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LETTER TO THE EDITOR
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 95-97

Giant visible parathyroid adenoma presenting with severe hypercalcemia


1 Department of Medicine, Maharaja Agrasen Hospital, New Delhi, India
2 Department of Endocrinology and Diabetes, Maharaja Agrasen Hospital, New Delhi, India
3 Department of Endocrinology, Gangaram Bansal Hospital, Sri Ganganagar, Rajasthan, India
4 Department of Endocrine Surgery, Maharaja Agrasen Hospital, New Delhi, India
5 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
6 Department of Radiology, Maharaja Agrasen Hospital, New Delhi, India

Date of Submission08-Apr-2020
Date of Acceptance11-Apr-2020
Date of Web Publication17-Jul-2020

Correspondence Address:
Dr. Deepak Khandelwal
Department of Endocrinologyand Diabetes, Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/trp.trp_26_20

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How to cite this article:
Kumar A, Khandelwal D, Dhingra A, Aggarwal V, Damle NA, Garg M. Giant visible parathyroid adenoma presenting with severe hypercalcemia. Thyroid Res Pract 2020;17:95-7

How to cite this URL:
Kumar A, Khandelwal D, Dhingra A, Aggarwal V, Damle NA, Garg M. Giant visible parathyroid adenoma presenting with severe hypercalcemia. Thyroid Res Pract [serial online] 2020 [cited 2020 Aug 10];17:95-7. Available from: http://www.thetrp.net/text.asp?2020/17/2/95/290000



Sir,

We would like to discuss a case of a 64-year-old female presented to us with complaints of extreme lethargy, nausea, vomiting, and abdominal pain for the past 15 days. She also complained of proximal muscle weakness and fatigue for the past 4 months and had a history of multiple renal calculi in the past. She had a visible swelling on the right side of the neck [Figure 1]a. There was no history suggestive of any local pressure symptoms. On examination, she had bony tenderness. There was a palpable firm nodule of approximately 3 cm size on the right side of the neck, corresponding to visible swelling. Blood investigation showed an elevated level of serum calcium 16.50 mg/dl (normal range: 8.8–10.8 mg/dl) and corresponding serum intact parathyroid hormone (iPTH) level was 1739.40 pg/ml (normal range: 15–65 pg/ml). Her thyroid function tests were within normal limits. Other biochemical investigations are summarized in [Table 1]. Biochemically, a diagnosis of primary hyperparathyroidism was confirmed. She was treated with intravenous fluids, diuretics, calcitonin, and also required intravenous zolendronate to control her hypercalcemia. Ultrasonography (USG) of the neck showed a hypoechoic solid lesion of 3.5 × 3 cm abutting the lower pole of the right lobe of thyroid suggestive of parathyroid adenoma. There was another suspicious lesion of 1.5 cm × 1 cm nodule in the right lobe thyroid close to the isthmus (TIRADS-4). In view of large adenoma and severe hypercalcemia, a possibility of malignant parathyroid adenoma was kept and a decision for parathyroidectomy and right hemithyroidectomy with frozen section was taken after discussion and consent from patient and family. A large lesion of 3.8 cm in maximum dimension and weighing 4.5 g was taken out [Figure 1]b and was confirmed as parathyroid adenoma in histopathology. Postoperatively, there was a significant improvement in serum calcium (9.6 mg/dl) and iPTH levels (60 pg/ml).
Figure 1: (a) Visible swelling seen on the right side of the neck; (b) resected large parathyroid lesion

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Table 1: Biochemical investigations of our patient

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Parathyroid adenomas account for 85% of cases of primary hyperparathyroidism. Parathyroid adenomas are usually small, measuring <2 cm and weighing <1 g. Those weighing >3.5 g are classified as giant parathyroid adenomas (GPTAs).[1] GPTA is a rare cause of primary hyperparathyroidism. However, they usually present with more severe clinical presentations along with high serum calcium and iPTH levels due to the larger tissue mass. Management is typically surgical, aiming at complete resection. Patients usually recover with no long-term complications or recurrence.[1] Approximately only 25 cases of GPTA are reported in the literature till date.[1],[2],[3] There are only limited reports of visible parathyroid adenoma in the literature.[1],[4],[5] In our case, a swelling was readily visible on inspection and palpable on physical examination. As palpable nodules are much more common in the thyroid, the most common differential diagnosis is thyroid nodule. USG alone by an experienced radiologist can diagnose GPTA with 79% accuracy; combining USG with sestamibi scan increases the accuracy of localization to 82%.[1] Such a large size of the parathyroid gland should raise a suspicion of parathyroid carcinoma also. In our case, histopathology did not suggest evidence of parathyroid malignancy. The patient has been kept on regular follow-up as well.

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.
Al-Hassan MS, Mekhaimar M, El Ansari W, Darweesh A, Abdelaal A. Giant parathyroid adenoma: A case report and review of the literature. J Med Case Rep 2019;13:332.  Back to cited text no. 1
    
2.
Mantzoros I, Kyriakidou D, Galanos-Demiris K, Chatzakis C, Parpoudi S, Sapidis N, et al. A Rare Case of Primary Hyperparathyroidism Caused by a Giant Solitary Parathyroid Adenoma. Am J Case Rep 2018;19:1334-7.  Back to cited text no. 2
    
3.
Rutledge S, Harrison M, O'Connell M, O'Dwyer T, Byrne MM. Acute presentation of a giant intrathyroidal parathyroid adenoma: A case report. J Med Case Rep 2016;10:286.  Back to cited text no. 3
    
4.
Das U, Iassac H, Kanchi H, Price DA, Humphrey GM, Hall CM. Severe hypercalcemia caused by a visible parathyroid adenoma in an adolescent female. Presented at 193rd Meeting of the Society for Endocrinology and Society for Endocrinology joint Endocrinology and Diabetes Day 2002, London, UK. Endocrine Abstracts (2002) 4 P12.  Back to cited text no. 4
    
5.
Racolta N, Wagner C, Lopez RC, Dupre LD, Patey M, Smagala A. Looked like a goiter, proved to be a giant parathyroid adenoma. Presented at 20th European Congress of Endocrinology 2018, Barcelona, Spain. Endocrine Abstracts (2018) 56 P268. DOI: 10.1530/endoabs.56.P268  Back to cited text no. 5
    


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