Primary hyperparathyroidism presenting as acute psychosis secondary to hypercalcaemia requiring curative parathyroidectomy

Middle-aged man with primary hyperparathyroidism-associated psychosis: A case report

Background

Primary hyperparathyroidism (PHPT) with mild hypercalcemia (Ca <12 mg/dL) often remains asymptomatic. However, PHPT may induce various psychiatric symptoms, including depression, cognitive dysfunction, and infrequently, psychotic symptoms, predominantly in older adults rather than in middle-aged or younger individuals.

Case‐presentation

A 48-year-old man, with no history of physical or mental illness, experienced delusions about a suspicious car in his neighborhood, believing it was linked to criminal activity. This led to his being taken into custody after harming himself and his family. He was admitted for psychiatric evaluation and diagnosed with PHPT after mild hypercalcemia was discovered. He was initially treated medically for the mild hypercalcemia; however, only his disorientation showed improvement, and his broader psychiatric symptoms persisted. His delusions ceased only after surgical intervention. Following discharge, he remained symptom-free without requiring antipsychotic medication.

Conclusion

This case highlights the importance of considering PHPT in patients of any age presenting with psychosis, even with mild hypercalcemia. Surgical options for patients with PHPT should be considered when medical interventions fail.

Parathyroid Paranoia: Unveiling Psychosis in Hyperparathyroidism

Primary hyperparathyroidism (PHPT) and subsequent hypercalcemia have been reported to be associated with psychosis. Here we report the case of a 28-year-old cannabis using male with his first contact with psychiatric care because of mood instability, bizarre behavior, and poor ability to carry out activities of daily living. Hypercalcemia was identified, and a subsequent endocrine workup confirmed PHPT. After parathyroidectomy, there was no longer any need for antipsychotic or other psychotropic medications; the report emphasizes the importance of considering organic causes, such as hyperparathyroidism, in patients presenting with psychotic-like symptoms, including in the setting of substance use disorder. Prompt recognition and appropriate management of the underlying condition are crucial for optimizing patient outcomes.

Ectopic parathyroid adenoma causing hyperparathyroidism-induced psychosis: A case report

Primary hyperparathyroidism is a disease with multisystemic and heterogeneous manifestations, characterized by underlying high parathormone concentrations. Despite neuropsychiatric involvement being one of the manifestations, psychosis is rare. This is the case of a 68-year-old female with a 10-day clinical course of anorexia, mutism, dysphagia, constipation, and weight loss. The patient had disorganized speech associated with paranoid delusions. Prior to this visit, the patient was recently diagnosed with a mixed anxiety-depressive disorder. For this reason, treatment with antidepressants in combination with atypical antipsychotics was administered without a satisfactory response. Neuroimaging, infectious panel, and toxicology screening showed no abnormal findings. Hypercalcemia secondary to a retropharyngeal ectopic parathyroid adenoma was the causative etiology of her primary hyperparathyroidism, and hypercalcemia treatment resolved the psychotic episode. We highlight the importance of recognizing psychosis as a possible initial presentation of hyperparathyroidism and hypercalcemia. Ruling out organic etiologies prior to diagnosing a primary cause of psychosis is crucial, as their treatment can reverse the psychotic symptoms.

Acute Psychosis Related to Primary Hyperparathyroidism in a Patient With Bipolar Disorder

