Category: Calcium/Bone Disorders

GIANT PARATHYROID ADENOMA: RARITY, SPECIAL FEATURES AND MANAGEMENT CHALLENGES

Monday, Apr 8
1:00 AM – 2:00 AM

Objective : To describe case of rare giant parathyroid and discuss the special features and management challenges.


Methods :

54-year woman, presented with symptoms of debilitating lower back pain worsening over last 7 months, making her unable to walk. After thorough evaluation, she was diagnosed with hyperfunctioning parathyroid adenoma localised using Sestamibi scan. She was also treated appropriately for overt hypercalcemia on admission. She underwent surgery to remove the parathyroid adenoma. Post operatively, her parathormone levels normalised within 24 hours. However, she developed hypocalcaemia and hungry bone syndrome and serum calcium stabilised after 8 weeks.


Results :

Physical examination: Neck: Visible swelling x 2 cm left of midline not moving with deglutition.


Endocrinology:Serum calcium= 16.4 gm/dl, Serum phosphorus= 2.1 mg /dl, Intact PTH= 1522 pg/ml.


Imaging: 99mTc body scan: Avascular necrosis of bilateral femoral head. MRI of spine:  Diffuse osteoporosis of spine with collapse of vertebral bodies. Sestamibi scan of the neck: Large hyperfunctioning solitary parathyroid adenoma in left lower pole of thyroid gland. Ultrasound Neck: Swelling in the neck reported as thyroid swelling.


FNAC neck swelling: Cytology colloid goitre.

Surgery: Patient underwent excision of the adenoma via minimally invasive technique. Specimen weight 41 grams; 4.5 x 5 x 1.8 cm.


Histopathology: Benign parathyroid adenoma.


Discussion :

Our patient suffered from debilitating symptoms of hypercalcemia. Parathyroid adenomas usually weigh below 1 gm. Giant adenomas have been defined as weight > 95th percentile or >3.5 gram.  Studies have reported that patients with giant adenomas have a diverse clinical presentation and possibly specify a functionally distinct pathophysiology [greater preoperative calcium; greater mean parathyroid hormone levels. Genetic characterisation revealed specific genomic features.  Adenoma weight has direct correlation with preoperative serum calcium and PTH and is inversely related to serum phosphate level. Following surgery in cases of larger adenomas, there is expected higher incidence of post-operative transient hypocalcaemia and lower mean serum calcium level on 3rd or 4th postoperative day.


Conclusion :

In our practice, this has been the second largest parathyroid adenoma that we have come across and as documented in the literature, larger the gland, greater is the risk of transient hypocalcaemia after surgery.  Serum calcium levels have to be more aggressively monitored promptly managed especially in giant adenomas.

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Vasanthi Nath

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes, Internal Medicine, Geriatrics
Clinical Interests: Neuroendocrinology and Neurometabolism, Metabolic Myopathies; Thyroid tumors, Geriatric Endocrinology, Inpatient Diabetes Care and Endocrine Emergencies; Type 1 diabetes across ages

Chandraprabha S

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes Metabolism
Clinical Interests: Pregnancy Diabetes, Pregnancy Thyroid Dysfunction, Women Health, Geriatric Endocrinology, Diabetes mellitus and Mental Health, Spiritual Medicine

Kavitha Muniraj

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty; Director Medical ; Director Research; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction; Diabetes Pharmacotherapy; Clinical Pharmacology; Pharmacovigilance; Clinical research Safety and Audits

Babitha D. T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes
Clinical Interests: Endocrine disorders of pregnancy, Pregnancy Diabetes, Cardiovascular Health, Thyroid, Inpatient diabetes care and endocrine metabolic emergencies

Reshma B. Vijay

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes and Metabolism
Clinical Interests: Pediatric Endocrinology; Diabetes mellitus; Insulin Pumps, Continuous Glucose Monitoring and Artificial Pancreas; Growth and Puberty; Thyroid; Pituitary Adrenal disorders

Muralidhara Krishna

Consultant Faculty Endocrinology Diabetes Biochemistry
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty: Endocrinology Diabetes Metabolism; Associate Professor: Clinical Biochemistry and Laboratory Medicine
Specialties: Endocrinology Diabetes Metabolism; Clinical Biochemistry
Clinical Interests: Diabetes mellitus; Thyroid Disorders; Obesity; Dyslipidemia.

Jayalakshmi T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty

Specialties: Endocrinology, Diabetes, Internal Medicine,
Clinical Interests: Diabetes mellitus, Cardiovascular Health, Thyroid, In Patient Diabetes Care, Endocrinology Metabolic emergencies and critical care

Nidhi Garg

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
bangalore, Karnataka, India

Designation: Senior Consultant and Faculty
Specialties: Diabetes and Metabolism
Clinical Interests: Comprehensive diabetes care, In-patient diabetes and metabolic care, Perioperative diabetes management, Diabetes and endocrine emergencies – Metabolic Intensive Care, Obesity management, Lipids and preventive cardiology, Gestational diabetes, Thyroid disorders, Type 1 diabetes across ages

Apoorva Govind

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, India

Designation: (a) Fellow: Endocrinology Diabetes Medicine, Samatvam Endocrinology Diabetes Centre and Jnana Sanjeevini Medical Centre and Diabetes Hospital ; (b) Co Investigator – Clinical Research, Samatvam Science and Research Center

Specialties: Endocrinology, Diabetes, Internal Medicine

MD Chitra

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Consultant and Faculty; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Diabetes, Obesity, Dyslipidemia, Osteoporosis, Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction;

Vasudha Srikanth


India

Sathvik Reddy Chinna Bainagari

Resident Doctor
Samatvam jnana sanjeevini Diabetes hospital and medical center
Chittoor, Andhra Pradesh, India

Namya Gaekwad

Siddartha Dinesha

Resident, Medicine Diabetes Endocrinology
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Resident: Medicine; Endocrinology Diabetes, Samatvam Endocrinology Diabetes Centre and Jnana Sanjeevini Medical Centre and Diabetes Hospital
Specialties: Endocrinology, Diabetes, Internal Medicine

Nalini Rayas

Monica Narayanaswamy

Resident doctor
Samatvam jnana sanjeevini diabetes hospital and medical centre
Chintamani, India

Sri Srikanta