Spontaneous cervical haemorrhage of a parathyroid adenoma
L Ulrich, G Knee, C Todd, Kingston Hospital, London
Haemorrhage of a parathyroid adenoma is a rare clinical presentation. Only thirty similar cases have been reported in the literature, the first of which was identified on autopsy by Capps in 1934 after a fatal parathyroid haemorrhage. As this manner of presentation is so unusual, each patient is presently treated on a case by case basis, rather than a standardised pathway.
This case describes a previously fit and well 54 year old woman who presented with acute neck swelling and pain with an overlying ecchymosis. Admission laboratory tests revealed a raised parathyroid hormone (PTH) and hypercalcaemia. A computed tomography (CT) scan showed widespread anterior cervical haemorrhage and a lesion at the inferior pole of the left thyroid gland. A working diagnosis of spontaneous haemorrhage from a parathyroid adenoma was made. As she was haemodynamically stable, she was treated conservatively with a period of observation in hospital to monitor for signs of neck organ compression.
Follow-up imaging with CT, ultrasound and sestamibi confirmed the likely source of haemorrhage as a parathyroid nodule with significant vascularity. The diagnosis was confirmed on histopathological analysis after elective surgical exploration of the neck six months after her presentation. This revealed a benign parathyroid adenoma with evidence of acute and chronic bleeding. The patient made a full recovery with immediate normalisation of her biochemistry post-operatively. Despite developing a hoarse voice in the immediate post-operative period, this resolved completely within one month.
The diagnosis of spontaneous haemorrhage of a parathyroid adenoma should be considered for all cases of acute cervical swelling or ecchymosis with no precipitating factor. The use of admission serum parathyroid biochemistry and detailed neck imaging in combination with a thorough history are essential for diagnostic work-up. Most importantly, this case provides further evidence to support a minimal delay for elective surgery after conservative management to reduce the risks associated with recurrent bleeding.