A 70-year-old white male with a history of benign prostatic hyperplasia, recurrent atrial fibrillation and right hemithyroidectomy for nodular hyperplasia, as well as unstudied chronic renal failure (baseline creatinine 1.5 mg/dl).
She came to the emergency department with a three-month history of gait instability and generalized weakness (previous admission to another center for these symptoms).
On physical examination, the patient is suffering from cough, confusion, brachypsychic and distal tremor.
Analytical data are summarized in (table 1), highlighting important deterioration of renal function, severe hypercalcemia and marked elevation of PTH (twice above the laboratory reference value).
Serum therapy, furosemide infusion and intravenous corticosteroids, bisphosphonates and calcitonin were initiated.
Due to the severity of neurological symptoms, urgent renal replacement therapy is simultaneously indicated by hemodialysis with low calcium concentration in the dialysate.
It presents transient clinical improvement, but due to persistent renal failure and rebound of hypercalcaemia (increased calcaemia > 24 hours post-dialysis), requires continued daily sessions
1.
As part of the etiologic study, myelooproliferative processes and other malignancies (non-monoclonal component in proteinogram, negative Bence-Jones proteinuria), infectious disease (negative serology) and autoimmune diseases were ruled out.
Urine ultrasound with kidneys of normal size and adequate corticomedullary differentiation.
Left CT scan revealed a retroesophageal mass of 5.6 × 3.2 × 6.8 cm, suspicious for parathyroid tumor 27 mm, and the image was confirmed by bilateral adrenal gammagraphy.
With these findings we consult with Endocrinology ruling out phaeochromocytoma (biliary tract and metanephrine negative).
In a joint session with General Surgery, surgical management was decided, resecting an 8 cm parathyroid tumor. Pathological Anatomy reports parathyroid adenoma without invasion or vascular adenoma.
1.
In the immediate postoperative period, "hamburger bone syndrome" occurs, so the patient requires intravenous and oral calcium supplementation due to severe hypocalcemia, and interday hemodialysis sessions up to nine days.
Nine months later, the patient is asymptomatic, with calcemia in range without the need for supplements, and with partial recovery of renal function (creatinine 2.7 mg/dl).
It is noteworthy that renal function persists altered one year after surgery, despite normalization of calcemia.
