Parathyroid Crisis: An Uncommon Etiology for an Acute Pancreatitis

Presentation Number: LB MON 47
Date of Presentation: April 3rd, 2017

Ernesto Sola Sanchez*1, Michelle M Mangual2 and Alex Gonzalez Bossolo3
1San Juan City Hospital, 2Sa, San Juan, PR, 3San Juan City Hospital, San Juan, PR

Abstract

Parathyroid crisis is a rare and fatal presentation of primary hyperparathyroidism. It has been described in approximately 200 cases worldwide1, and in 1-2% among patients with primary hyperparathyroidism (PHPT). This condition could be the initial presentation of PHPT or an acute exacerbation of a preexisting PHPT. Severe hypercalcemia with hemodynamically instability is the most common presentation and could be life threatening if it is not recognized. Diagnosis is made with severe hypercalcemia (usually >15 mg/dl), marked symptoms of hypercalcemia (mental status changes, bone disease, nephrolithiasis, pancreatitis) and intact PTH on average above 20 times the upper limit of normal2,3. We present a case of a 34 y/o woman with severe pancreatitis secondary to parathyroid storm who stabilized with bisphosphonate therapy.

A 34 y/o female patient G2P0 with medical history of HBP on enalapril 10 mg daily came to ER complaining of sudden abdominal pain. The pain was sharp and stabbing-like, 10/10 intensity, localized in the epigastric region with radiation to the back and umbilicus. Abdominal pain was associated with fever, nausea, multiple episodes of non-bloody vomiting, decreased appetite, polydipsia, polyuria and weight loss. Vital signs were remarkable for sinus tachycardia. EKG with no QT segment alterations. Physical examination was remarkable for an acutely ill patient with dry mucosa and severe tenderness to palpation on epigastric area with signs of peritoneal irritation. Laboratories showed marked leukocytosis (19.5) with left shifting (86.1%), pre-renal azotemia, Ca 19.6, amylase: 1,160, lipase: 28,870, AST: 37, ALT: 28 and ALP: 680 with normal GGT. Abdominopelvic CT scan findings correlated with acute pancreatitis. No adrenal adenomas. Patient was admitted to ICU. Hypercalcemia work up showed intact PTH: 363 (33 times the upper limit of normal), PTHrP negative, 1,25 Vit D elevated and normal TFTs. She was treated with more than 10 liter of saline infusion, however hypercalcemia persisted. One dose of pamidronate 90 mg IV was given and serum calcium stabilized to 9.5 mg/dl. Thyroid US showed a 5 mm hypoechoic nodule with negative serum calcitonin therefore MEN type 2 was ruled out. A Parathyroid Sestamibi Scan reported a right parathyroid adenoma. Hypercalcemia resolved with no systemic complications. The final diagnosis was a parathyroid crisis with severe pancreatitis as her first manifestation of primary hyperparathyroidism. At this time she is on schedule for surgery. The most likely etiology of this event could be a parathyroid carcinoma (given the aggressive initial presentation) vs infarction/hemorrhage at the adenoma among others such as an acute illness as a precipitant factor or severe volume contraction. Prompt diagnosis and treatment was fundamental in our patient’s outcome that for this condition on literature it is described to have an almost 100% mortality4.

 

Nothing to Disclose: ES, MMM, AG