A rare case of multi-organ failure due to acute Parathyroid crisis
B Inayat, A Iqbal, N Haya, Great Western Hospital NHS Trust Foundation Swindon
Abstract: Parathyroid crisis also described as a parathyroid storm or parathyrotoxicosis, is a rare and life-threatening complication of primary hyperparathyroidism. Parathyroid adenoma and hyperplasia are common causes of primary hyperparathyroidism. Parathyroid cancer can rarely cause primary hyperparathyroidism (0.5%-4%). Atypical parathyroid adenomas, a sub-set of parathyroid neoplasms, with uncertain malignant potential, are also found to be associated with acute and sever hypercalcemia.
Hypercalcemia is severe, usually > 3.5mmol/L with associated signs and symptoms of multi organ dysfunction, including metabolic encephalopathy, renal insufficiency, gastrointestinal symptoms and cardiac dysfunction. Parathyroid crisis requires prompt recognition, immediate medical management of hypercalcemia followed by urgent surgery. Initial management includes aggressive fluid resuscitation, cardiac monitoring and administration of intravenous bisphosphonates.
We present a case of 58 years old man with background of mild learning difficulties, COPD, Ischemic heart disease, depression and high BMI. His medications include Amitriptyline, Aspirin, Docusate, GTN, ISMN, Lisinopril, Mirtazapine, Risperidone, Senna, Simvastatin and Topiramate. He presented to ED with acute confusion, recurrent falls, slurred speech and increased urinary frequency. Systemic examination was unremarkable. CT head and subsequent MRI head ruled out stroke. Laboratory investigations revealed new hypercalcemia of 4.64mmol/L (2.12-2.62), PTH 267pmol/L (1.8-6.8), AKI stage 2, vitamin D 19nmol/L, and Myeloma screen negative.
Parathyroid ultrasound showed a right lower gland adenoma. SPECT CT, was not possible due to high BMI. CT Chest abdomen pelvis showed some coronary artery calcification and 8mm stone in left kidney.
His clinical presentation was thought to be due to acute severe hypercalcemia secondary to aggressive parathyroid cancer. He was placed under close monitoring, and resuscitated with intravenous fluids, loop diuretics, cinacalcet and bisphosphonate.
His clinical and metabolic derangement improved and serum calcium improved to normal level, 2.46mmol/L.
Due to high surgical risk, he was transferred to tertiary centre for parathyroidectomy. A very experienced endocrine surgeon described his surgery challenging due to co-morbidities, and surgical tissue adherent to surrounding structures. Histology confirmed features suggestive of atypical parathyroid adenoma with, occasional tumour cells, but low proliferation activity(<2%). Study of Immunohistochemical markers and epigenetics is underway.