Discovery of Primary Hyperparathyroidism in a Patient with Nephrolithiasis and Multiple Limb Fractures
by Besim Lama1, Eva Muja (Duraku)2*, Sonil Marko3, Ilirian Laçi4
1Internal Medicine Department, University hospital of Trauma, Tirana, Albania
2Cardiology Department, Catholic Hospital Our Lady of Good Counsel, Tirana, Albania
3Internal Medicine Department, Catholic Hospital Our Lady of Good Counsel, Tirana, Albania
4Radiology Department and Nuclear Medicine, University Hospital of Tirana, Tirana, Albania
*Corresponding author: Eva Muja Duraku, Cardiology Department, Catholic Hospital Our Lady of Good Counsel, Tirana, Albania
Received Date: 14 November 2023
Accepted Date: 17 November 2023
Published Date: 21 November 2023
Citation: Lama B, Muja E, Marko S, Laçi I (2023) Discovery of Primary Hyperparathyroidism in a Patient with Nephrolithiasis and Multiple Limb Fractures. Ann Case Report 8: 1517. https://doi.org/10.29011/2574-7754.101517
Abstract
Primary hyperparathyroidism (PHPT) is an endocrine disorder characterized by excess secretion of parathyroid hormone (PTH), resulting from the hyperfunction of one or more of the parathyroid glands. The leading cause of primary hyperparathyroidism is the solitary parathyroid adenoma in 80% to 85% of cases [1–4]. Secondary causes include parathyroid hyperplasia (10% to 15% of cases), multiple adenomas (5% of cases), and rarely parathyroid cancer (<1% to 5% of cases) [1,2]. Biochemical distinctive features are hypercalcemia and high or inappropriately normal PTH (1-3). The prevalence of primary hyperparathyroidism is approximately 1–7 per 1000 in the general population, affecting predominantly postmenopausal women [4]. Consequences, in this case, are nephrocalcinosis, renal lithiasis, and spontaneous fractures in the field of osteoporosis.
Keywords: Primary Hyperparathyroidism; Parathyroid Adenoma; Renal Calculus; Spontaneous Fracture
Case Report
A 66-year-old female patient presented to the Trauma Hospital Emergency after a light fall in the apartment, with pain in the right leg. She was diagnosed with trochanteric fracture of the right femur and was hospitalized in the Orthopedic department.
In 2008, the patient was diagnosed with Fracture of the right humerus from a very light fall. The fracture was treated with immobilization and after 6 weeks she had 25 radiotherapy sessions for an undetermined mass at the site of the fracture. In 2009, the patient was diagnosed with a fracture of the left femur, which occurred without any stimulus other than shock or radiation, for which intervention was performed. In 2013, in a routine abdominal echography, numerous calculi with different dimensions were observed in both kidneys (Figure 1).
Figure 1: Radiography of the treated fracture of the femur
In 2015 and 2016, the patient performed surgical procedure for the calculi removal. In 2018, the patient was diagnosed with Chronic Renal Disease and was followed regularly by a nephrologist. Meanwhile, the patient during this period was treated also with stage 2 arterial hypertension. In December 2022, the patient was diagnosed with Acute Pancreatitis, for which she was treated in hospital.
Based on the patient’s anamnesis, medical and surgical antecedents, radiological laboratory examinations (x-ray, scintigraphy, echography) are performed, resulting in a positive diagnosis of Primary Hyperparathyroidism caused by Parathyroid Adenoma, and manifested with multiply fractures and nephrocalcinosis (Figure 2).
Figure 2: Abdominal CT scan showing nephrolithiasis.
Laboratory examination results
Urea 104 mg/dl, creatinine 2.42 mg/dl, calcium 10.4 mg/dl, ionized calcium 1.37 mmol/l, phosphoremia 3.5 mg/dl, potassium 4.33 mmol/l, total protein 6.7 g/dl, albuminemia 3.5 g/dl.
LDH 106 u/l, ferritin 1023.62 ng/ml, TSH 0.029 mu/l, ft4 0.59 pmol/l (0.7-1.48), ft3 ng/l (1.58-3.91), urine complete; leukocyte fields filled, erythrocyte fields filled. PTH 1492 ng/l (1565). Eco of the thyroid and parathyroid gland showed an adenoma of the left inferior parathyroid gland measuring 2 x 3 cm.
Scintigraphy of the parathyroid gland resulted in a massive adenoma of the left parathyroid.
Under these conditions, the patient was scheduled for surgical intervention, where she first started treatment with Rocaltrol 0.25 mg 2 times 2 tablets a day and calcium gluconate 500 mg 3 times 1 tablet a day [5].
On the scheduled date, the patient underwent the inferior sinister parathyroidectomy (Figure 3,4)