E-Poster Presentation ESA-SRB-ANZBMS 2021

A case of recurrent hyperparathyroidism after parathyroidectomy with autotransplantation (#383)

Reetu Gogna 1 , Kate Flentje 1 , John Burgess 1 2
  1. Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
  2. School of Medicine, University of Tasmania, Hobart, Tasmania, Australia

Introduction

Primary hyperparathyroidism (PHPT) is the most frequent manifestation of Multiple Endocrine Neoplasia 1 (MEN 1) developing in almost all carriers by 50 years of age. However, recurrence is reduced after near total parathyroidectomy with parathyroid auto-transplantation.

Case

A 40-year-old woman with MEN 1 underwent near total parathyroidectomy with left forearm auto-transplantation for hyperparathyroidism twenty years prior but was unfortunately lost to follow up. She was referred to the Endocrine Neoplasia Clinic for ongoing management of MEN 1 and was found to be hypercalcaemic, ionised calcium 1.41mmol/L [1.14 – 1.29], with an inappropriately normal parathyroid hormone (PTH) 3.18 pmol/L [0.32 – 8.2] with adequate vitamin D levels. She was asymptomatic. A parathyroid sestamibi scan demonstrated persistent activity in the proximal left forearm without any abnormal neck or mediastinal activity. A left/right arm study was performed to substantiate these results. Venous blood was taken from the left arm 2 minutes after tourniquet application proximal to the transplant site. Subsequently, blood was drawn from the right arm with the left arm tourniquet still in situ. The samples demonstrated a significantly elevated PTH from the left arm sample at 37 pmol/L and undetectable PTH from the right arm sample. Ultrasound of the neck and forearm demonstrated no neck abnormality but two left forearm hypoechoic masses at the transplant site; 9x2mm and 6x3mm, both with prominent vascularity. These findings were consistent with hyperplastic recurrence of PHPT in the transplanted tissue. The patient has been referred for partial debulking of the parathyroid transplant tissue.

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Conclusion

We report a case of recurrent hyperparathyroidism in a parathyroid auto-transplant in a patient with MEN 1. This case highlights the importance of long-term follow-up and the approach to investigation and management when it occurs after parathyroid auto-transplantation in patients with MEN 1.