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Van de Kerkhof J, Bijnens J, De Geeter F, Dick C, De Paepe P, Van den Bruel A. Parathyroid adenoma apoplexy mimicking a thyroid bleeding cyst: a seemingly innocent condition that can be life-threatening. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0385. [PMID: 38064892 PMCID: PMC10762588 DOI: 10.1530/edm-22-0385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/07/2023] [Indexed: 01/05/2024] Open
Abstract
Summary Primary hyperparathyroidism most commonly presents with hypercalcaemia. Rarely, parathyroid apoplexy or haemorrhage mimicking a thyroid bleeding cyst is the first presentation of a parathyroid adenoma. A woman presented with a sudden-onset painful 'goitre'. Ultrasound showed a cystic nodule located posterior to rather than in the right thyroid lobe, suggesting parathyroid adenoma bleeding. Biochemistry showed mild primary hyperparathyroidism. 99mTc-pertechnetate/sestamibi showed no uptake in the nodule, which was interpreted as a cold thyroid nodule. 18F-fluorocholine PET/CT showed uptake in the nodule, suggestive of a parathyroid adenoma. Persistent mild primary hyperparathyroidism complicated by nephrolithiasis and osteopenia favoured parathyroidectomy over a wait-and-see approach. The patient was referred for parathyroidectomy along with right thyroid lobectomy. Pathology showed an adenoma, with an eccentrically located cystic structure filled with red blood cells surrounded by a thickened fibrous capsule. In conclusion, cervical pain/haemorrhage with hypercalcaemia points to the diagnosis of parathyroid apoplexy, mimicking a thyroid bleeding cyst. Workup with ultrasound and, if available, 18F-choline PET/CT allows for timely surgery, minimizing the risk of recurrent and severe bleeding. Learning points A bleeding cyst may be located posterior to rather than in the thyroid, suggesting a parathyroid haemorrhage. Neck pain and/or haemorrhage along with primary hyperparathyroidism point to parathyroid apoplexy. A two-step presentation has been described, with a first phase of local symptoms to be followed by visible and possibly life-threatening compressing bleeding. Therefore, an expedited workup is needed, allowing for timely surgery.
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Affiliation(s)
| | - Jacqueline Bijnens
- Department of ENT, H&N Surgery, General Hospital Sint-Jan, Bruges, Belgium
| | - Frank De Geeter
- Department of Nuclear Medicine, General Hospital Sint-Jan, Bruges, Belgium
| | - Catherine Dick
- Department of ENT, H&N Surgery, General Hospital Sint-Jan, Bruges, Belgium
| | - Pascale De Paepe
- Department of Anatomopathology, General Hospital Sint-Jan, Bruges, Belgium
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Han YZ, Zhou Y, Peng Y, Zeng J, Zhao YQ, Gao XR, Zeng H, Guo XY, Li ZQ. Difficult airway due to cervical haemorrhage caused by spontaneous rupture of a parathyroid adenoma: A case report. World J Clin Cases 2023; 11:1217-1223. [PMID: 36874418 PMCID: PMC9979279 DOI: 10.12998/wjcc.v11.i5.1217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Cervical haemorrhage due to spontaneous rupture of a parathyroid adenoma is a rare complication that may cause life-threatening acute airway compromise.
CASE SUMMARY A 64-year-old woman was admitted to the hospital 1 day after the onset of right neck enlargement, local tenderness, head-turning difficulty, pharyngeal pain, and mild dyspnoea. Repeat routine blood testing showed a rapid decrease in the haemoglobin concentration, indicating active bleeding. Enhanced computed tomography images showed neck haemorrhage and a ruptured right parathyroid adenoma. The plan was to perform emergency neck exploration, haemorrhage removal, and right inferior parathyroidectomy under general anaesthesia. The patient was administered 50 mg of intravenous propofol, and the glottis was successfully visualised on video laryngoscopy. However, after the administration of a muscle relaxant, the glottis was no longer visible and the patient had a difficult airway that prevented mask ventilation and endotracheal intubation. Fortunately, an experienced anaesthesiologist successfully intubated the patient under video laryngoscopy after an emergency laryngeal mask placement. Postoperative pathology showed a parathyroid adenoma with marked bleeding and cystic changes. The patient recovered well without complications.
CONCLUSION Airway management is very important in patients with cervical haemorrhage. After the administration of muscle relaxants, the loss of oropharyngeal support can cause acute airway obstruction. Therefore, muscle relaxants should be administered with caution. Anaesthesiologists should pay careful attention to airway management and have alternative airway devices and tracheotomy equipment available.