Primary hyperparathyroidism (PHPT) can cause hypercalcemia secondary to high parathyroid hormone secretion. Hyperparathyroidism- and hypercalcemia-related acute psychotic symptoms can be challenging to diagnose in patients with mental health-related disorders, and it should be considered a possible differential in these patients besides medications. It can sometimes be the first manifestation of the disease, and diagnosis can be challenging, especially in patients with a previous psychiatric history without checking their biochemistry profile. The hypercalcemia severity can vary from mild to severe, and signs and symptoms may also vary depending on the calcium levels. Hypercalcemia can cause neuropsychiatric dysfunction, and patients may present with confusion, agitation, delusions, and hallucinations. We present a case of a 54-year-old patient with a previous history of bipolar disorder and a recent diagnosis of depression and schizophreniform disorder, who presented to the emergency department with acute agitation, violent behavior, and disorientation. She was being managed by the community mental health team at a local behavioral health hospital for new onset psychosis over the past few months. She was refusing blood tests prior to hospital admission. Calcium level on laboratory tests was 3.54 mmol/l, and parathyroid hormone level was 45 pg/ml. She was managed with intravenous fluids initially, followed by zoledronic acid (4 mg intravenously over 15 minutes). She was then commenced on cinacalcet 30 mg twice daily initially, which was later increased to 60 mg twice daily. Ultrasound of the neck demonstrated a large left parathyroid mass, and she underwent left parathyroidectomy as an urgent outpatient. She has remained asymptomatic, and her psychiatry symptoms resolved following parathyroidectomy.

Acute Psychosis in the Setting of Undiagnosed Normocalcemic Hyperparathyroidism: A Case Report

Hyperparathyroidism (HPT) causes an elevation of parathyroid hormone (PTH). This can result in elevated calcium levels, which can cause bone, kidney, muscle, gastrointestinal, and neuropsychiatric symptoms, including psychosis. Our report presents a unique case of an elderly woman who presented to the emergency department in an unconscious state with a working diagnosis of metabolic encephalopathy secondary to sepsis and urinary tract infection. Despite fluids and antibiotic treatment, the patient showed hallucinations. The acuteness of her psychotic episodes prompted the medical team to further investigate the cause of her hallucinations. Additional labs revealed HPT, which she had never been diagnosed with prior to the hospital admission. Our patient's novel clinical presentation revealed elevated PTH and normal calcium levels as the cause of her psychosis. We determined that the normal calcium levels were due to the patient's calcium loss secondary to acute kidney injury. Cinacalcet administration showed resolution of the patients' hallucinations, highlighting the importance of PTH screening even in normocalcemic patients. In this report, we present a rare clinical presentation of acute psychosis in the setting of undiagnosed normocalcemic HPT.

Primary Hyperparathyroidism Causing Psychosis: A Case Report

New-onset psychotic symptoms presenting late in life can be caused by various medical and psychiatric conditions. The index of suspicion for an organic cause for psychotic symptoms in an elderly person should be high, and every presenting patient should undergo a detailed history-taking and evaluation before attributing these symptoms to a primary psychiatric condition. Hyperparathyroidism is one condition that can present with psychiatric symptoms such as low mood and anxiety. While psychiatric symptoms are not uncommon in hyperparathyroidism, acute psychosis is rare. This case report highlights the importance of a thorough evaluation of an elderly person presenting with a new onset of psychosis.

Psychosis in a primary hyperparathyroidism patient with mild hypercalcemia: A case report

INTRODUCTION

Primary hyperparathyroidism (PHPT) is characterized by hypercalcemia and an elevated level of serum parathyroid hormone (PTH). PHPT presents with a complex set of renal, skeletal, and neuropsychological symptoms. Parathyroidectomy (PTX) is a radical treatment that is recommended for all physically symptomatic patients with PHPT. However, psychiatric symptoms are not considered as an indication for surgery. There remains an important issue from the view of perioperative management of whether PTX should be performed with the presence of uncontrolled psychiatric symptoms or deferred until severe psychiatric symptoms have been controlled. We report a case of mild hypercalcemia that caused severe psychosis in PHPT, which improved dramatically following PTX and resulted in successful postoperative management.

PATIENT CONCERN

Our patient was a 68-year-old Japanese woman. She was diagnosed with PHPT, which was triggered by mild hypercalcemia. She was due to receive an operation for osteoporosis and kidney stones. She had severe psychosis, despite medication. Blood examinations revealed mild hypercalcemia (10.4 mg/dL, 8.8-10.1 mg/dL) and elevated serum levels of intact PTH (184.0 pg/mL, 10-65 pg/mL).

