Acute Pancreatitis As an Initial Presentation of Parathyroid Disease

Presentation Number: MON 316
Date of Presentation: April 3rd, 2017

Antonio Costantino*1 and Sachin K Majumdar Jr.2
1Yale New Haven Health Bridgeport Hospital, 2Yale New Haven Health Bridgeport Hospital, Bridgeport, CT

Abstract

Background: The development of acute pancreatitis in the setting of hypercalcemia is a well-established phenomenon. However, with increased screening for hypercalcemia and therefore earlier detection of hyperparathyroidism, curative intervention has made subsequent development of pancreatitis exceedingly rare and almost obsolete.

Clinical Case: We discuss a case of a 57 year old Liberian woman who reports being healthy most of her life except for one episode of acute pancreatitis 5 years prior which was found to be due to an obstructive gallstone. Subsequently, patient underwent elective cholecystectomy with resolution of symptoms. She now presented to hospital with a 1 week history of worsening nausea , vomiting, and abdominal pain similar to her previous episode of pancreatitis. In the emergency department, significant labs revealed a leukocytosis of 12 x 103 mcL (n = 4.8 – 10.8 x 103 mcL), Calcium of 13.8 mg/dL (n=8.4-10.2 mg/dL), Albumin of 4.3 g/dL (n= 3.5- 5.0g/dL), Alk phos of 124 u/L (n= 38-126 u/L), ALT of 28 u/L (n= 9-54 u/L), AST of 27u/L (n=14-26 u/L) and a lipase of 5028 u/L (23-300u/L). EKG at the time showed sinus tachycardia and non-specific T wave abnormality. Urine toxicology was negative. Patient denied any history of alcohol use. Lipid panel was sent which revealed a triglyceride level of 148 mg/dL (n<150mg/dL). CT abdomen and pelvis was suggestive of recurrent interstitial pancreatitis with adjacent fluid collection and interval cholecystectomy with mild prominence of intra and extrahepatic biliary collecting systems likely within normal limits. At this time a PTH level was sent which revealed a markedly elevation to 968.1 pg/mL (n <53.5 pg/mL). Infectious work up at the time was negative including blood cultures, urine cultures, Chest Xray (without infiltrates) and HIV screening. A screening ANA titer was sent which was negative with a ratio < 1:80 and no pattern reported. Ultimately, patient was scheduled for parathyroidectomy. Patient's right inferior parathyroid gland was removed and her calcium normalized with resolution of acute abdominal symptoms. Pathology reported the sample as parathyroid gland which measured 2.5 cm and weighed 3496 mg (normal average female parathyroid gland weight approximately 35 mg). The impression reported by the pathologist was parathyroid disease (hyperparathyroidism). Patient was shortly discharged from hospital after post-operative recovery. She was seen in surgical clinic for discharge follow up. Per record she was asymptomatic and her calcium levels had normalized to 8.3 mg/dL (n=8.4-10.2 mg/dL).

Conclusion: This case is an example of why hypercalcemia as a possible etiology for acute pancreatitis should remain as an essential differential diagnosis.

 

Nothing to Disclose: AC, SKM Jr.