Category: Calcium/Bone Disorders

Monitor: 3

3 - HALLUCINATIONS AND PARANOIA IN THE SETTING OF AN INTRATHYROID PARATHYROID HORMONE SECRETING NODULE

Saturday, Apr 27
10:30 AM – 11:00 AM

Objective :

Hypercalcemia typically presents with bone disease, renal stones, abdominal symptoms and cognitive changes. Here we present a case of severe primary hyperparathyroidism (PHPT) from a 2.4 cm nodular lesion in the right thyroid lobe with presenting symptoms of severe paranoia and threatening hallucinations.


Methods : Review of a case of a patient with PHPT with symptomatic hypercalcemia necessitating resection of a parathyroid hormone (PTH) secreting nodule in the thyroid.


Results :

A 54 year old woman with no past medical history presented to the hospital with three weeks of hallucinations, paranoia, headache and lower extremity pain, and was found to have a calcium of 14.4 mg/dL, albumin 4.0 g/dL, PTH of 759 pg/mL, and phosphorus 2.0 mg/dL. Her hypercalcemia was treated with intravenous fluids, calcitonin, and zoledronic acid which only lowered her corrected calcium to 12.0 mg/dL. Psychosis symptoms persisted prompting psychiatric consultation and antipsychotic medications. Ongoing workup showed a repeat PTH of 3860 pg/mL and a 2.4 cm nodule in the right lower thyroid pole on ultrasound. Sestamibi scan was negative for a parathyroid adenoma. Fine needle aspiration of the nodule showed normal parathyroid issue with washings revealing PTH level of 30,080 pg/mL. Pathology could not rule out malignancy and patient had resection of right thyroid lobe. Intraoperatively, there was dense inflammatory reaction of the right thyroid gland to the sternothyroid muscle, suggesting possible local invasion. PTH levels steadily decreased intraoperatively and was 8 mg/dL on post-operative day 1 and corrected calcium of 10 mg/dL. Post-operatively, her psychosis persisted but slowly improved until day of discharge.


Discussion :

PHPT is caused by either parathyroid hyperplasia, adenoma or carcinoma. Here we present a nodule within the thyroid gland secreting extremely high levels of PTH in a patient symptomatic from hypercalcemia. Surgery is definitive treatment, but an atypical presentation of an intrathyroidal parathyroid adenoma, which has a known incidence of less than 3%, delayed diagnosis. The extremely elevated PTH suggested possible parathyroid carcinoma. Parathyroid carcinoma involves local invasion or distant metastases, neither of which were directly observed during the procedure, but surgical pathology can further raise suspicion and follow-up may yield more answers.


Conclusion :

This case characterizes psychosis of extreme hypercalcemia and a PTH secreting nodule in the thyroid, and the concerns one should have for underlying parathyroid carcinoma

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Robert H. Gaffey

Medical Student
Rutgers- Robert Wood Johnson Medical School
New Brunswick, New Jersey

Robert Gaffey is a 3rd year medical student at Rutgers- Robert Wood Johnson Medical School.

Eric Pagan

Medical Resident
Medical Resident

Resident

Briette V. Karanfillian

Internal Medicine Resident
Rutgers- Robert Wood Johnson Medical School
New Brunswick, New Jersey

Current Internal Medicine Resident at Rutgers- Robert Wood Johnson Medical School. Graduate of Rutgers- Robert Wood Johnson Medical School.

Sahil Parikh

Endocrinology Fellow
Robert Wood Johnson Medical School
New Brunswick, New Jersey

First year endocrinology fellow.

Ankit Shah

Assistant Professor
Rutgers Robert Wood Johnson Medical School

I am an assistant professor of medicine and endocrinologist at Rutgers Robert Wood Johnson Medical School.