MANAGING A YOUNG MALE WITH PRIMARY HYPERPARATHYROIDISM PRESENTING WITH SEVERE HYPERCALCAEMIA IN A DISTRICT HOSPITAL

A CASE REPORT

Abstract

INTRODUCTION/BACKGROUND
Primary hyperparathyroidism (PHPT) is characterized by hypercalcemia with an inappropriately elevated intact parathyroid hormone level (iPTH). Clinical presentation may range from asymptomatic to severe symptomatic hypercalcemia with complications such as osteoporosis, fracture and renal stones.

CASE
A 31-year-old male was admitted following a motor vehicular accident where he sustained a fracture over the midshaft of the left ulnar and radial bones. On further history, he had experienced right hip and bilateral knee pain in the past 3 months prior to the accident. During this admission, his serum calcium was elevated at 4 mmol/L with a low phosphate level at 0.65 mmol/L. His PTH level was markedly elevated (858 pg/ml). Renal profile, vitamin D level and liver function test were normal. X-ray of bilateral knee joint and hip was suggestive of generalized osteopenia. He required several admissions for severe refractory hypercalcemia managed with bisphosphonate and hyperhydration. Ultrasound of the parathyroid revealed a homogenous hypoechoic lesion at the right posterior thyroid lobe measuring 0.9 x 2.1 x 2.8 cm. Preoperatively, he was given hyperhydration along with furosemide and cinacalcet to achieve a target calcium level of 3 mmol/L. He successfully underwent a right inferior parathyroidectomy. Histopathological examination revealed a right parathyroid adenoma. Post-operatively, the patient required calcium infusion and was able to be discharged with a calcium supplement and active vitamin D. Solitary parathyroid adenoma accounts for the majority of primary hyperparathyroidism followed by multiple gland hyperplasia and less commonly, parathyroid carcinoma. The definitive treatment is parathyroidectomy. Our patient fulfilled the criteria for surgery and successfully underwent total parathyroidectomy at our district hospital by a visiting endocrine surgeon. Intra-operative PTH monitoring was not done as it was not available at our centre. Genetic testing should be considered in this case because PHPT was diagnosed below the age of 40.

CONCLUSION
Primary hyperparathyroidism presenting with severe refractory hypercalcemia warrants immediate treatment in order to prevent complications from hypercalcemia. In addition to hyperhydration and bisphosphonate, cinacalcet is another option to reduce calcium levels in PHPT.