|LETTER TO THE EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 95-97
Giant visible parathyroid adenoma presenting with severe hypercalcemia
Aman Kumar1, Deepak Khandelwal2, Atul Dhingra3, Vivek Aggarwal4, Nishikant Avinash Damle5, Monika Garg6
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 Submission||08-Apr-2020|
|Date of Acceptance||11-Apr-2020|
|Date of Web Publication||17-Jul-2020|
Dr. Deepak Khandelwal
Department of Endocrinologyand Diabetes, Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi
Source of Support: None, Conflict of Interest: None
|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 Dec 4];17:95-7. Available from: https://www.thetrp.net/text.asp?2020/17/2/95/290000
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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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). 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. Approximately only 25 cases of GPTA are reported in the literature till date.,, There are only limited reports of visible parathyroid adenoma in the literature.,, 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%. 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.
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Conflicts of interest
There are no conflicts of interest.
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