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Affiliation(s)
- Yong-Zheng Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
- Beijing Center, Quality Control and Improvement on Clinical Anesthesia, Beijing 100191, China
| | - Yang Zhou
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
- Beijing Center, Quality Control and Improvement on Clinical Anesthesia, Beijing 100191, China
| | - Ying Peng
- Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Jin Zeng
- Department of Otorhinolaryngology Head and Neck Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Yu-Qing Zhao
- Department of Radiology, Peking University Third Hospital, Beijing 100191, China
| | - Xiao-Ru Gao
- Department of Anesthesiology, Haidian Maternal and Child Health Care Hospital, Beijing 100191, China
| | - Hong Zeng
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
- Beijing Center, Quality Control and Improvement on Clinical Anesthesia, Beijing 100191, China
| | - Xiang-Yang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
- Beijing Center, Quality Control and Improvement on Clinical Anesthesia, Beijing 100191, China
| | - Zheng-Qian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
- Beijing Center, Quality Control and Improvement on Clinical Anesthesia, Beijing 100191, China
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Familiari M, Di Santo D, Galli A, Danè G, Giordano L, Mellone R, Bussi M. Spontaneous extracapsular parathyroid adenoma hemorrhage: when surgery is required? Endocrine 2022; 75:575-582. [PMID: 34554413 DOI: 10.1007/s12020-021-02876-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 09/12/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Spontaneous bleeding is a rare but serious complication of parathyroid adenomas and few cases were reported in the literature. Clinical manifestations and treatment may vary but sometimes an immediate surgery is required. In other cases a conservative approach can be preferred based on clinical stability and patients' conditions. The purpose of this work is to describe our case and to carry out a review of the current literature on this topic. METHODS We reported a case of a parathyroid adenoma hemorrhage in an elderly patient describing its management. Moreover, a literature review of 57 cases was carried out, with the aim of collecting data about the most involved parathyroid gland and identifying the most correct management based on clinical manifestations and chosen treatments. RESULTS The patients had an age between 29 and 81 years (mean 56.9 ± 16.4 years). Forty-four patients were females (77.2%), whereas 12 were males (21.8%). Based on clinical severity, age, comorbidities and calcemic status, three possible scenarios were identified, each with a recommended management. CONCLUSIONS In parathyroid adenoma hemorrhages a careful clinical assessment is crucial to identify emergency conditions requiring immediate intubation, tracheostomy or neck exploration. Elderlies and comorbid patients have a higher risk of perioperative complications and indication for surgery should be evaluated case by case: whenever feasible, a conservative approach should be preferred in these subjects, especially in those with a stable course and without hypercalcemia-related symptoms.
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Affiliation(s)
- Marco Familiari
- Department of Otolaryngology-Head and Neck Surgery, Scientific Institute of Hospitalization and Care San Raffaele Hospital, Vita-Salute University, Milan, Italy.
| | - Davide Di Santo
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56 Rozzano, 20089, Milan, Italy
| | - Andrea Galli
- Department of Otolaryngology-Head and Neck Surgery, Scientific Institute of Hospitalization and Care San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Giulia Danè
- Department of Otolaryngology-Head and Neck Surgery, Scientific Institute of Hospitalization and Care San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Leone Giordano
- Department of Otolaryngology-Head and Neck Surgery, Scientific Institute of Hospitalization and Care San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Renata Mellone
- Department of Radiology, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Mario Bussi
- Department of Otolaryngology-Head and Neck Surgery, Scientific Institute of Hospitalization and Care San Raffaele Hospital, Vita-Salute University, Milan, Italy
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Liu Y, Li J, Liu H, Yang H, Qiao J, Wei T, Wang T, Yu Y. Spontaneous Remission After a Hypercalcemic Crisis Caused by an Intracystic Hemorrhage of Bilateral Parathyroid Adenomas: A Case Report and Literature Review. Front Endocrinol (Lausanne) 2021; 12:766234. [PMID: 34759892 PMCID: PMC8573193 DOI: 10.3389/fendo.2021.766234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 09/28/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hyperparathyroidism is a common cause of hypercalcemia; however, spontaneous remission after a hypercalcemic crisis caused by an intracystic hemorrhage of parathyroid adenomas is very rare. The question, then, is "What is the best treatment strategy for this type of case?" METHOD A 47-year-old male patient with primary hyperparathyroidism and a hypercalcemic crisis is reported. Hypercalcemia was spontaneously relieved thereafter. Postoperative paraffin pathology results indicated an intracystic hemorrhage of bilateral parathyroid adenomas. RESULTS After the case report, a literature review is also included to summarize the clinical features of this patient and to provide special reference for clinical diagnosis and treatment of similar cases. CONCLUSIONS The choice of surgical timing for such cases can be made based on the comprehensive consideration of clinical symptoms and changes in parathyroid function.
