoural mass lat­eral of the right N. Laryngeus recurrens and below the carotid artery. The mass was resected in toto and consisted of brown-dark yellow tissue 4.5 × 2.3 × 1.4 cm, weigh­ing 6000 mg. A frozen section followed by conventional histology confirmed a large parathyroid adenoma, type giant parathyroid adenoma. Histology showed no signs of malignancy suggesting giant parathyroid adenoma.


Take Home Message/Conclusions

Patients with clinical signs of hypercalcemia and early onset osteoporosis should be extensively evaluated including parathyroid scintigraphy as classical ultra-sound investigation can be false negative even in the case of a giant parathyroid adenoma. SPECT-CT with MIBI-Techne­tium substraction scintigraphy is an essential element for evaluating both the morphology of the parathyroid glands as well as the (patho)physiological function of the parathyroid glands.