DIAGNOSIS

She was diagnosed with severe psychosis caused by mild hypercalcemia in PHPT.

INTERVENTIONS

Although she was treated with 37.5 mg quetiapine and 2 mg risperidone daily, she was excessively sedated and rejected oral treatment. Therefore, we decided to perform the operation.

OUTCOMES

Immediately following surgery, serum levels of calcium, and intact PTH were normalized. Her psychotic symptoms ceased completely 5 days after surgery.

CONCLUSION

We emphasize that PHPT presents with various severe psychiatric symptoms, even in mild hypercalcemia. Psychiatric symptoms may be the only salient symptoms in PHPT, and thus clinicians should suspect PHPT in patients with psychiatric symptoms and mild hypercalcemia. Furthermore, PTX is recommended for PHPT-even in the presence of severe uncontrolled psychiatric symptoms, which carries risks for postoperative management-because psychiatric symptoms are expected to improve and good postoperative management is possible.

PARKINSONISM AS AN ATYPICAL MANIFESTATION OF PRIMARY HYPERPARATHYROIDISM

OBJECTIVE

Primary hyperparathyroidism (PHPT) occurs as a result of hyperfunctional parathyroid glands resulting in an elevation of serum calcium levels. The association between hypoparathyroidism and parkinsonism have been frequently reported in the literature, while evidence of hyperparathyroidism associated with parkinsonism is rare.

METHODS

The present study reports a case of a patient that had PHPT and developed symptoms of parkinsonism.

RESULTS

A 75-year-old female patient with a history of diabetes mellitus, dyslipidemia, and systemic arterial hypertension presented to the emergency room due to unexplained drowsiness. Her serum calcium at the time was 14.2 mg/dL. A cervical ultrasound was performed, and the presence of a 2.5 × 1.9-cm nodule in the left lower parathyroid region was identified. Three days later, scintigraphy with the use of sestamibi showed an increased capture of the marker in the same region, suggesting parathyroid hyperfunction. During hospitalization, the patient developed symptoms of parkinsonism. A left inferior parathyroidectomy was performed, with normalization of serum calcium levels and a remission of drowsiness, in addition to a significant improvement in parkinsonian symptoms. The patient remained free of parkinsonism over 3 years of follow up.

CONCLUSION

Parathyroidectomy can provide a significant remission of parkinsonism in a patient with PHPT. Even though it is rare, the relation between parkinsonism and PHPT exists.

Primary hyperparathyroidism: should surgery be performed on all patients? Current evidence and residual uncertainties

Primary hyperparathyroidism (pHPT) is the third most common endocrine disease and is characterized by hypercalcaemia and elevated or inappropriately 'normal' levels of the parathyroid hormone (PTH). The main target organs of PTH are the skeletal system and the kidneys. Before the 1970s, pHPT was a rarely detected disease associated with notable morbidity and premature mortality. Introduction of biochemical screening, allowing for a wide range of indications, has contributed to the detection of the full spectrum of the disease. A new entity with an isolated elevation of PTH, normocalcaemic HP, has emerged and is currently being explored. The highest incidence of pHPT, 3-5%, is observed amongst women, and the prevalence increases with age. The female-to-male ratio is 3-4 : 1 except in younger patients where distribution is equal and known hereditary causes account for approximately 10% of the cases. In the last few decades, it has become evident that fewer patients than previously believed are truly asymptomatic. The cause of pHPT is often a benign tumour, a parathyroid adenoma, and the only definite treatment is parathyroidectomy (PTX). No medical treatment, single or combined, can achieve a curing of pHPT. Recent data indicate that PTX, despite being proven to be cost-effective compared to conservative treatment, is underutilized, especially in elderly pHPT patients. The decision of PTX should always be based on a safe diagnosis, and the potential benefits of curative treatment should not be outweighed by the risks of surgery or anaesthesia.