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Affiliation(s)
- Yaoxia Liu
- Department of Endocrinology and Metabolism, West China School of Medicine/West China Hospital of Sichuan University, Chengdu, China
- Department of Geriatrics, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Geriatrics, Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Jianwei Li
- Department of Endocrinology and Metabolism, West China School of Medicine/West China Hospital of Sichuan University, Chengdu, China
| | - Hui Liu
- Department of Endocrinology and Metabolism, West China School of Medicine/West China Hospital of Sichuan University, Chengdu, China
| | - Han Yang
- Department of Endocrinology and Metabolism, West China School of Medicine/West China Hospital of Sichuan University, Chengdu, China
| | - Jingtao Qiao
- Department of Endocrinology and Metabolism, West China School of Medicine/West China Hospital of Sichuan University, Chengdu, China
| | - Tao Wei
- Department of Thyroid Surgery, West China School of Medicine/West China Hospital of Sichuan University, Chengdu, China
| | - Tao Wang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children’s Health, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- *Correspondence: Tao Wang, ; Yerong Yu,
| | - Yerong Yu
- Department of Endocrinology and Metabolism, West China School of Medicine/West China Hospital of Sichuan University, Chengdu, China
- *Correspondence: Tao Wang, ; Yerong Yu,
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Schini M, Eastell R. Response to Letter to the Editor: "Normocalcemic Hyperparathyroidism: Study of its Prevalence and Natural History". J Clin Endocrinol Metab 2020; 105:dgaa278. [PMID: 32422658 PMCID: PMC7271762 DOI: 10.1210/clinem/dgaa278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Marian Schini
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Richard Eastell
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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Novodvorsky P, Hussein Z, Arshad MF, Iqbal A, Fernando M, Munir A, Balasubramanian SP. Two cases of spontaneous remission of primary hyperparathyroidism due to auto-infarction: different management and their outcomes. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180136. [PMID: 31063971 PMCID: PMC6510711 DOI: 10.1530/edm-18-0136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 04/12/2019] [Indexed: 12/18/2022] Open
Abstract
Spontaneous remission of primary hyperparathyroidism (PHPT) due to necrosis and haemorrhage of parathyroid adenoma, the so-called 'parathyroid auto-infarction' is a very rare, but previously described phenomenon. Patients usually undergo parathyroidectomy or remain under close clinical and biochemical surveillance. We report two cases of parathyroid auto-infarction diagnosed in the same tertiary centre; one managed surgically and the other conservatively up to the present time. Case #1 was a 51-year old man with PHPT (adjusted (adj.) calcium: 3.11 mmol/L (reference range (RR): 2.20-2.60 mmol/L), parathyroid hormone (PTH) 26.9 pmol/L (RR: 1.6-6.9 pmol/L) and urine calcium excretion consistent with PHPT) referred for parathyroidectomy. Repeat biochemistry 4 weeks later at the surgical clinic showed normal adj. calcium (2.43 mmol/L) and reduced PTH. Serial ultrasound imaging demonstrated reduction in size of the parathyroid lesion from 33 to 17 mm. Twenty months later, following recurrence of hypercalcaemia, he underwent neck exploration and resection of an enlarged right inferior parathyroid gland. Histology revealed increased fibrosis and haemosiderin deposits in the parathyroid lesion in keeping with auto-infarction. Case #2 was a 54-year-old lady admitted with severe hypercalcaemia (adj. calcium: 4.58 mmol/L, PTH 51.6 pmol/L (RR: 1.6-6.9 pmol/L)) and severe vitamin D deficiency. She was treated with intravenous fluids and pamidronate and 8 days later developed symptomatic hypocalcaemia (1.88 mmol/L) with dramatic decrease of PTH (17.6 pmol/L). MRI of the neck showed a 44 mm large cystic parathyroid lesion. To date, (18 months later), she has remained normocalcaemic. Learning points: Primary hyperparathyroidism (PHPT) is characterised by excess parathyroid hormone (PTH) secretion arising mostly from one or more autonomously functioning parathyroid adenomas (up to 85%), diffuse parathyroid hyperplasia (<15%) and in 1-2% of cases from parathyroid carcinoma. PHPT and hypercalcaemia of malignancy, account for the majority of clinical presentations of hypercalcaemia. Spontaneous remission of PHPT due to necrosis, haemorrhage and infarction of parathyroid adenoma, the so-called 'parathyroid auto-infarction', 'auto-parathyroidectomy' or 'parathyroid apoplexy' is a very rare in clinical practice but has been previously reported in the literature. In most cases, patients with parathyroid auto-infarction undergo parathyroidectomy. Those who are managed conservatively need to remain under close clinical and biochemical surveillance long-term as in most cases PHPT recurs, sometimes several years after auto-infarction.
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Affiliation(s)
- Peter Novodvorsky
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Ziad Hussein
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Muhammad Fahad Arshad
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ahmed Iqbal
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Malee Fernando
- Department of Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Alia Munir
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Sabapathy P Balasubramanian
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Lirov R, Kairi S, Gauger PG. Spontaneous Near-Remission of Hyperparathyroidism after Parathyroid Crisis. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2017-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mewani V, Dhillon S, Cai X, Wang X. Transient Primary Hyperparathyroidism: A Case Report. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15779.cr] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Silva BC, Fleischer J, Lenane Z, Fan WW, McMahon DJ, Bilezikian JP. Spontaneous Remission of Primary Hyperparathyroidism Related to an Autoimmune Disease: A Case Report. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14353.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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