Case 2

A 43 year old man was evaluated for a two year history of re­current kidney stones with the suspect of pHPT. Measurement of blood and urine calcium in three different days on a diet containing 1 gr/day of calcium and 100 mEq/day of sodium showed circulating total calcium and PTH (1-84) levels at the upper limits (respectively, 10.4 and 10.8 mg/dl and 68 and 73 pg/ml). Blood levels of ionized calcium were frankly ele­vated (5.5-5.7 mg/dl, N.V. 4.2-5.3 mg/dl), serum phosphorus levels were low (1.9-2.2 mg/dl, N.V. = 2.5-4.5 mg/dl), and total serum protein levels were in the normal range. Urine calcium excretion was increased (450-530 mg/24 hr) and biohumoral data showed activation of the indexes of bone turnover. Lumbar bone density showed the presence of osteoporosis (lumbar BMD: T-score = -2.63).

All the above data supported the diagnosis of normocalcemic symptomatic pHPT.

Imaging studies were requested in order to detect and define the morphovolumetric assessment of the pathologic PT gland(s), before surgical removal.

Tc-MIBI scintigraphy showed a mediastinic uptake area, also detected in delayed (2 hours) images (Fig. 2b). US and CT- scan demonstrated a 3.5x4x4 cm mediastinic mass contiguous to the inferior pole of the left lobe of the thyroid gland (Fig. 2a and 2c). Post-contrastographic CT-scan showed a strong en­hancement. No hypotheses on the characterization of the mass were suggested, however, its localization was suitable with a pathologic ectopic parathyroid gland.

 

Figure 2 - Patient 2 parathyroid adenoma

Figure 2 – Patient 2: parathyroid adenoma. A) Ultrasound: at the infrajugular left parasagittal site a scarcely echoic mass, with sharp edges is present. B) 99TcMIBI Scintigraphy: image obtained 90 min. after injection of the tracer; a “hot” spot is shown in the left upper mediastinum-low neck. C) Computed tomography: a strongly contrast-enhanced spherical mass was visible in the left side of the esophagus between the trachea and a vertebral body.

The patient underwent surgery for removal of the suspected parathyroid adenoma. Surgical and histopathologic data con­firmed the presence of the parathyroid adenoma. Biochemical testing two and eight weeks after surgery, revealed normal PTH levels (50-45 pg/ml) with normocalcemia (9-9.3 mg/dl), normophosphoremia (3.8-4 mg/dl), and normocalciuria (240 and 200 mg/24 hours). Don’t suffer without medication. Buy online