CASES OF THE WEEK - “Unusual Presentation of Primary Hyperparathyroidism” by Dr Shekhar Shikare, Consultant & HOD, Nuclear Medicine, NMC Royal Hospital Sharjah

CASES OF THE WEEK - “Unusual Presentation of Primary Hyperparathyroidism” by Dr Shekhar Shikare, Consultant & HOD, Nuclear Medicine, NMC Royal Hospital Sharjah

Unusual Presentation of Primary Hyperparathyroidism

Metabolic bone disease is the third most common endocrine disorders after diabetes and thyroid diseases. The common metabolic bone diseases (MBD) include osteoporosis, rickets/ osteomalacia, flurosis and primary hyperparathyroidism (PHPT), while the rare MBDs include Paget's disease, tumor induced osteomalacia, fibrous dysplasia, osteogenesis imperfecta and so on.

Bone disease in severe primary hyperparathyroidism (PHPT) is described classically as osteitis fibrosa cystica (OFC). Bone pain, skeletal deformities and pathological fractures are features of OFC. Bone mineral density is usually extremely low in OFC, but it is reversible after surgical cure.

What are the complications of primary hyperparathyroidism?

Weakened bone. High PTH levels trigger the bones to release more calcium than normal into the blood. The loss of calcium from the bones may weaken them. 2 Kidney stones. The small intestine may absorb more calcium from food, adding to high levels of calcium in your blood. 3 Other complications. High blood calcium levels might play a part in other problems, such as heart disease, high blood pressure, and trouble concentrating.

Case

Seventeen years old girl with history of fall and sustained fracture left proximal shaft humorous, thought to be pathological and hence referred for 99mTc MDP Whole Body Bone Scan 99mTc MDP Whole body Bone scan shows features of metabolic bone disease (Hungary bone pattern i.e. increased tracer uptakes in skull bones, long bones and axial skeletal with non-visualization of kidney uptakes mimicking like super scan / beautiful

scan) as shown in images. Nucl Med Rev Cent East Eur. 2012 Aug 25;15(2):124-31.Bone scan in metabolic bone diseases.

Review.

On subsequent biochemical investigations found to have elevated parathormone, calcium levels and low phosphorous levels and suspected hyperparathyroidism.

Referred for Technetium-Thallium 201 parathyroid subtraction scan and it shows presence of large sized left lobe parathyroid adenoma inferiorly (as shown in images). Arch Intern Med. 1986 Jun;146(6):1077-80. Thallium-technetium parathyroid scan. A useful noninvasive technique for localization of abnormal parathyroid tissue.

Surgery- Confirmed the large sized left lobe parathyroid adenoma inferiorly and on follow up patient is doing well.

Hyperparathyroidism involves functional and morphologic parathyroid abnormalities and leads to skeletal changes in many cases.

Parathyroid scintigraphy and whole-body bone scans can demonstrate abnormal parathyroid uptake and skeletal changes caused by hyperparathyroidism. We illustrate a case of a typical parathyroid adenoma and its bone changes on whole-body bone scan and Tc-Tl201 subtraction parathyroid imaging.

Unique Cases 055b