Gestational Ectopic Hyperparathyroidism: A Case Report of Perioperative and Perinatal Outcomes

In the realm of obstetric care, discerning the subtle signs of primary hyperparathyroidism (PHPT) amidst common pregnancy symptoms remains a formidable challenge. Our exploration into a case of gestational hypercalcemia peels back the layers of this complexity, revealing the clinical conundrum posed by overlapping gastrointestinal manifestations. The journey from diagnosis through surgical intervention to the resolution of symptoms underscores the importance of vigilance for PHPT in pregnant patients. This case further prompts consideration of gamma-aminobutyric acid (GABA) as a potential piece in the puzzle of persistent symptoms post-calcium normalization, inviting a broader dialogue on the intricacies of parathyroid pathology in pregnancy.

Utility of 99mTc-Sestamibi Single-Photon Emission Computed Tomography (SPECT)/CT Single Imaging Strategy in the Preoperative Localization of Parathyroid Adenoma

Background Primary hyperparathyroidism is an endocrinopathy associated with dysregulated calcium homeostasis. The most common etiology is a parathyroid adenoma most definitely managed via a parathyroidectomy. The two main surgical approaches include a minimally invasive parathyroidectomy (MIP) and open four-gland exploration (4-GE). MIP is the preferred operative strategy since it is associated with less postoperative complications. Accurate preoperative imaging is essential in informing the optimal approach to surgery. MIP is only considered if adenoma is able to be localized precisely. The most commonly used imaging modality includes ultrasound and sestamibi single-photon emission computed tomography (SPECT)/CT, either as a single or combination strategy. Other options include MRI, PET, and 4D CT. There is no universally accepted preoperative imaging strategy. The literature is discordant and recommendations proposed by existing guidelines are incongruous. Objectives This study aimed to evaluate currently utilized preoperative parathyroid imaging modalities at our institution and correlate them with surgical and histological findings to determine the most efficient imaging strategy to detect adenomas for our patient cohort. This will ultimately guide the best surgical approach for patients receiving parathyroidectomies. Methods This is a retrospective observational study of all patients undergoing first-time surgery for biochemically proven primary hyperparathyroidism at our institution over the past five years. Multiple data points were collected including modality of preoperative disease localization, operation type, final histopathology, biochemical investigations, and cure rate. Patients were categorized into one of three groups based on the method of disease localization. Results A total of 244 patients had parathyroidectomies performed at our institution in the past five years from January 2018 to December 2022. Ninety-six percent (n=235) of all patients received dual imaging preoperatively with SPECT/CT and ultrasound performed on the same day and therefore included in this study. A total of 64.3% (n=151) underwent MIP. Eighty percent (n=188) of all histopathology revealed adenomas and 26.8% (n=63) of patients had adenoma localized on SPECT/CT only (sensitivity: 58.1%, specificity: 71%, and positive predictive value {PPV}: 85.7%). A total of 9.8% (n=23) had adenoma localized on ultrasound only (sensitivity: 15.6%, specificity: 73.3%, and PPV: 65.2%). A total of 45.1% (n=106) were dual localized on both SPECT/CT and ultrasound (sensitivity: 75.6%, specificity: 46.6%, and PPV: 84.9%). The cure rate was 91.5% in the dual-localized group, 86% in the dual-unlocalized group, and 96.5% when localized with SPECT/CT alone. Conclusion A dual-imaging modality with SPECT/CT and ultrasound should remain the first-line imaging strategy. This approach has higher sensitivity rates and poses no inherent patient or surgical-related risks. Patients with disease unlocalized on SPECT/CT alone had a positive predictive value, specificity, and likelihood ratio for adenoma detection comparable to dual-localized patients. Therefore, SPECT/CT alone is sufficient for directing MIP in the presence of a negative ultrasound.

