Large parathyroid adenoma presenting as a femoral fracture in a young male

doi:10.4236/crcm.2013.28120

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Vol.2, No.8, 457-459 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.28120

Large parathyroid adenoma presenting as a femoral

fracture in a young male

Duncan Light*, Chakri Munipalle, Vijay Kurup

General Surgery, North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees, UK;

*Corresponding Author: [email protected]

Received 16 September 2013; revised 13 October 2013; accepted 2 November 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Parathyr oid adenoma classical ly prese nt s symp-

toms of hypercalcaemia. Here, we present a

case of a rare presentation of a parathyroid ade-

noma in a young male patient with a pathologi-

cal fracture.

Keyw ords: Parathyroid Adenoma; Hypercalca emia;

Femoral Fracture

1. INTRODUCTION

Osteoporosis secondary to hyperparathyroidism is a

rare presentatio n in young patients. Th e case study below

illustrates a case of a young male who presents a

pathological fracture secondary to giant parathyroid ade-

noma.

2. CASE PRESENTATION

A 27-years-old male presented to the emergency de-

partment with femoral fracture following a fall onto his

left hip (Figure 1). He had been previously fit and well

though he had developed increasing thirst and lethargy in

the preceeding weeks. He was of normal build and nu-

tritional status. He underwent a femoral nail the fol-

lowing day. Initial investigations revealed a corrected

calcium of 3.32 and PTH of 2.7. Other biochemical tests

were normal. Sestamibi scan showed a likely parathyro id

adenoma in the right inferior pole of the thyroid gland

(Figure 2). An ultrasound of his neck confirmed the

finding. He was taken for neck exploration where the

diagnosis was confirmed and a large parathyroid ade-

noma weighing 4 grams was removed (Figures 3 and 4).

Histology did not reveal any evidence of malignancy and

subsequent phenotyping excluded the presence of MEN

syndrome. Over the subsequent weeks his calcium level

rose and at 6 months follow-up his calcium level had

returned to normal and he was asymptomatic.

3. DISCUSSION

Hyperparathyroidism commonly presents with

symptoms of hypercalcaemia such as abdominal pain,

bone pain, fatigue, depression and nephrolithiasis. It can

be classified into three main groups. Primary hyper-

parathyroidism is due to parathyroid adenoma in 85% of

patients, the remainder are due to multiple adenomas and

parathyroid cancers. It affects 1 in 2000 men annually.

Secondary hyperparathyroidism is due to chronic vitamin

D deficiency as a result of chronic renal failure. Tertiary

hyperparathyroidism is a result of autonomous parathy-

roid stimulation following a period of persistent parathy-

roid stimulation. Biochemical investigations reveal raised

calcium, raised PTH and decrease in phosphate levels in

the blood. Urinary calcium will be low in comparison to

Figure 1. Femoral fracture.

D. Light et al. / Case Reports in Clinical Medicine 2 (2013) 4 57-459

458

Figure 2. Sestamibi scan.

Figure 3. Excision of a large parathyroid adenoma.

Figure 4. Excised parathyroid adenoma.

familial hypercalcaemia hypocalciuria.

Pathological fractures are rare in young adults. A

pathological fracture is defined as a fracture which oc-

curs without adequate trauma and is caused by a pre-

existent pathological bone lesion. Causes include resorp-

tion of bone mass (osteoporosis, hyperpara-thyroidism),

reduction of bone quality (osteomalacia, osteonecrosis),

insufficient bone production (osteogenesis imperfecta,

fibrous dysplasia), au gmented bone resorption (giant cell

granulomas, aneurysmal bone cyst), pathological bone

remodelling (Paget's disease) or local bone destruction

due to malignancy. It must be detected clinically as well

as radiologically and its cause diagnosed histologically in

order to ensure adequate therapy.

