Hyperparathyroidism with hypercalcaemia in chronic kidney disease: primary or tertiary?

Effects of microplastic exposure on the blood biochemical parameters in the pond turtle (Emys orbicularis)

The accumulation of microplastics (MPs) is a growing problem in aquatic ecosystems. Despite increased research on MPs in the last decade, their potential threat to freshwater ecosystems remains an open question. In the present study, the negative impacts of MPs were investigated on blood biochemical parameters in the European pond turtle (Emys orbicularis). Pond turtles were distributed into three experimental groups (n = 9 for each group) and were fed diets containing 250, 500, and 1000 mg MPs (PE100 polyethylene) per kg of food for 30 days, and a control group fed with a standard uncontaminated diet. The results indicated that exposure to 500 and 1000 mg kg^-1 MPs caused a significant increase in the activities of alanine and aspartate aminotransferases, and in the levels of cholesterol, glucose, creatinine, urea, and calcium (Ca⁺²) compared with the control group. On the contrary, the activity of gamma-glutamyl transferase and the levels of total protein, albumin, total immunoglobulins, and phosphorus were significantly reduced in E. orbicularis exposed to 500 and 1000 mg kg^-1 MPs when compared with the controls. In all the MP-exposed groups, the activity of lactate dehydrogenase and globulin and magnesium (Mg⁺²) levels were significantly reduced; while creatine phosphokinase and alkaline phosphatase activities were increased with respect to the control turtles. A significant decrease in triglyceride levels was reported in E. orbicularis exposed to 1000 mg kg^-1 MPs. MPs intake induced notable alterations in blood biochemical parameters of E. orbicularis. These results suggest that changes in the blood biochemical parameters could be an appropriate bio-indicator to evidence the existence of tissue damage in E. orbicularis.

[Adenoma of the parathyroid gland in a young woman with chronic kidney disease: primary or tertiary hyperparathyroidism?]

Clinical observation of a young woman with chronic kidney disease IV stage and hyperparathyroidism is presented. Ultrasound and99mTc-sestamibi scintigraphy of the anterior surface of the neck visualized a tumor of the left upper parathyroid gland. In a histological examination of distant education was diagnosed a solid parathyroid adenoma. The difficulty of differential diagnosis between primary and secondary/tertiary hyperparathyroidism in chronic kidney disease is discussed.

Rare Imaging Findings of Concomitant Presence of Multiple Parathyroid Adenomas and Carcinoma in a Chronic Kidney Disease Patient with Tertiary Hyperparathyroidism Detected on 99mTc-Sestamibi Single-Photon-Emission Computed Tomography/Computed Tomography Scintigraphy

Parathyroid carcinoma (PC) is a rare endocrine carcinoma. It is one of the rare causes for primary hyperparathyroidism. It is very uncommon in individuals with secondary or tertiary hyperparathyroidism. We report a rare case of 53-year-old male, a known case of chronic kidney disease on dialysis, who presented with fatigue and muscle cramps. Lab reports revealed elevated parathyroid hormone (PTH) and serum calcium levels. ^99mTc-Sestamibi single-photon-emission computed tomography/computed tomography scintigraphy showed 4 foci of increased tracer uptake with retention, suggestive of parathyroid adenomas, including two ectopic foci in the mediastinum. At surgery, the enlarged bilateral superior, left inferior parathyroid gland, and two calcified left superior mediastinal lesions were removed. Histopathology revealed parathyroid adenomas in the right superior, left inferior, supernumerary ectopic left superior mediastinum lesion and PC in the left superior parathyroid lesion. Intraoperative serum PTH became normal, and the patient is asymptomatic now.

Adrenal crisis presented as acute onset of hypercalcemia and hyponatremia triggered by acute pyelonephritis in a patient with partial hypopituitarism and pre-dialysis chronic kidney disease

A 57-year-old woman with pre-dialysis chronic kidney disease (CKD) was hospitalized because of fever and fatigue. On admission, increased inflammatory response and pyuria with bacteriuria were observed. Pyelonephritis was successfully treated with antibiotics, whereas her fatigue continued and she developed progressive hypercalcemia and hyponatremia; serum sodium level, 116 mEq/L and corrected serum calcium level, 13.4 mg/dL. Plasma concentrations of adrenocorticotropic hormone and cortisol and serum luteinizing hormone were under the detection level. Although the reaction of other anterior pituitary hormones and the serum antidiuretic hormone (ADH) was preserved, the response of serum luteinizing hormone to administration of luteinizing hormone releasing hormone was impaired. Magnetic resonance imaging showed no structural abnormality in the thalamus, hypothalamus, and pituitary gland. She was diagnosed with adrenal insufficiency caused by partial hypopituitarism in concomitant with pyelonephritis. After starting hydrocortisone replacement, serum levels of sodium and calcium were rapidly normalized. This case highlights the importance of adrenal insufficiency as a differential diagnosis of hypercalcemia in patients with pre-dialysis CKD, especially when hyponatremia was concomitantly observed. Besides, infection should be considered as an important trigger for the development of latent adrenal insufficiency since it could increase the physiological demand of corticosteroid in the body. Also, CKD may enhance the magnitude of hypercalcemia since CKD patients have decreased capacity to increase urinary calcium excretion.