A 49-year-old male, hypertensive for 2 years presented with recurrent renal colic of 6 months duration. x-Ray abdomen and intravenous pyelogram showed multiple stones in both kidneys and ureters resembling beads in a necklace (figure 1A and B) with hydronephrotic changes. His renal function tests reflected mild renal insufficiency (serum urea 55.5 mg/dl, serum creatinine 2.5 mg/dl) serum uric acid was 8.9 mg/dl. Serum calcium was 13.0 mg/dl and serum phosphate 2.9 mg/dl. Intact plasma parathyroid hormone (PTH) was ordered which came 375.1 pg/ml against normal of 14–72 pg/ml. There was a small, firm palpable nodule in the left lobe of thyroid measuring 1.5 cm in diameter. USG neck showed a well circumscribed nodule at the left lower pole of thyroid which was neither lobulated nor had any irregular margins. There was no invasion of surrounding structures. Since sestamibi has high sensitivity and specificity for localising parathyroids, a sestamibi scan was done which showed hyperfunctioning left lower parathyroid gland (figure 2).
There was no history suggestive of multiple endocrine neoplasia in the family.
Patient underwent selective parathyroidectomy of left lower parathyroid along with adenoma. Histopathology of the dissected nodular tissue was consistent with benign parathyroid adenoma (figure 3). Signs of parathyroid carcinoma, like fibrous trabecule, nuclear pleomorphism with capsular and vascular invasion, and increased mitotic figures were absent.
Postoperatively, serum calcium dropped to 7.1 mg (which subsequently improved to normal), plasma intact PTH dropped to 3.6 pg/ml. Patient remained normotensive without antihypertensive drugs. Patient underwent subsequent surgery for nephrolithiasis.