Amir Hayat currently working in Darent Valley Hospital, United Kingdom.
Background: Primary hyperparathyroidism is a common cause of hypercalcemia. Uncontrolled secretion of parathyroid hormone leads to renal, gastrointestinal, neuropsychiatric and cardiovascular symptoms . Quick intraoperative parathyroid hormone measurement confirms immediately the success of surgical treatment . Coexistent of parathyroid adenoma and multinodular goiter is quite rare . Case Presentation: A 60 years old patient presented with one week history of constipation, agitation and vomiting on background of hypertension. No significant family history. Examination: Dehydrated and mild confusion. Normal systemic examination. Tachycardiac, Tachypneic and has low blood pressure. Glasgow coma scale of 15/15. Investigations: Venous blood gas: PH 7.39, Glucose 9.1 mmol/L, Potassium 3.6 mmol/L and Lactate 4.1 mmol/L. Electrocardiogram showed sinus tachycardia. Laboratory blood investigations: White cell count 12*10^9/L, High Sensitivity C-reactive protein 16 mg/L, Serum Sodium 148 mmol/L, Serum Potassium 3.5 mmol/L, Blood Urea 11.7 mmol/L, Serum Creatinine 115 umol/L, AKI stage 0, Blood adjusted calcium 5.72 mmol/L, Serum Magnesium 0.66 mmol/L, Myeloma screen negative, Thyroid stimulating hormone 0.30 mIU/L, Serum Total proteins 61 g/L, Normal Immunoglobulins (IgG,IgA and IgM), serum Parathyroid hormone 2473 ng/L and Urine calcium 13.83 mmol/24hrs. Imagings: Chest Radiograph unremarkable. Computed Tomography (CT) of head normal. No obvious malignancy identified on CT Thorax abdomen and Pelvis .Ultrasound Thyroid reported as multinodular goiter and a 4x2x1.7 cm mass at right tracheoesophageal groove. Parathyroid gland nuclear scan reported findings consistent with right parathyroid adenoma. Management: Initial management with intravenous fluids resuscitation, Intravenous loop diuretic treatment, Intravenous Pamidronate and Calcitonin. Due to resistance to medical treatment, right side inferior parathyroidectomy performed. Biopsy: Report confirms the diagnosis of benign tumor, measuring 6.20g. No evidence of malignancy. Outcome: Post-operative, Parathyroid hormones and serum calcium levels decreased, with few episodes of hypocalcemia which resolved with calcium replacement. Alfacalcidol prescribed to prevent hungry bone syndrome Follow-up: The patient was followed in ambulatory care clinic for symptoms and bloods reviews. Discussion: Diagnosis of Parathyroid adenoma depends on clinical presentation, biochemistry, histology and imaging including nuclear scans . Adenoma constitutes 85% of the cases of primary hyperparathyroidism. Hypocalcemia and Hungary bone syndrome are major complications postoperatively that need to be addressed and warrants regular follow-ups.