General Surgery · Year 3 · from General Surgery

Case 2: Primary Hyperparathyroidism

Patient Demographics

  • Age: 58 years
  • Sex: Female
  • Occupation: Retired nurse

Chief Complaint

"I've been having kidney stones and my bones are getting weaker."

History of Present Illness

The patient was found to have hypercalcemia (calcium 11.4 mg/dL) on routine bloodwork 3 months ago. Further workup revealed elevated PTH. She reports a history of two calcium oxalate kidney stones in the past 3 years, requiring lithotripsy for one. She also had a DEXA scan showing osteoporosis (T-score -2.8 at lumbar spine). She complains of fatigue, mild constipation, and difficulty concentrating ("brain fog") that she attributed to aging. She denies bone pain or fractures.

Past Medical History

  • Nephrolithiasis (2 episodes)
  • Osteoporosis
  • Hypertension
  • GERD

Family History

  • Mother had "calcium problems" and kidney stones
  • No known MEN syndrome

Medications

  • Lisinopril 10 mg daily
  • Omeprazole 20 mg daily
  • Calcium + Vitamin D (recently stopped after hypercalcemia diagnosis)

Physical Examination

  • Vitals: BP 142/88 mmHg, HR 76 bpm
  • General: Well-appearing woman
  • Neck: No palpable masses or nodules
  • Neurological: Alert, oriented, no focal deficits
  • Musculoskeletal: No bone tenderness

Laboratory Results

  • Calcium: 11.2 mg/dL (elevated, normal 8.5-10.5)
  • Ionized calcium: 1.42 mmol/L (elevated)
  • Phosphorus: 2.4 mg/dL (low-normal)
  • PTH: 128 pg/mL (elevated, normal 15-65)
  • 25-OH Vitamin D: 28 ng/mL (normal)
  • Creatinine: 1.0 mg/dL
  • 24-hour urine calcium: 380 mg/day (elevated, normal <250)
  • Calcium/creatinine clearance ratio: 0.018 (>0.01 rules out FHH)

Diagnosis

Primary hyperparathyroidism with end-organ manifestations (nephrolithiasis, osteoporosis)

Localization Studies

Sestamibi Parathyroid Scan with SPECT:

  • Focal uptake in the right inferior parathyroid region
  • Consistent with parathyroid adenoma

Neck Ultrasound:

  • 1.2 x 0.8 cm hypoechoic nodule posterior to right thyroid lobe
  • Consistent with parathyroid adenoma
  • Thyroid appears normal

4D-CT Parathyroid (confirmatory):

  • Right inferior parathyroid adenoma confirmed
  • Other parathyroid glands not enlarged

Surgical Indications

Patient meets criteria for parathyroidectomy:

  1. Symptomatic (kidney stones)
  2. Osteoporosis (T-score <-2.5)
  3. Age <70 with asymptomatic disease would also qualify
  4. 24-hour urine calcium >400 mg (borderline)

Preoperative Preparation

  • Adequate hydration
  • Avoid thiazide diuretics
  • Hold calcium/vitamin D supplements
  • Baseline laryngoscopy: Vocal cords mobile

Operative Procedure

  • Minimally invasive parathyroidectomy (MIP) via focused lateral approach
  • Right inferior parathyroid adenoma identified and excised
  • Intraoperative PTH monitoring:
  • Baseline: 135 pg/mL
  • 10 minutes post-excision: 38 pg/mL (>50% drop - Miami criterion met)
  • Other parathyroid glands not explored given successful PTH drop

Pathology

  • Parathyroid adenoma, 480 mg
  • Benign, no malignant features

Postoperative Course

  • POD 1 calcium: 8.8 mg/dL
  • PTH: 22 pg/mL (normal)
  • Mild perioral tingling (hungry bone syndrome) - treated with calcium supplementation
  • Discharged POD 1 on calcium carbonate 500 mg TID and vitamin D

Follow-up

  • 2 weeks: Calcium 9.2 mg/dL, tolerating calcium taper
  • 3 months: Calcium 9.4 mg/dL, PTH 35 pg/mL, off supplements
  • 1 year: DEXA shows 5% improvement in BMD

Teaching Points

  1. Primary hyperparathyroidism: elevated calcium with inappropriately normal/elevated PTH
  2. "Stones, bones, groans, and psychiatric overtones"
  3. Localization studies identify adenoma location for focused surgery
  4. Intraoperative PTH monitoring confirms successful adenoma removal
  5. MIP reduces operative time, hospital stay, and complications
  6. Hungry bone syndrome: postoperative hypocalcemia due to bone remineralization

Clinical Image

Image Description: Sestamibi parathyroid scan demonstrating focal uptake in the right inferior parathyroid region consistent with a parathyroid adenoma. The delayed images show persistent uptake in the abnormal gland while thyroid uptake has washed out.

Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Parathyroid_glands

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