Tertiary Hyperparathyroidism Requiring Parathyroidectomy

Abstract

A 36-year-old male with diagnosis of obstructive uropathy having undergone DJ stenting for bilateral renal stones, and hypertension and CKD having undergone renal transplant 2 years back referred to our institution for post-transplant follow-up. He was found to have raised serum calcium and PTH, and referred for further management to Endocrine surgery. He has no history of bony pains, proximal muscle weakness, fractures, or mood disturbances. He has past history of bilateral renal calculi, post PCNL, URS, ESWL, and HTN on hemodialysis. Also gave a history of h/o renal stones in his brother. On evaluation he was found to have low serum Phosphorous: 1, 9, 2, 0, 1, 9, elevated serum calcium:11.1, 11.3, 14.7, 14.0 mg/dL and elevated PTH: 518.8 pg/mL, with low 25(OH) levels: 14.7. Thus, a diagnosis of tertiary hyperparathyroidism was made. USG neck showed 1.4 cm well-defined lobulated hypoechoic lesion at the lower pole of the left lobe of the thyroid which was confirmed by MIBI scan. He had severe osteoporosis at the forearm with a T-score of −5.2. Indications for parathyroidectomy in him included persistent hypercalcemia even after 2 years of medical treatment, very high PTH > 500 pm/L, USG: parathyroid >1 cm(500 mg) and hypophosphatemia. Bilateral Neck Exploration with 3 gland parathyroidectomy with intraoperative parathyroid hormone (IOPTH) monitoring was done. Findings included: 1.5 × 1.5 cm maroon-colored nodule, posterior to the lower pole of the left lobe of the thyroid, anterior to left RLN, left superior parathyroid not seen. Right superior and inferior parathyroid glands were identified. There was a curative fall in IOPTH. IOPTH values (pmol/l) − Pre-incision − 57.5 Pre-excision − 21.1, Post-excision 5 min: 12.8, Post-excision 10 min −10.2, Post-excision 15 min 7.64 Gross: Left Inferior: Weight- 0.4 g 1.5 × 1.5 cm Right Superior: Weight- 0.1 g Size 0.5 × 0.5 cm Right Inferior: Weight- 0.1 g Size- 0.5 × 0.5 cm. He is eucalcemic on 2 years follow-up (Figs. 1, 2, and 3).

Amit Agarwal is the lead author of this chapter.