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.
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.