A RARE PRESENTATION OF ECTOPIC MEDIASTINAL PARATHYROID ADENOMA PRESENTING AS SEVERE HYPERCALCEMIA WITH ACUTE KIDNEY INJURY

Introduction:

Primary hyperparathyroidism (PHPT) is characterized by excessive production of parathyroid hormone leading to high calcium level and low phosphate and vitamin D levels. The most common causes of PHPT are parathyroid hyperplasia and parathyroid adenomas. Ectopic parathyroid glands are somewhat common with an incidence of up to 25%.There is still disagreement on what constitutes the definition of a mediastinal parathyroid gland; therefore, their reported incidence varies between 1% and 2%.Ectopic locations of the parathyroid gland are related to the embryologic migratory pathway as it descends to the target location in adulthood. 

Methods:

A 48 yr old male patient presenting as abdominal pain,vomiting,decreased appetite,weight loss,bodyache since past 2 months for which he had consulted multiple practitioners and was diagnosed as having hypercalcemia  with pancreatitis and  and was treated for the same.patient symptoms persisted and was evaluated  outside for parathyroid adenoma but sestamibi scan did not show increased uptake  and serum PTH(parathyroid hormone) values were variable outside.Subsequently patient visited to our hospital and was  admitted  with primary diagnosis of severe  hypercalcemia with AKI(acute kidney injury) ,started on iv hydration and Vitamin d and phosphorus level were normal and S. PTH -2434 .USG abdomen done showed normal sized kidney.CT NECK  was done as sestamibi scan was normal,which revealed presence of ectopic parathyroid adenoma with multiple lytic lesion, it was further confirmed with PTH Level from ectopic tissue under USG guidance  which revealed PTH -5000pg/ml.Serum protein electrophoresis done which showed no evidence of M band. Patient aki and hypercalcemia improved with iv hydration and 1 dose of inj zolendronic acid(s creatinine 3.26-1.16) .After stabilisation  surgical oncologist  reference was taken and planned for surgery accordingly .Tissue  biopsy  confirmed parathyroid adenoma

Results:

Patient aki and hypercalcemia improved following treatment.Post surgery patient improved symptomatically.Patient was observed for post surgery hypocalcemia and tetany ,and was started on iv and oral calcium supplementation .patient was adequately hydrated .He was discharged with oral calcium supplementation and had normal renal function on discharge.now patient came for follow up after one and half month  and was asymptomatic and had a weight gain of 10 kg ,appetite improved.

Conclusions:

Multiple imaging modalities may be required to diagnose ectopic parathyroid adenoma  as accurate localization is extremely important to guide surgery and reduce the rate of recurrence. In this report, we described a rare case of mediastinal ectopic parathyroid adenoma that highlighted the importance of using multiple imaging modalities to reach a curative endpoint and alone sestamibi scan may not be adequate to diagnose it.Whenever patient presents with hypercalcemia ,thorough workup should be done.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.