On July 21, 2012 a 71-year-old Caucasian woman with primary hyperparathyroidism awaiting surgery because of significant hypercalcemia and hypercalciuria presented to her local emergency department after acute onset of discomfort within her neck that ran transversely from left to right from the mid to lower neck, sore throat, and difficulty swallowing that had progressively gotten worse over the previous 3 days. She denied chest pain, jaw pain, arm pain, fever, or vomiting. Her past medical history included primary hyperparathyroidism, diagnosed eight months previously, which was due to a left sided parathyroid adenoma. The patient was subsequently scheduled for parathyroid surgery. Prior to this acute event, her parathyroid hormone had been elevated, with concurrent hypercalcemia, hypophosphatemia, and an increased ionized calcium level ().
Laboratory findings indicating hyperparathyroidism.
A CT scan performed in the emergency department showed a 2.1 × 2.4 × 3.6
cm soft tissue mass posterior to the left thyroid, lateral to the esophagus, and abutting the anterior aspect of the C5-C6 vertebral bodies. Localization of this adenoma was consistent with previous findings resulting from a sestamibi scan. Laboratory data in the emergency department revealed hypocalcemia (8.1
mg/dL), a negative rapid strep test, and a normal white blood cell count (6.6/mm3
). The patient was discharged with a diagnosis of retropharyngeal mass and instructed to followup with a surgeon in two days.
Three days following emergency department discharge (July 24, 2012), the patient reported to her endocrinologist for followup. An ultrasound performed that day reported a soft tissue mass posterior to the left lobe of the thyroid measuring 3.3 × 1.2 × 1.3
cm, results consistent with a parathyroid adenoma. Follow-up laboratory data revealed normal calcium, PTH, and phosphate levels of 8.77
pg/mL, and 2.71
mg/dL, respectively. A second ultrasound performed 16 days after the emergency department visit demonstrated a decrease in the mass to 2.0
cm. Based on the patient's reported symptoms, sudden decrease in PTH and calcium levels, and decrease in size of the adenoma, the patient was diagnosed with infarction of her left lower parathyroid adenoma. The scheduled parathyroid surgery was canceled, and, because of the possibility of parathyroid adenoma recurrence, the patient was counseled to continue routine followup with her endocrinologist.