LBSAT309 Recurrent Nephrolithiasis As A Presenting Feature Of Primary Hyperparathyroidism

Abstract

Introduction Primary hyperparathyroidism entails hyperfunctioning of the parathyroid gland and is characterized by hypercalcemia in the setting of inappropriately normal or elevated PTH. Evidence of nephrolithiasis is an indication for surgical intervention. We present a case of primary hyperparathyroidism presenting as recurrent nephrolithiasis. Case presentation A 57 year old female with past medical history significant for hypertension, pre-diabetes and recurrent nephrolithiasis presented to the ED with subjective fever, chills and dysuria. Of note, she had a long standing history of nephrolithiasis with multiple instances of cystoscopic lithotripsy and stent placement with recurrent UTIs over the past decade. She was noted to be in septic shock secondary to urosepsis. She was managed in the ICU with broad spectrum intravenous antibiotics and pressor support. Her workup revealed hypercalcemia with serum calcium 12 mg/dL (8.6 - 10.3), albumin 3.4 g/dL (3.5 - 5.7) in the setting of inappropriately elevated parathormone PTH at 120.4 pg/ml (12 - 88). Endocrinology was consulted. Extensive chart review revealed that she had a long standing history of hypercalcemia and prior urinary calculi analysis were consistent with calcium oxalate and calcium phosphate stones. She endorsed polyuria, polydipsia, constipation and low mood. Medications were reviewed and she had not been on any agents known to cause hypercalcemia. 25 Hydroxyvitamin D was low at 20 ng/ml (30 -100) and appropriately 24 hour urine calcium was low - suppressed at 157 mg (100 - 300). The Sestamibi scan did not show an adenoma. A parathyroid ultrasound showed a possible hypoechoic area bilaterally in the parathyroid region. She underwent parathyroid exploration with excision of right superior parathyroid adenoma. Pathology report showed hypercellular parathyroid tissue consistent with a parathyroid adenoma. Post operatively, calcium and PTH value normalized. Discussion Primary hyperparathyroidism is associated with nephrolithiasis and nephrocalcinosis. Nephrolithiasis is an indication for surgical intervention. Our patient had the classic signs of primary hyperparathyroidism for at least a decade; however, it was not diagnosed until she presented with urosepsis and ended up in the ICU. Primary hyperparathyroidism is often thought of as a disease commonly seen in the outpatient setting. However, a high radar of suspicion must be maintained in both inpatient and outpatient settings as this disorder, when left untreated can have dangerous consequences. Similarly, in patients presenting with nephrolithiasis, a thorough history and physical examination in addition to a complete review of systems and medication review must be carried out to effectively rule out primary hyperparathyroidism. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.