TERIPARATIDE [HUMAN PARATHYROID HORMONE (PTH) 1-34] FOR THE MANAGEMENT OF POST-THYROIDECTOMY HYPOCALCEMIA EXACERBATED BY CHYLE LEAK

Authors

  • Ken Seng Chiew
  • Quan Hziung Lim
  • Nicholas Ken Yoong Hee
  • Sharmila Paramasivam
  • Lee Ling Lim
  • Jeyakantha Ratnasingam
  • Shireene Vethakkan

Keywords:

TERIPARATIDE [HUMAN PARATHYROID HORMONE, PTH, POST-THYROIDECTOMY HYPOCALCEMIA, CHYLE LEAK

Abstract

INTRODUCTION/BACKGROUND
Hypocalcaemia secondary to hypoparathyroidism is a common complication of thyroidectomy. Another less common but serious complication is chyle leak which may also lead to electrolyte abnormalities, including hypocalcaemia. We report a case of refractory hypocalcaemia following thyroidectomy complicated by chyle leak which was successfully managed with teriparatide.

CASE
A 37-year-old male had undergone total thyroidectomy with central and left lateral neck dissection for papillary thyroid carcinoma. After the surgery, up to 200 cc/day of milky fluid were noted in his neck drain. Biochemical analysis showed high triglyceride content (2.3 mmol/L), consistent with chyle. He was initially treated conservatively with total parenteral nutrition, pressure dressing and subcutaneous octreotide. On postoperative day (POD) 3, he had symptomatic hypocalcaemia (corrected calcium 1.95 mmol/L). PTH was undetectable (<0.5 pmol/L). However, despite intravenous calcium gluconate infusion, high doses of activated vitamin D and calcium supplements (calcitriol 4.5 mcg/day, alphacalcidol 2 mcg/day and calcium carbonate 6 g/day), his calcium level remained as low as 1.9 mmol/L by POD 10. Subcutaneous teriparatide was then started, titrated up to 20 mcg, bid. This stabilized his corrected calcium at 2.1 mmol/L. On POD 16, the chyle leak was successfully sealed surgically. By POD 19, his calcium level improved to 2.34 mol/L. Subcutaneous teriparatide was discontinued after a course of 14 days. To date, 5 months after his surgery, he is normocalcaemic while on alphacalcidol 2.5 mcg/day and calcium carbonate 3 g/day. His PTH remains undetectable. Chyle leak occurs in 0.5-1.4% of thyroidectomies and 2-8% of neck dissections. As the thoracic duct ends at the junction of the left subclavian and jugular veins, most chyle leaks occur following left neck dissection. About 70% of chyle consist of dietary fats. Hence, asides from calcium, chyle leak also results in loss of dietary fat-soluble vitamins, including vitamin D.

CONCLUSION
Post-thyroidectomy hypocalcaemia due to hypoparathyroidism can be exacerbated by chyle leak, thus necessitating use of parenteral therapy with teriparatide.

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Author Biographies

Ken Seng Chiew

Endocrine Unit, Department of Medicine, University of Malaya Medical Centre, Malaysia

Quan Hziung Lim

Endocrine Unit, Department of Medicine, University of Malaya Medical Centre, Malaysia

Nicholas Ken Yoong Hee

Endocrine Unit, Department of Medicine, University of Malaya Medical Centre, Malaysia

Sharmila Paramasivam

Endocrine Unit, Department of Medicine, University of Malaya Medical Centre, Malaysia

Lee Ling Lim

Endocrine Unit, Department of Medicine, University of Malaya Medical Centre, Malaysia

Jeyakantha Ratnasingam

Endocrine Unit, Department of Medicine, University of Malaya Medical Centre, Malaysia

Shireene Vethakkan

Endocrine Unit, Department of Medicine, University of Malaya Medical Centre, Malaysia

References

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Published

2023-07-06

How to Cite

Chiew, K. S., Lim, Q. H. ., Hee, N. K. Y., Paramasivam, S., Lim, L. L., Ratnasingam, J., & Vethakkan, . S. (2023). TERIPARATIDE [HUMAN PARATHYROID HORMONE (PTH) 1-34] FOR THE MANAGEMENT OF POST-THYROIDECTOMY HYPOCALCEMIA EXACERBATED BY CHYLE LEAK. Journal of the ASEAN Federation of Endocrine Societies, 38(S2), 39–40. Retrieved from https://asean-endocrinejournal.org/index.php/JAFES/article/view/3725

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