CASE OF THE WEEK – "Fairly large sized parathyroid adenoma with rather unusual clinical presentation of swelling & pain in neck, difficulty in swallowing & joints pain since last two months (a case report)." by Dr. Shekhar Shikare, Consultant, Nuclear Medicine and Dr. Bashar Neamat, Specialist, Endocrinology at NMC Royal Hospital Sharjah

CASE OF THE WEEK – "Fairly large sized parathyroid adenoma with rather unusual clinical presentation of swelling & pain in neck, difficulty in swallowing & joints pain since last two months (a case report)." by Dr. Shekhar Shikare, Consultant, Nuclear Medicine and Dr. Bashar Neamat, Specialist, Endocrinology at NMC Royal Hospital Sharjah

Introduction

Primary hyperparathyroidism is a condition where the parathyroid gland produces excessive amount of parathyroid hormone which plays a key role in maintaining the calcium level in the blood within normal range.

The most common cause of primary hyperparathyroidism is a benign adenoma in one of the four parathyroid glands which constitutes around 85% of the cases. Enlargement in the four parathyroid glands is the second most common cause and responsible for about 14% of the cases. Rarely parathyroid cancer can give rise to primary hyperparathyroidism.

Excessive release of parathyroid hormone by the parathyroid glands is a direct cause of increase in the blood calcium level.

Having too much calcium in the blood can produce multiple signs and symptoms which can be summarized as "Bones, stones, abdominal groans and psychic monas".

1) Bones: Bone pains, osteoporosis and fractures.

2) Stones: Kidney stones.

3) Abdominal groans: Sickness, abdominal pain and vomiting.

4) Psychic moans: Depressive symptoms, irritability and memory impairment.

The diagnosis of primary hyperparathyroidism is confirmed biochemically by having high circulating level of calcium and PTH.

Imaging is needed to localize parathyroid adenomas and aid the surgeon in removing the diseased parathyroid gland. The hybrid SPECT CT 99mTc-MIBI scintigraphy method is suitable in determining the place of adenomas.

The Sestamibi scan is now the best method for detecting a diseased parathyroid gland before an operation. No other tests come close to it in terms of accuracy. The Sestamibi scan has 90% sensitivity and 98-100% specificity.

Case

41 years old gentleman attended the endocrinology clinic complaining of pain and swelling in neck, difficulty in swallowing, hair loss and joints pain since two months. He has an associated history of hepatomegaly and hyperlipidaemia.

On investigations he was found to have diabetes, deranged LFT and primary hyperparathyroidism.

Biochemistry

PTH 398 pg/ml (18.0- 80.1), Sr calcium 14.50 mg/dl ( 8.7-10.4), Urine calcium 500, GGT 147.0 U/L ( 8-61, Sr alkaline phosphatase 232 U/L ( 40-129, SGOT 34.20U/L ( 0-38), SGPT 68.80 U/L (0.41), Uric acid 415 umol/L ( 0-420), FBS 154.60 mg/dl ( 70-99),

USG thyroid- one large nodule 16 mm in left lobe & one 12 mm large nodule in right lobe small nodules in both the lobes of thyroid gland suggestive of multinodular goiter.

99m Tc – SESTAMIBI (389.4 MBq) HYBRID SPECT CT PARATHYROID SCAN

99mTc-MIBI PARATHYROID IMAGES (Dual isotope technique)
EARLY AND DELAYED MIBI IMAGES OF NECK AND CHEST

It shows large sized focal area of increased MIBI tracer uptakes (approximately 1.98*1.09 cms in size) seen in upper/mid medial portion of left lobe posteriorly. of the thyroid gland (Better appreciated in SPECT-CT fused images) with persistent more tracer retention in the same region on delayed washout images (Better appreciated in SPECT CT images).

Rest of the thyroid gland shows decreased tracer uptakes on early images and adequate washout pattern on delayed images.

No focal area of any abnormal tracer uptakes seen in mediastinal region.

99mTc-THYROID (178.4 MBq) IMAGES

The right lobe measures 6.2*2.7cms in size and left lobe 6.4* 2.8 cms in size approximately. Tracer distribution is inhomogeneous and asymmetrical in nature (right lobe shows better tracer uptakes in lower 2.3rd, while relatively reduced in upper 3rd portion, left lobe shows better tracer uptakes lower 3rd portion medially, while relatively reduced in rest of the gland.

THERE IS LARGE SIZED FOCAL METABOLICALLY ACTIVE PARATHYROID ADENOMA (approximately 1.98* 1.09 cms in size) SEEN UPPER/MID MEDIAL PORTION OF LEFT LOBE POSTERIORLY OF THE THYROID GLAND.


Figure 1,2,3 Right lobe shows uniformly increased tracer uptakes, while left lobe uptakes are decreased.

Figure 2
Early hybrid SPECT CT 99mTc Sestamibi parathyroid images (Coronal view)

Figure 3
Delayed hybrid SPECT CT 99mTc Sestamibi parathyroid images (Coronal view) showing focally active parathyroid adenoma in left lobe (as shown with arrow)

Figure 4
Early hybrid SPECT CT 99mTc Sestamibi parathyroid images (Axial view) showing focally active parathyroid adenoma in left lobe (as shown with arrow).

Figure 5
Early hybrid SPECT CT 99mTc Sestamibi parathyroid images (Sagital view) showing focally active parathyroid adenoma in left lobe (as shown with arrow).
Figure 6
Hybrid SPECT (CT) images showing corresponding parathyroid adenoma in left lobe.

Conclusion

Patient with hyperparathyroidism (Parathyroid adenoma) can have varying range of symptoms such as dysphagia, neck discomfort, swelling, tenderness in neck, sore throat, sore throat pain and hoarseness.

In addition, physicians should also pay attention to other series of non-specific symptoms including fatigue, irritability, cognitive impairment which can accompany hyperparathyroidism.

Parathyroid imaging can be quite helpful for surgeons to remove the diseased parathyroid gland and achieving a cure.