Pathological fracture in severe hyperparathyroidism

can be associated with osteitis fibrosa cystica. It can be

seen as a classical skeletal complication of hyperpara-

thyroidism in some patients, although it is rare in the

modern era. It occurs in approximately 2% of individuals

diagnosed with hyperparathyroidism [1]. It is associated

with a loss of bone mass due to increased osteoclast ac-

tivity in the matrix secondary to raised PTH. In additio n,

there is experimental evidence that elevated PTH secre-

tion may be implicated in the enhanced degradation of

25-hydroxy-vitamin D which could contribute to the for-

mation of osteoporosis. As a result there is a weakening

of the bones as their calcified supporting structures are

replaced with fibrous tissue and the formation of cyst-

like brown tumors in and around the bone increasing the

risk of fracture. A number of studies have confirmed that

there is a both an increased risk of fracture in patients

with primary hyperparathyroidism and a reduced risk of

fractures i n p atients who u nderg o pa ra thyroidecto my [2].

The use of preoperative localisation studies is contro-

versial. Main methods of imaging are ultrasound, com-

puted tomography and nuclear imaging. Technetium Tc

99 m sestamibi is the radio-pharmacological agent of

choice, with a sensitivity reported to be between 72% -

100% [3]. One reason for the controversy around sesta-

mibi is the variable quality and accuracy of scans be-

tween different units. This is also countered by the fact

that studies have shown that experienced surgeons have a

90% - 95% cure rate in patients who undergo neck

exploration for the first time. A recent study has shown

that sestamibi combined with ultrasound increases the

accuracy of detection for parathyroid adenomas [4].

Surgical management is the main modality of treat-

ment in parathyroid adenoma. It involves resection of the

parathyroid gland by traditional neck exploration or

minimally invasive parathyroidectomy. As yet there is no

definitive evidence for the benefit of either technique

over the other. There is however a growing trend towards

minimally invasive surgery either through preoperatively

localised single gland excision or intraoperative locali-

D. Light et al. / Case Reports in Clinical Medicine 2 (2013) 4 57-459

459

[2] VanderWalde, L.H., Liu, I.L. and Haigh, P.I. (2009) Ef-

fect of bone mineral density and parathyroidectomy on

fracture risk in primary hyperparathyroidism. World Jour-

nal of Surgery, 33, 406-411.

sation. Indeed, in a number of asian countries there is a

growing trend towards parathyroid surgery via remote

endoscopic access through the axilla and chest due to

patients reluctance to have incisions visible in the neck

[5]. [3] Shen, W., Sabanci, U., Morita , E.T., Si perstein, A.E., Duh,

Q.Y. and Clark, O.H. (1997) Sestamibi scanning is in-

adequate for directing unilateral neck exploration for

first-time parathyroidectomy. Archives of Surgery, 132,

969-976.

http://dx.doi.org/10.1001/archsurg.1997.01430330035005

Another facet of modern parathyroid surgery is intra-

operative monitoring of parathyroid hormone levels. Due

to the short half-life of parathyroid hormone in the blood

stream, it is possible to assess operative success with

serum PTH levels intra-operatively. It is also possible to

perform recurrent laryngeal monitoring intraoperatively

although this is still controversial and neither technique

has become standar d pr a ctice.

[4] Patel, C.N., Salahudeen, H.M., Lansdown, M. and Scars-

brook, A.F. (2010) Clinical utility of ultrasound and 99

mTc sestamibi SPECT/CT for preoperative localization of

parathyroid adenoma in patients with primary hyperpara-

thyroidism. Clinical Radiology, 65, 278-287.

[5] Lang, B. (2009) Minimally invasive thyroid and parathy-

roid surgery.

http://www.fmshk.org/database/articles/03mb2_6.pdf

4. CONCLUSION

This case illustrates a rare presentation of a large para-

thyroid adenoma in a young patient and the successful

management of complications with surgery.

REFERENCES

[1] Kronenberg, H.M., Schlomo, M., Polansky, K.S. and

Larsen, P.R. (2008) The parathyroid glands, hypercalce-

mia, and hypocalcemia. Williams textbook of endocri-

nology. 11th Edition, WB Saunders, St. Louis, Chapter

266.