Concurrent parathyroid carcinoma and adenoma: A rare presentation of a rarer disease entity
A 45-year-old male patient presented to the Medicine out patients’ department with history of gradually progressive generalized body pain, with severe pain in multiple joints of the body for past four months. He was advised to get investigated and given symptomatic treatment. The patient lost to follow up. He was brought to the emergency of the hospital a month later, with history of inability to move both lower limbs and the right upper limb for last five days.\nThe patient was admitted, and diagnosed to have bilateral femoral shaft fractures and left fracture shaft humerus. Radiological skeletal survey revealed gross osteoporosis, bilateral shaft femur fractures, fracture of the left humerus, multiple rib fractures on right side, tufting of the phalanges of the metacarpals of both hands and mottling of the skull bones [].\nHematological examinations were within normal limits, except a hemoglobin level of 8.5 g/dl. Serum urea, creatinine, sodium and potassium were within normal limits. But serum calcium was elevated to a level of 14.9 mg/dl, while serum phosphate was 2.4 mg/dl. His 24 hours urinary calcium was 1176 (Normal – 100-300). Bone marrow biopsy was also within normal limits. Serum parathyroid hormone was 1842 pg/ml (Normal – 15-65 pg/ml). Primary hyperparathyroidism was suspected and an ultrasonography of the neck done. Though clinically the neck was normal, ultrasonography of the neck [] revealed a pair of hypoechoic well defined SOLs abutting both lobes of thyroid from the posterior aspect. The one on the right side was 3.6 × 2.6 cm, and the one on the left was 1.5 × 1.2 cm in size. Both lobes of thyroid were normal and there was no evidence of lymphadenopathy. Technetium Tc99 m sestamibi scan revealed increased uptake consistent with the parathyroid gland only on the right side.\nBilateral neck exploration was planned. During exploration, a hard greyish mass of around 4 × 2 cm was seen in the area of the right inferior parathyroid gland, densely adherent to the right lobe of thyroid. Tissue from the mass was sent for frozen section and reported to be parathyroid adenoma. But in view of clinical suspicion, intraoperative findings and hard grating sensation on cutting through the mass, an en block resection of the right thyroid lobe with the parathyroid mass and adjacent soft tissues was done. On the left side the left lower parathyroid gland was seen to be enlarged to 1 × 2 cm approximately. It was firm and could be easily dissected free from the left lobe of thyroid. This gland was also excised. No lymphadenopathy was seen in the region. The upper two glands were identified and found to be normal. Intraoperative PTH assessment was not done as all four glands were identified. Post-operatively, the serum PTH came down to 16.2 pg/ml.\nThe post-operative period was uneventful and the serum calcium levels returned to normal levels within fourdays. The final histopathology revealed carcinoma of the right sided gland with capsular and vascular invasion. There was invasion into the adjacent thyroid lobe. The left lobe was reported to be a parathyroid adenoma [].\nAnemia improved and was 10 g/dl a week after surgery. The fractures were treated conservatively initially in view of the gross osteoporosis. The patient was started on bisphosphonates. Definitive fixation of the fractures was done a month later, after the bone density improved.