Management of Primary Hyperparathyroidism in a frail elderly gentleman
Alice Walker, Preeshila Behary, Christopher Kyriacou, Akila De Silva, Neary Nicola, Karim Meeran.
We present a case of an 84 year old frail gentleman who presented with severe hypercalcaemia associated with primary hyperparathyroidism, successfully treated with a minimally invasive parathyroidectomy under local sedation.
Case Report :
This gentleman presented to hospital following a simple fall. He was found incidentally to have a corrected calcium of 3.82mmol/l on a background of prostate cancer. Due to the very high calcium level, the initial assumption was hypercalcaemia of malignancy. However, further investigations revealed a parathyroid hormone level of 94.3pmol/l and vitamin D level of 22.8nmol/l. He was treated with intravenous fluids which led to reduction of calcium to 3.42mmol/l. This was followed with an infusion of Pamidronate 60 mg which was not effective. Cinacalcet 30 mg and Cholecalciferol 20,000 units twice weekly was commenced. The aim at this point was medical rather than surgical management of his primary hyperparathyroidism. It was felt he would be at high risk of a general anaesthesia. On discharge, his calcium level was 2.77mmol/l. However within 3 weeks, his calcium went up to 3.54mmol/l requiring a second admission.
Ultrasound and Sestamibi imaging of the parathyroids were consistent with a lesion posterior to the right thyroid lobe. A DEXA scan confirmed osteoporosis of the spine and hip. He therefore underwent minimally invasive parathyroidectomy under local anaesthesia. His calcium level has since normalised. The histology was consistent with a hyperplastic parathyroid gland.
Although hypercalcaemia usually responds to Cinacalcet and the effect shown to be sustained up to 5 years, there is no improvement observed in bone mineral density (1). Our patient did tolerate Cinacalcet but failed to respond to the drug. Another option for elderly patients is a targeted parathyroidectomy under local anaesthesia (2).
Peacock et al. Cinacalcet treatment of primary hyperparathyroidism: Biochemical and Densitometric outcomes in a five year study. JCEM Dec 2009; 94(12): 4860
Biertho L et al. Image directed parathyroidectomy under local anaesthesia in the elderly. Br J Surg 2003 Jun; 90 (6):738-42