• Users Online: 185
  • Print this page
  • Email this page


 
 
Table of Contents
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 4  |  Page : 232-233

Parathyroid crisis: Delayed diagnosis


1 Department of Surgery, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
2 Department of Orthopaedics, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
3 Department of ENT, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
4 Department of Endocrinology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India

Date of Web Publication5-Dec-2018

Correspondence Address:
Krishnan Swaminathan
Department of Endocrinology, Kovai Medical Center and Hospital, Coimbatore - 641 014, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_75_18

Rights and Permissions
  Abstract 


Parathyroid crisis is a rare endocrine emergency, but such presentations do happen in this day and age. It is imperative for clinicians to have low threshold for measuring serum calcium in any one with unexplained skeletal symptoms and lethargy.

Keywords: Calcium, emergencies, parathyroid


How to cite this article:
Das A, Babu V L, Dhiwakar M, Swaminathan K. Parathyroid crisis: Delayed diagnosis. Apollo Med 2018;15:232-3

How to cite this URL:
Das A, Babu V L, Dhiwakar M, Swaminathan K. Parathyroid crisis: Delayed diagnosis. Apollo Med [serial online] 2018 [cited 2018 Dec 15];15:232-3. Available from: http://www.apollomedicine.org/text.asp?2018/15/4/232/246900




  Introduction Top


Parathyroid crisis or parathyroid storm is a rare but potentially fatal complication of primary hyperparathyroidism. Primary hyperparathyroidism is often easily misdiagnosed or overlooked as symptoms of hypercalcemia are generally nonspecific and not as straightforward as the medical college mnemonic “stones, bones, abdominal moans, or psychic groans.” We report a case of parathyroid crisis that highlights the importance of including hypercalcemia in the differential diagnosis in patients presenting with atypical symptoms.


  Case Report Top


A 41-year-old previously fit female presented with a 3-year history of severe body aches, bone pain, and gradually decreasing mobility to the extent that she was practically bedbound. Multiple specialists had seen her over the 2-year period including rheumatologists, neurologists, orthopedicians, and physiotherapists in different hospitals. The “branded” diagnosis was severe rheumatoid arthritis, for which was given multiple doses of steroids with worsening symptoms and confusional state. Examination revealed a patient in severe distress with the classical “bones, abdominal moans, and psychic groans” (no stones).

Laboratory investigations revealed severe hypercalcemia with corrected calcium of 17.5 mg/dl (normalized ratio [NR]: 8.5–10.2 mg/dl), serum parathormone in excess of 3000 pg/l (NR: 10–65 pg/ml), and a grossly elevated alkaline phosphatase. Radiological parameters revealed radiolucency with osteoporotic fractures of left humerus and left proximal and distal femur on X-rays. Computed tomography scan of the knees showed distal femur fracture with classic lytic lesions [Figure 1]. Ultrasound of the neck showed a large right superior parathyroid adenoma which was confirmed on Sestamibi scan [Figure 1]. There was no evidence of internal malignancy. She underwent a parathyroidectomy, and histopathology was confirmatory of large parathyroid adenoma with no evidence of malignancy. As expected, she had a brief period of severe hypocalcemia postoperatively (hungry bone syndrome) but recovered well with no sequelae. The fractures were conservatively managed, and by 4 weeks, she was pain free, within 3 months, she was able to weight bear with walkers, and by 5 months, she walked into our clinic unaided with radiological evidence of bone healing.
Figure 1: (a and b) Severe lytic lesions in the distal femur, and Sestamibi scan showing a large right superior parathyroid adenoma

Click here to view



  Discussion Top


We report a case of severe life-threatening parathyroid crisis due to a large parathyroid adenoma missed over a period of 2 years by a number of specialists. Identification and successful surgical management of the parathyroid adenoma not only led to a complete resolution of symptoms and mobility without any need for orthopedic intervention for the severe parathyroid bone disease, but also probably saved her life. One wonders whether parathyroid crisis in this day and age of easily available low-cost calcium testing is a crisis of specialization, similar to the parable of the blind men and elephant, rather than a crisis of the parathyroid.

Our patient never had a calcium level checked for 3 years in spite of worsening symptoms. While primary hyperparathyroidism was increasingly detected since the advent of automated calcium analyzers about three decades ago, this condition is at risk of becoming a forgotten entity due to the appearance of random access analyzers, which allow selective analysis of chemistries.[1] However, even in tertiary referral centers where calcium is routinely tested, primary hyperparathyroidism seems to be significantly missed. In a study of 2.7 million patients from a referral center who had their calcium levels screened as outpatients, 2% had hypercalcemia. Even after identifying hypercalcemia, 67% of those patients never had a parathormone level measured. It was estimated that this would have missed 28% of primary hyperparathyroidism.[2]

Parathyroid crisis is a rare endocrine emergency, with a couple of long-term studies estimating the risk of 1%–2% in those with known primary hyperparathyroidism.[3],[4] The crisis is characterized by severe hypercalcemia with calcium values >15 mg/dl and central nervous symptoms as in our case. Patients from India with primary hyperparathyroidism seem to present at a younger age and have more severe biochemical abnormalities with predominant skeletal symptoms in >50% of patients.[5] It is imperative therefore to routinely check serum calcium at least in those who present with bone pain in the Indian subcontinent so that cases like the ones presented in this case report can be avoided. Our case highlights the need for all specialists to do the “internist hat” in difficult nonresponsive cases to ensure that easily treatable conditions are not missed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Salinas M, López-Garrigós M, Pomares F, Lugo J, Asencio A, López-Penabad L, et al. Serum calcium (S-ca), the forgotten test: Preliminary results of an appropriateness strategy to detect primary hyperparathyroidism (pHPT). Bone 2013;56:73-6.  Back to cited text no. 1
    
2.
Press DM, Siperstein AE, Berber E, Shin JJ, Metzger R, Monteiro R, et al. The prevalence of undiagnosed and unrecognized primary hyperparathyroidism: A population-based analysis from the electronic medical record. Surgery 2013;154:1232-7.  Back to cited text no. 2
    
3.
Corlew DS, Bryda SL, Bradley EL 3rd, DiGirolamo M. Observations on the course of untreated primary hyperparathyroidism. Surgery 1985;98:1064-71.  Back to cited text no. 3
    
4.
Scholz DA, Purnell DC. Asymptomatic primary hyperparathyroidism 10-year prospective study. Mayo Clin Proc 1981;56:473-8.  Back to cited text no. 4
    
5.
Bhadada SK, Arya AK, Mukhopadhyay S, Khadgawat R, Sukumar S, Lodha S, et al. Primary hyperparathyroidism: Insights from the Indian PHPT registry. J Bone Miner Metab 2018;36:238-45.  Back to cited text no. 5
    


    Figures

  [Figure 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed27    
    Printed2    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal