1. A Case of Hyperparathyroidism Presenting With Diffuse Pain
Asena Coşgun*, Sabiha Banu Denizeri*, Ayşe Palanduz*, Buğu Usanma Koban** * Istanbul University, Istanbul Faculty of Medicine, Department of Family Medicine **Haydarpaşa Numune Education and Research Hospital, Department of Family Medicine
INTRODUCTION AND AIM
Diffuse pain is a frequent complaint in primary care. Hypercalsemia should be considered in its diferential diagnosis and ethiology. Effects of hypercalsemia in the muscloskeletal system are muscle weakness, bone pain and osteopenia/osteoporosis (1). Primary hyperparathyroidism is the most common reason of hypercalsemia (2). It is frequently seen in postmenopausal women. Parathyroid adenomas can be the cause. In this case, we aimed to emphasize the importance of hypercalsemia in the differential diagnosis of patients presenting with diffuse pain.
CASE
A 64 year old woman, presented to our clinic with diffuse pain which continued for 7 months. A year ago, at another health center, her bone mass dansity (BMD) T-scores were -2.8 for vertebra and -2.3 for femur. Alendronat therapy was initiated with the diagnosis of osteoporosis. Alendronat was stopped because of the side effects; calcium and vitamin D was started. When she applied to our clinic she was taking calcium and vitamin D pills. Her physical examination revealed a palpable right thyroid lobe. Hypercalcemia (12.6 mg/dL) and hyperparathyroidism (261 pg/ml) was detected in her laboratory findings (Table). Her T score in 1/3 distal radius was The calcium pills were stopped. At her thyroid ultrasound, an 8 mm hyperechoic solid nodul at the right lobe of the thyroid gland was seen. In the thyroid scintigraphy, a solitary nodule, which was compatible with parathyroid mass, was seen (Figure). Endocrinology and surgery consultation was done and after achieving eucalcemia surgical excision was planned. Infusion with saline solution and İV furosemide was given for hypercalcemia therapy. After eucalcemia was achieved, the lower right parathyroid gland was excised. Pathology report was compatible with parathyroid adenoma. In the postoperative follow-up, serum calcium and parathyroid hormone levels were in the normal range and her complaints regressed.
Table- Laboratory Findings
Figure- Parathyroid Scintigraphy
Laboratory Findings
Referance Range
Serum calcium
12.6
mg/dL
Serum phosphorus
2.3
mg/dL
Alkaline phosphatase 80
U/L
Parathyroid hormone (PTH)
261
pg/ml
Urine calcium
568
mg/gün
25-OH-D vitamin
ng/ml
Parathyroid Scintigraphy Dual Phase MIBI+ SPECT :
An 8mm lesion at the right lobe in the posteriomedial region of the thyroid gland, showing high MIBI enhancement, was found compatible with a parathyroid mass.
RESULT AND DISCUSSION
As a result calcium, vitamin D and PTH values should be seen in patients with diffuse pain, keeping in mind the possibilty of hypercalcemia and hyperparathyroidism. When the literature is reviewed, patients with hyperparathyroidism presenting with diffuse or local pain similar to our case, have been reported (3). Osteoporosis should be kept in mind for postmenopausal women in the differential diagnosis of diffuse pain. For this reason, we don’t recommend prescribing calcium supplements before checking serum calcium levels.
REFERANCES
Ghada El­Hajj Fuleihan, Shonni J Silverberg,Clifford J Rosen, Jean E Mulder, Primary hyperparathyroidism: Clinical manifestations, UpToDate,2016.
Türkiye Endokrinoloji ve Metabolizma Derneği, Metabolik Kemik Hastalıkları Tanı ve Tedavi Kılavuzu, 2015
Hui-I Yu, Chich-Hsiang Lu, Arch Osteoporos, Sacroiliitis-like pain as the initial presentation of primary hyperparathyroidism (2012).