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Table of Contents
LETTER TO THE EDITOR
Year : 2020  |  Volume : 24  |  Issue : 3  |  Page : 288-289

Large mediastinal parathyroid adenoma presenting with acute pancreatitis


1 Department of Medicine, Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi, India
2 Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), Punjabi Bagh, New Delhi, India
3 Department of Endocrinology and Diabetes, Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi, India
4 Department of Endocrine Surgery, Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi, India

Date of Submission29-Mar-2020
Date of Decision30-Mar-2020
Date of Acceptance30-Mar-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Deepak Khandelwal
Department of Endocrinology and Diabetes, Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijem.IJEM_160_20

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How to cite this article:
Kumar A, Damle NA, Khandelwal D, Aggarwal V. Large mediastinal parathyroid adenoma presenting with acute pancreatitis. Indian J Endocr Metab 2020;24:288-9

How to cite this URL:
Kumar A, Damle NA, Khandelwal D, Aggarwal V. Large mediastinal parathyroid adenoma presenting with acute pancreatitis. Indian J Endocr Metab [serial online] 2020 [cited 2020 Jul 15];24:288-9. Available from: http://www.ijem.in/text.asp?2020/24/3/288/288548



Sir,

We want to discuss a case scenario of 63-year-old female who was admitted with acute pain in abdomen in another hospital 1 week before she was referred to us. She was diagnosed with acute pancreatitis after thorough evaluation based on significantly elevated serum amylase and serum lipase and subsequent ultrasonography (USG) and computed tomography (CT) of abdomen. She was managed conservatively for same and recovered after 7 days. During the evaluation she was detected to have hypercalcemia (multiple reports between 11 and 13 mg/dl (normal range 8.8–10.8 mg/dl)]) and subsequently was referred to us for evaluation of hypercalcemia. She also complained of anorexia and nausea from last 1 month. There was no history of any bony pains, low trauma fracture or renal calculi. Her biochemistry at our center confirmed hypercalcemia with serum calcium of 13.1 mg/dl and her serum intact parathyroid hormone (iPTH) level was 1104 pg/ml (normal 15–65 pg/ml) [Table 1]. A biochemical diagnosis of primary hyperparathyroidism (PHPT) was made. For localization of lesion, she underwent USG of neck, which did not show any abnormal parathyroid mass in the neck. Tc-99m sestamibi scan was done which showed large focus of increased tracer uptake in the mediastinum [Figure 1]. Also, CT trans-axial images reveal a soft tissue density lesion of ~5.0 × 2.5 cm in retrosternal location, just anterior to ascending aorta (correlating with MIBI uptake area). A diagnosis of mediastinal parathyroid adenoma was considered. After discussion and consent with patient and family, she underwent video-assisted thoracoscopic surgery for parathyroidectomy. After surgery postoperatively, her serum calcium returned to normal (9.2 mg/dl) and there was significant drop in serum iPTH level (110 pg/ml). Histopathology confirmed parathyroid adenoma.
Table 1: Biochemical investigations of our patient

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Figure 1: There is a large focus of increased tracer uptake in the mediastinum. Physiological uptake is seen in the myocardium, liver, thyroid and salivary glands. No other focus of increased MIBI uptake is seen

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Hypercalcemia is considered to be a rare cause of pancreatitis but the true cause and effect relationship between PHPT and pancreatitis remains controversial.[1] The incidence of acute pancreatitis in patients with hyperparathyroidism was reported to be only 1.5% in western series.[1] However, in a series of 218 patients published from India, pancreatitis was observed in 16% of PHPT patients; with ~50% of its being acute pancreatitis.[2] A high/high normal serum calcium value in a patient of pancreatitis should always draw suspicion and warrants further work up. In fact, many patients can rather present with normal or low serum calcium during the acute episode of pancreatitis and hypercalcemia rather become overt only once acute pancreatitis settle.[3] In all patients with pancreatitis serum calcium should be checked especially after settlement of acute phase of pancreatitis and those with hypercalcemia should have further work up.

Ectopic mediastinal parathyroid adenoma presenting with pancreatitis is rare and after thorough review of literature, we could find only few such previous reports.[1],[3],[4],[5] In our case, patient presented with hypercalcemia during evaluation of pancreatitis and diagnosed to have PHPT with large mediastinal parathyroid adenoma. In fact, such large size mediastinal tumor should raise suspicion of parathyroid carcinoma as well, which was not revealed in histopathology in our case. Also, we have planned to keep this patient on regular follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Thareja S, Manrai M, Shukla R, Sood AK, Jha A, Tyagi AK, et al. Pancreatitis and hyperparathyroidism: Still a rare association!. Med J Armed Forces India 2019;75:444-9.  Back to cited text no. 1
    
2.
Arya AK, Bhadada SK, Mukherjee S, Singh P, Rana SS, Dahiya D, et al. Frequency and predictors of pancreatitis in symptomatic primary hyperparathyroidism. Indian J Med Res 2018;148:721-7.  Back to cited text no. 2
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3.
Foroulis CN, Rousogiannis S, Lioupis C, Koutarelos D, Kassi G, Lioupis A. Ectopic paraesophagealmediastinal parathyroid adenoma, a rare cause of acute pancreatitis. World J SurgOncol 2004;2:41.  Back to cited text no. 3
    
4.
Imachi H, Murao K, Kontani K, Yokomise H, Miyai Y, Yamamoto Y, et al. Ectopic mediastinal parathyroid adenoma: Acause of acute pancreatitis. Endocrine 2009;36:194-7.  Back to cited text no. 4
    
5.
Urata T, Yamasaki A, Sasaki A, Tonaki G, Iwasaki H, Minami N, et al. Acute pancreatitis caused by an ectopic mediastinal parathyroid adenoma. Clin J Gastroenterol 2012;5:393-7.  Back to cited text no. 5
    


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