The role of cinacalcet in a patient with persistent hypercalcaemia despite parathyroidectomy

G Mlawa, S Nageshwaran, M Silveira, D Oforiwaah

Queens Hospital Romford, Winchester Hospital, Darent Valley Hospital

Introduction: Parathyroid adenoma is the commonest cause of primary hyperparathyroidism,but 10% of these adenomas can be ectopic, leading to  persistent and recurrent hypercalcaemia.

Case: We present a case of 82 years old man was admitted in June 2011  with increased confusion, slurred speech,poor balance (ataxia). He had no features of sepsis and no other focal neurology. His past medical history included constipation, dry eyes.He was on Aspirin, hypromellose,and laxido.

Blood test:Hb 15.2, WCC 8.3, Na+ 138,K 4.4,Urea 4.9, creatinine 84, ALP 70, Cor ca2+ 3.12, PTH-9.6,phosphate 0.79, ALT 100,Myeloma screen negative,Vitamin D 100,Urine: 24 hour urinary calcium 8.2. Imaging;CXR normal, CT normal, sestamibi scan normal. He underwent  exploratory surgery left sided parathyroidectomy July 2011 with normalisation of calcium levels initially. Normal looking parathyroid tissue  (140g). One month later he had relapse of hypercalcaemia.Readmitted for iv fluids & pamidronate. Staging CT chest,abdomen and pelvis-normal apart right subcarina lymphnode measuring 11mm.He remained hypercalcaemic despite multiple doses of iv pamidronate. He was started on cinacalcet 30mg od daily for presumed ectopic parathyroid adenoma with normalization of calcium.

Discussion: The commonest cause of hypercalcaemia is primary hyperparathyroidism,but hypercalcaemia due to ectopic  parathyroid adenoma although  rare is not uncommon.

Conclusion: Cinacalcet can successful be used to control hypercalcaemia in patients with persistent and recurrent hypercalcaemia due ectopic parathyroid adenoma as demonstrated in this case report.