Category: Calcium/Bone Disorders
Parathyroid adenomas encompass 85% of all cases of primary hyperparathyroidism. Of these cases, there are a few select cases that fall under the subcategory of Giant Parathyroid Adenoma (GPA); adenomas weighing more than 2 g fall under this pathology. GPAs tend to present with higher calcium and parathyroid hormone (PTH) concentrations than other parathyroid adenomas. We present a case of GPA where dialysis was the mainstay therapy for the management of hypercalcemia.
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58 year old male with PMH of bladder cancer (currently in remission) presenting initially for weakness and low back pain for 3 weeks. While being evaluated in the ER, he was found to have a calcium level >20.1 mg/dL. He was awake, alert and oriented. His speech was sluggish but he was able to answer questions appropriately. He had no EKG changes. Other notable labs include phosphorus of 4.4 mg/dL, magnesium 1.7 mg/dL, creatinine 4.54 mg/dL, ionized calcium 2.57 mmol/L, 1, 25-dihydroxyvitamin D 7.6 ng/dL, 25-hydroxyvitamin D 22.5 ng/dL and PTH 1444 pg/nL. He denied any history of kidney disease or renal stones. Neck US, 4D CT of the neck, MRI of the neck and sestamibi scan all consistently showed a very large right lower parathyroid adenoma.
Patient was oliguric with acute renal injury, which limited conventional medical therapy. He was started on IV fluids but ultimately was taken to dialysis immediately due to his renal status. Although patient received medical management with calcitonin, pamidronate 45mg IV, cinacalcet (titrated up to 90 mg bid), and IV hydration, dialysis was ultimately the treatment that reduced his calcium concentration to allow for surgical intervention. He received hemodialysis 7 of his 9 inpatient days preceding surgery. During surgery, no invasion was noted. Final pathology was consistent with a benign GPA weighing 4 g and measuring 3.5 x 2.2 x 1.1 cm.
We present a case of refractory hypercalcemia due to GPA that only responded to repeated sessions of hemodialysis. Dialysis is typically considered a “last resort” treatment for hypercalcemia, but in patients with renal failure and persistently high calcium levels, dialysis should be considered earlier.
Trisha Newaz– Endocrinology Fellow, Northwell Health- Lenox Hill Hospital, Bronx, New York
Arpita Bhalodkar– Endocrinology Fellow, Northwell Health- Lenox Hill Hospital, new york, New York
Emilia Liao– Endocrinology Attending, Northwell Health-Lenox Hill Hospital, New YOrk, New York
Northwell Health- Lenox Hill Hospital
Bronx, New York
Trisha Newaz is an endocrinology fellow training at Lenox Hill Hospital in New York City. She is currently in her second year of fellowship. She went to Stony Brook University for her Bachelors in Science and Masters is Science. For medical school, she attended NYIT- College of Osteopathic Medicine. Her residency training was also completed at Lenox Hill Hospital.
Northwell Health- Lenox Hill Hospital
new york, New York
Arpita Bhalodkar is endocrinology fellow at Lenox Hill Hospital in NYC. She is in her first year of fellowship. She went to NYIT for her Bachelors in Science and AUA for medical school. She trained in Bronx Lebanon hospital for residency in Bronx, NY.
Northwell Health-Lenox Hill Hospital
New YOrk, New York
Dr. Emilia Pauline Liao earned a Bachelor of Science at Massachusetts Institute of Technology and graduated medical school from Albany Medical College. She completed internal medicine residency at NJ Medical School (Rutgers-Newark), where she was Chief Resident and completed fellowship in endocrinology at Mount Sinai School of Medicine. Dr. Liao is currently part of the endocrinology division at Northwell Health Lenox Hill Hospital in New York City, where she is program director for the endocrinology fellowship.