Intraoperative parathormone increase after focused parathyroidectomy in a patient with sarcoidosis – Case report

Introduction Hypercalcaemia is most commonly a sign of primary hyperparathyroidism but can also be a sign of an active granulomatous disease. Standard treatment for primary hyperparathyroidism caused by a solitary parathyroid gland adenoma identified by localisation studies is minimally invasive focused parathyroidectomy. If unsuccessful, bilateral neck exploration is recommended. Case presentation We report the case of hypercalcaemia and ostheoporosis in a 63–year -old woman with a history of sarcoidosis and suspected primary hyperparathyroidism. Localisation studies for parathyroid adenoma were inconclusive due to active cervical and mediastinal granulomatous lymph nodes. Sarcoidosis was treated with corticosteroids but hypercalcaemia persisted. Focused parathyroidectomy was attempted with intraoperative parathyroid hormone measurement but an increase in parathyroid hormone levels was observed. However, with high clinical probability of a successfully removed adenoma and frozen section evaluation, we decided not to proceed with bilateral neck exploration. Serum parathyroid hormone and calcium levels dropped accordingly the following day. Clinical discussion We explored all possible underlying mechanisms for persistent elevated parathyroid hormone level described in literature. Conclusion We conclude that Wisconsin Criteria with intraoperative parathyroid hormone measured 20 minutes after adenoma removal should be applied in such cases.
Highlights • Primary hyperparathyroidism (PHP) and sarcoidosis can both cause hypercalcaemia. Other possible mechanisms also contribute and can present a diagnostic and therapeutic challenge. • When Miami criterion fails, it is not always necessary to proceed with bilateral neck exploration. Wisconsin criteria can be used.