Delayed Diagnosis of Primary Hyperparathyroidism: A Case Report

Primary hyperparathyroidism (PHPT) is characterized by an elevation in serum calcium levels, sometimes leading to aggravated clinical conditions, namely nephrolithiasis, nephrocalcinosis, and/or fractures. A 55-year-old patient was admitted to the hospital with acute obstructive pyelonephritis in March 2021, having another episode one year later. Initial blood and urine analysis detected inflammatory markers, namely C-reactive protein, and the presence of leucocytes and blood in the urine. The renal computed tomography scan exhibited renal asymmetry, nephrocalcinosis, and multiple kidney stones. The patient was scheduled for a follow-up one year later to perform blood and urine analysis to uncover the cause of nephrocalcinosis, displaying high serum calcium and parathyroid hormone (PTH) levels. The thyroid ultrasound revealed a parathyroid adenoma, which was removed through a right lower parathyroidectomy, improving the symptoms. The clinical condition described here is an atypical manifestation of this disease because PHPT is normally asymptomatic. In the present case study, nephrocalcinosis and nephrolithiasis were strong indicators of the underlying disease. However, the delay in the follow-up consultation resulted in complications for the patient, such as microabscesses in the kidneys, which could lead to reduced renal function in the future. Early detection of key aspects of the disease could avoid further complications and suffering for the patient. For example, the family physician's follow-up of the patient's condition could surpass the waiting time between consultations with different specialties, and promote early treatment.

Coexistence of a Calcium-Sensing Receptor Mutation and Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) and familial hypocalciuric hypercalcemia (FHH) are the main differential diagnoses in a patient presenting with parathyroid hormone (PTH)-mediated hypercalcemia. PHPT is most often caused by a single-gland parathyroid adenoma and FHH is the result of an inactivating mutation of the calcium-sensing receptor (CaSR) gene. In this paper, we present a unique case of the co-existence of an inactivating CaSR gene mutation and PHPT due to a single-gland parathyroid adenoma. The patient is a 67-year-old female with a history of recurrent nephrolithiasis who presented with hypercalcemia, elevated PTH level, and hypocalciuria. As a result of the patient's hypocalciuria, familial hypocalciuric hypercalcemia was suspected, and genetic testing was pursued. CaSR gene analysis revealed a heterogeneous inactivating mutation of the CaSR gene. Additionally, nuclear imaging with technetium sestamibi revealed a large focus of activity on the right side of the neck suspicious of a parathyroid adenoma. This was resected and confirmed to be a hypercellular parathyroid adenoma. Two years after her surgery, the patient continues to have normal calcium levels with no further episodes of nephrolithiasis. She is currently undergoing treatment for osteoporosis and is being periodically monitored for recurrence of hypercalcemia due to the presence of the inactivating CaSR gene mutation. This case highlights an exceedingly rare case of a patient with both an inactivating CaSR gene mutation and PHPT due to a single parathyroid adenoma, and it underscores the importance of further research to determine any potential relationship between the two.

Concurrent Primary Hyperparathyroidism and Sarcoidosis in a Patient With Severe Hypercalcemia

Hypercalcemia is a common biochemical abnormality caused by various etiologies, with primary hyperparathyroidism (PHPT) and malignancies being the most common culprits. Differentiating between PTH-dependent and PTH-independent hypercalcemia is crucial in clinical practice. However, in certain clinical contexts, it is important to consider the rare occurrence of two separate conditions causing hypercalcemia simultaneously. Herein, we have described the case of a patient who presented with high serum calcium, a normal PTH level, and histopathological evidence of active granulomatous disease, indicating the presence of both PHPT and sarcoidosis. The coexistence of these conditions poses diagnostic challenges due to their biochemical and clinical similarities. This case highlights the importance of individualized management for patients with concurrent conditions contributing to hypercalcemia. It also emphasizes the need for further research to unravel the underlying interactions between PHPT and sarcoidosis in the context of calcium metabolism. A better understanding of these interactions can guide optimal diagnostic and therapeutic strategies for patients with complex presentations of hypercalcemia.

A Rare Case of Recurrent Parathyroid Adenomas After Initial Parathyroidectomy

Hyperparathyroidism usually presents asymptomatically with elevated levels of calcium and parathyroid hormone; this biochemical imbalance establishes the diagnosis. In 80-85% of cases of primary hyperparathyroidism, singular parathyroid adenomas occur. In rare cases, this problem occurs due to multiple adenomas, multiglandular hyperplasia, or parathyroid carcinoma. Recurrent primary hyperparathyroidism (R-PHPT), as demonstrated in this case, is defined as hypercalcemia that arises after six months of normocalcemia following initial surgery for PHPT. The aim of this report is to describe the diagnosis and management of three parathyroid adenomas in a patient, two of which occurred after an initial partial parathyroidectomy.

