Severe Primary Hyperparathyroidism Masked by Profound Vitamin D Deficiency Presenting With an Atraumatic Fragility Fracture

Abstract

The coexistence of mild primary hyperparathyroidism (PHP) and vitamin D deficiency (VDD) is common and usually presents with hypercalcemia and mild metabolic bone disease. We present a young man with severe PHP and profound VDD who was completely asymptomatic until he sustained an atraumatic hip fracture. His total and ionized serum calcium were normal, intact parathyroid hormone (iPTH) was markedly elevated, and 25-hydroxyvitamin D (25(OH)D) was undetectable. He had highly elevated markers of bone turnover and radiologic evidence of severe bone disease. After removal of a large benign parathyroid adenoma and long-term replacement with calcium and vitamin D, the patient showed marked improvement in bone mineral density (BMD). We also describe detailed follow-up of the gradual changes and near normalization of bone turnover markers and iPTH levels over an 18-month period. This case illustrates that severe PHP can be masked by profound VDD and may remain undetected before the occurrence of a fragility fracture. Key Words: primary hyperparathyroidism, vitamin D deficiency, metabolic bone disease, atraumatic bone fracture (The Endocrinologist 2008;18: 300 -303) Learning Objectives• Explain the effects of vitamin D deficiency on the clinical picture of hyperparathyroidism.• Summarize the effects of vitamin D repletion on coexistent hyperthyroidism.

Hypovitaminosis D masking hypercalcemia in primary hyperparathyroidism: case report

“…Three similar cases were previously reported. [9][10][11] Two females and one male, middle aged between 21 and 43 years. They showed multiple similarities to the present reported case.…”