World Journal of Surgery

, Volume 35, Issue 2, pp 331–335

Clinical and Histopathological Characteristics of Hyperparathyroidism-induced Hypercalcemic Crisis

  • Lee F. Starker
  • Peyman Björklund
  • Constantine Theoharis
  • William D. LongIII
  • Tobias Carling
  • Robert Udelsman



The clinical and pathological characteristics of hyperparathyroidism-induced hypercalcemic crisis (HIHC) are incompletely described. The present study was designed to elucidate the nature and effects of HIHC in patients undergoing parathyroidectomy in our unit.


A prospective database of 1,754 consecutive patients with primary hyperparathyroidism (PHPT) who underwent parathyroidectomy from 1991–2009 identified 67 (41 women) patients presenting with HIHC. Hyperparathyroidism-induced hypercalcemic crisis was defined as symptoms and signs of acute calcium intoxication with a concomitant total albumin corrected calcium level >13.5 mg/dl (range: 8.8–10.2 mg/dl). Clinical and pathological characteristics were evaluated. Data are expressed as mean ± SEM.


Mean age at presentation was 56.7 ± 2.2 years. Twenty-four of 67 patients (35%) required preoperative in-hospital management. Of these, all were treated with saline resuscitation, whereas 20/24 (83%) were treated pharmacologically. Neurocognitive derangements and nephrolithiasis with associated hematuria were the most common presenting symptoms and signs. Preoperative serum calcium and the intact parathyroid hormone level (PTH) were 14.0 ± 0.19 mg/dl and 393 ± 43 pg/ml (reference range: 12–65 pg/ml), respectively. Minimally invasive parathyroidectomy under local cervical block was performed in 28/67 patients (42%); the remainder underwent standard cervical exploration. All patients had postoperative normalization of serum calcium and intact PTH. Hyperparathyroidism-induced hypercalcemic crisis was due to parathyroid carcinoma in 3/67 patients (4.5%), whereas the remainder of patients displayed a single parathyroid adenoma (n = 57) or multiglandular hyperplasia (n = 7). Histopathological evaluation from HIHC patients revealed a chief cell microcystic pattern in 15/21 (71.4%) of examined parathyroid tumors.


Hyperparathyroidism-induced hypercalcemic crisis is most commonly due to a single parathyroid adenoma, often associated with a microcystic histopathological pattern. The condition is optimally managed with saline hydration and urgent parathyroidectomy.


  1. 1.
    Lew JI, Solorzano CC, Irvin GL 3rd (2006) Long-term results of parathyroidectomy for hypercalcemic crisis. Arch Surg 141:696–699 (discussion 700)CrossRefPubMedGoogle Scholar
  2. 2.
    Coffey RJ, Lee TC, Canary JJ (1977) The surgical treatment of primary hyperparathyroidism: a 20 year experience. Ann Surg 185:518–523CrossRefPubMedGoogle Scholar
  3. 3.
    Ziegler R (2001) Hypercalcemic crisis. J Am Soc Nephrol 12(Suppl 17):S3–S9PubMedGoogle Scholar
  4. 4.
    Lowenburg H, Ginsburg TH (1932) Acute hypercalcemia: report of a case. J Am Med Assoc 99:1166Google Scholar
  5. 5.
    Flink EB, Desper PC, Jones JE (1966) Primary hyperparathyroidism causing hypercalcemic crisis and acute pancreatitis. Minn Med 49:734–744PubMedGoogle Scholar
  6. 6.
    Huang SC, Wu VC, Chou G et al (2007) Benign parathyroid adenoma presenting with unusual parathyroid crisis, anemia and myelofibrosis. J Formos Med Assoc 108(2 Suppl):S13–S16CrossRefGoogle Scholar
  7. 7.
    Lemann J Jr, Donatelli AA (1964) Calcium intoxication due to primary hyperparathyroidism. A medical and surgical emergency. Ann Intern Med 60:447–461PubMedGoogle Scholar
  8. 8.
    MacLeod WA, Holloway CK (1967) Hyperparathyroid crisis. A collective review. Ann Surg 166:1012–1015CrossRefPubMedGoogle Scholar
  9. 9.
    Carling T, Donovan P, Rinder C et al (2006) Minimally invasive parathyroidectomy using cervical block: reasons for conversion to general anesthesia. Arch Surg 141:401–404 (discussion 404)CrossRefPubMedGoogle Scholar
  10. 10.
    Carling T, Udelsman R (2008) Focused approach to parathyroidectomy. World J Surg 32:1512–1517CrossRefPubMedGoogle Scholar
  11. 11.
    Roman S, Udelsman R (2002) Minimally invasive parathyroid surgery. Minerva Chir 57:105–110PubMedGoogle Scholar
  12. 12.
    Wang CA, Guyton SW (1979) Hyperparathyroid crisis: clinical and pathologic studies of 14 patients. Ann Surg 190:782–790CrossRefPubMedGoogle Scholar
  13. 13.
    Kelly TR, Zarconi J (1981) Primary hyperparathyroidism: hyperparathyroid crisis. Am J Surg 142:539–542CrossRefPubMedGoogle Scholar
  14. 14.
    Mazzaferri EL, O’Dorisio TM, LoBuglio AF (1978) Treatment of hypercalcemia associated with malignancy. Semin Oncol 5:141–153PubMedGoogle Scholar
  15. 15.
    Shane E (2001) Clinical review 122: parathyroid carcinoma. J Clin Endocrinol Metab 86:485–493CrossRefPubMedGoogle Scholar
  16. 16.
    Sandelin K (1997) Parathyroid carcinoma. Cancer Treat Res 89:183–192PubMedGoogle Scholar
  17. 17.
    Wani S, Hao Z (2005) Atypical cystic adenoma of the parathyroid gland: case report and review of literature. Endocr Pract 11:389–393PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2010

Authors and Affiliations

  • Lee F. Starker
    • 1
  • Peyman Björklund
    • 1
    • 3
  • Constantine Theoharis
    • 2
  • William D. LongIII
    • 1
  • Tobias Carling
    • 1
  • Robert Udelsman
    • 1
  1. 1.Department of SurgeryYale University School of MedicineNew HavenUSA
  2. 2.Department of PathologyYale University School of MedicineNew HavenUSA
  3. 3.Department of Surgical SciencesUppsala UniversityUppsalaSweden

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