Large Water-Clear-Cell Parathyroid Adenoma: A Report of a Rare Case

Water-clear-cell parathyroid adenomas are extremely rare tumors characterized by cells that contain clear, foamy cytoplasm. Here we report a case of a large water-clear-cell parathyroid adenoma in a 70-year-old male. The patient was presented to an outside hospital with severe abdominal pain and supporting CT imaging confirming a small bowel obstruction. Initial laboratory studies revealed hypercalcemia and elevated parathyroid hormone levels. Subsequent ultrasound imaging revealed a 2.7 × 2.1 cm neck mass suspicious for a parathyroid adenoma. A parathyroidectomy was performed, and microscopic evaluation revealed an expansile proliferation of cells with characteristic water-clear cell features. Although rare, water-clear-cell parathyroid adenomas are clinically indistinguishable from more common subtypes and should be considered in the differential diagnosis of an anterior neck mass.

Giant Parathyroid Adenoma: A Case Report

Parathyroid adenomas rarely weigh more than 4 grams. Our patient had a 5.3-gram adenoma causing bilateral knee pain limiting mobility, constipation, low back pain, and frontal headache. Presenting with calcium of greater than 17 mg/dl, the patient was treated with two rounds of hemodialysis, calcitonin, Zoledronate, and aggressive IV hydration to decrease calcium levels before parathyroidectomy. The patient then went on to develop the hungry bone syndrome, which was treated with calcium carbonate and calcitriol. This rare giant parathyroid adenoma presents a unique opportunity to learn about the pathogenesis and treatment of longstanding hyperparathyroidism causing hypercalcemia-associated symptoms and hungry bone syndrome after parathyroidectomy.

Primary Hyperparathyroidism Secondary to a Sestamibi-Negative Cystic Parathyroid Adenoma

The most common cause of primary hyperparathyroidism (PHPT) is a solid parathyroid adenoma. Less than 2% of cases of PHPT are caused by cystic parathyroid adenomas formed from degeneration of pre-existing solid parathyroid adenomas. Cystic parathyroid adenomas are non-functional in over 90% of cases. In this case we describe management of a 56-year-old man with acute-onset polydipsia, polyuria, xerostomia, nausea, and constipation. Serum chemistry upon admission revealed hypercalcemia, hyperparathyroidism, and reduced serum phosphorus. Neck sonogram revealed a predominantly anechoic lesion later confirmed by pathology to be a cystic parathyroid adenoma in the right thyroid lobe. Sestamibi scan did not show uptake in parathyroid gland, and parathyroid hormone (PTH) was elevated in fine-needle aspiration sample. Otolaryngology removed the cystic lesion via surgical excision, which led to normalization of PTH level. This case demonstrates the importance of evaluation of cystic components for PTH levels and if confirmed should be treated as a parathyroid adenoma.

Caffeine as a Neoadjuvant Therapy in Parathyroid Adenomas: A Narrative Review

Caffeine is the most used central nervous system stimulant drug to date. Many studies have shown the association of caffeine with bone remodeling, urinary calcium excretion, kidney stones, acid peptic disease, and the development of cancer. However, there has been very little research exploring the association between caffeine use and parathyroid gland disorders. We shed light on the possible connection between caffeine and parathyroid adenomas, as suggested in the literature.

Revisiting a Case of Parathyroid Adenoma With Bilateral Staghorn Calculus

Parathyroid gland adenoma is responsible for approximately 80%-85% cases of primary hyperparathyroidism. Although not much is diagnostic on clinical examination, the blood investigations of the patients reveal raised serum calcium and serum parathyroid hormone levels. We present a case of chronic kidney disease with bilateral staghorn calculi and a right parathyroid adenoma localized on ultrasonography. Parathyroid adenoma was surgically excised by minimally invasive parathyroidectomy.

Imaging and Diagnostic Challenges in a Patient With Refractory Hypoglycemia Caused by Insulinomas Related to Multiple Endocrine Neoplasia Type 1

Insulinoma is a rare neuroendocrine tumor. It may occur sporadically or as part of the genetic tumor syndrome multiple endocrine neoplasia type 1 (MEN1). Diagnosis is challenging because of the small size of insulin producing tumors that lead to hyperinsulinemia. Advances in imaging modalities may provide more accurate diagnosis of primary tumors, metastasis, and tumor functional status. Advances allow for improved medical and surgical management with new tools for research of neuroendocrine tumors. Surgical excision of the primary tumor is often curative; however, insulinomas in MEN1 syndrome are often multifocal with a high rate of recurrence presenting unique challenges in management. Here, we present the case of a 34-year-old male with recurrent hypoglycemic episodes and hyperparathyroidism diagnosed with multiple pancreatic insulinomas secondary to MEN1. Furthermore, we provide a brief review of the literature and discuss the approach to diagnosis and management in patients with MEN1 syndrome and future areas of investigation.