Parathyroid adenoma and hypercalcemia in a patient presenting with multiple pathological fractures of the long bones

Abstract

The rarity and variable presentation of primary hyperparathyroidism can make its diagnosis a challenge - especially in the developing world where malnutrition may mask hypercalcaemia. Our case report is of a 25-year-old Yemeni woman who presented at AL Buraihi General Hospital with a pathological fracture of the right femur and a past history of multiple limb fractures. The diagnosis of primary hyperparathyroidism was suspected after full history and examination. It was then confirmed biochemically by raised PTH and serum calcium levels, and radiologically by ultrasonography of the patient's neck, which demonstrated a right inferior parathyroid adenoma. The patient underwent open reduction and internal fixation of her right femoral fracture but suffered a fracture of her left femur which was treated conservatively so as not to delay parathyroidectomy. Post-operatively, the patient suffered from transient hypocalcaemia, which was treated medically, and eventually went on to make a full recovery.

THERAPY OF ENDOCRINE DISEASE: Hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism: a systematic review of the literature

“…administration is often required (15,17,21,22,23,29,40). When calcium-containing solutions are given intravenously, administration into large veins or via a central venous catheter is recommended to minimise the risk of local irritation or tissue necrosis by accidental extravasation in surrounding tissues.…”

“…Severe hypocalcaemia (serum calcium concentration %2.1 mmol/l) is associated with neuromuscular irritability, clinically manifested by carpopedal spasms, perioral paresthesiae, tingling extremities, Chvostek sign and Trousseau sign (15,16,17,18,19,20,21,22,23,24,25,26). Patients can also develop generalised convulsions, which can lead to pathological fractures (27,28), and ultimately if remaining uncorrected to coma and even death.…”

“…The reported amount of calcium supplementation required to treat the severe hypocalcaemia varies between 6 and 12 g/day (17,21,23,29,40,43,44). Initially, calcium is supplemented intravenously, but treatment with oral preparations should be initiated as early as possible, with concomitant use of adequate doses of active metabolites of vitamin D (calcitriol) or alfacalcidol (2-4 mg/day) (17, 21, 22, 23, 38, 42, 43, 44), or very occasionally higher doses (unpublished personal observations), and with replenishment of magnesium stores as required.…”

“…The amount of magnesium required to correct hypomagnesaemia has not always been reported, and supplementation has been variably given intravenously as magnesium chloride or sulphate or orally as magnesium sulphate (15,17,19,22,26,38,43). In 11 of 18 cases, serum magnesium level was not mentioned, and in one of 18 cases serum magnesium level was within the normal range (16,18,21,23,24,25,27,29,40,41,42,44).…”

Finger Fractures as an Early Manifestation of Primary Hyperparathyroidism Among Young Patients

“…Currently, PHPT in younger generations is usually diagnosed only after the development of serious femoral fractures or multiple fractures, unless incidentally discovered in health checkups. 14 However, an early diagnosis of PHPT at the time of minor fractures can help to prevent further morbidities. There is a need for awareness among clinicians that fragility fractures may occur at fingers, and other major osteoporotic fracture sites, owing to PHPT in young adults.…”