The difficulties of differential diagnosis of severe hyperparathyroidism detected in esrd patient (clinical observation)

Astract. Clinical observation of a 57-year-old woman who underwent cholecystectomy performed for calculous cholecystitis in the age of 46 years is reported. Four years later staghorn stones were found in both kidneys and chronic kidney disease (CKD) was diagnosed (blood creatinine level 272 mM). Then nephrolithotomy, nephrostomy, left nephrectomy were performed. At the age of 54 years, cancer of the left breast (T3N0M0) was diagnosed and operated. In preoperative checkup, the total and serum ionized calcium were 2.47 mM and 1.46 mM, respectively. Parathyroid hormone (PTH) was 1486 pg/ml, albumin 42 g/L. 99mTc-sestamibi scintigraphy shown a zone of hyperfixation of radiopharmaceutical agent in the lower segment of the right lobe (27×20 mm). Five months later the patient was transferred to hemodialysis, however then she was diagnosed with severe hyperparathyroidism (HPT): PTH 1278 pg/ml, serum calcium 2.7 mM, phosphorus 2.2 mM, alkaline phosphatase 152 u/l (norm 30-115). Neck ultrasonography revealed a hypoechoic nodular formation with clear margins (26×16×10 mm, V=2177 mm3) in the projection of the right lower parathyroid gland (PTG). Computer tomography revealed an elongated formation in the posterior surface of the right lobe of the thyroid gland: 27 mm (antero-posterior) x 18 mm (transverse) x 31 mm (cranio-caudal); staghorn stone in the right kidney; calcification of the coronary artery; calcified focuses in liver and in spleen. Bone mineral densitometry revealed osteoporosis in the 1/3 of radial bone (T-score -2.5). Echocardiography have shown a calcification of the aortic and mitral valves. Surgical parathyroidectomy was performed. A single nodal education was detect and removed. Pathologist conclusion: an encapsulated unit (weight 6 g, 3.5×2.5×1.0 cm); histologically - PTG adenoma made of the main type cells with follicular and trabecular growth type. The «hungry bone syndrome» was observed postoperatively with PTH 81 pg/ml. Six months later secondary HPT has developed.

Околощитовидные железы, аденома, первичный гиперпаратиреоз, хроническая болезнь почек, Parathyroid gland, adenoma, primary hyperparathyroidism, chronic kidney disease

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