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Clinical Cases in mineral and bone metabolism

A case of hypercalcemic parathyroid crisis in a patient with normocalcemic hyperparathyroidism

Case report, 397 - 399
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We present a man with normocalcemic primary hyperparathyroidism who developed hypercalcemic parathyroid crisis following years of normal blood calcium levels. The patient was a 59-year-old male with a history of recurrent nephrolithiasis. Initial PTH was 70 ng/L (13-54) with serum calcium of 2.44 mmol/L (2.1-2.5), albumin 39 g/L, and phosphate 0.70 mmol/L (0.8-1.5). Many repeat serum total calcium levels were normal. 24-hour urine calcium was within normal limits at 6.82 mmol/day. He was followed with regular
monitoring of serum calcium and PTH, and remained asymptomatic and normocalcemic for 8 years until he suddenly presented feeling unwell and was found to have a serum calcium of 4.05 mmol/L and PTH of 585 ng/L. He was referred to hospital and treated with intravenous fluids and pamidronate. Sestamibi scan revealed a large MIBI-avid soft tissue nodule, highly suspicious for a parathyroid adenoma. Six weeks later, he underwent right unilateral parathyroidectomy. Pathology demonstrated a 2.2x 2.0 x2.1 cm benign parathyroid adenoma. Postoperatively he has remained normocalcemic with normal PTH.
Normocalcemic primary hyperparathyroidism is not clearly associated with adverse clinical outcomes and longitudinal studies suggest it rarely progresses to overt hypercalcemia.
This is the first case of normocalcemic primary hyperparathyroidism that evolved to hypercalcemic crisis.
We postulate an infarct of the large parathyroid adenoma resulting in sudden marked increase in PTH secretion. Normocalcemic hyperparathyroidism may not have a benign course if associated with a large parathyroid adenoma. Progression to severe hypercalcemia may occur suddenly in rare cases.

Vol. XV (No. 3) 2018 September - December

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