Intrathyroid parathyroid gland and neonatal primary hyperparathyroidism

Surgical management of neonatal severe hyperparathyroidism

BACKGROUND

Neonatal severe hyperparathyroidism (NSHPT) is a rare disease that can be lethal. Most patients require parathyroidectomy.

OBJECTIVE

Report experience in managing this severe disease.

DESIGN

Retrospective chart review of case series.

SETTING

Tertiary health care center.

PATIENTS AND METHODS

We reviewed data on patients managed for NSHPT from June 2001 to January 2023. Demographic, clinical, and follow-up data were collected, and descriptive data were generated.

MAIN OUTCOME MEASURES

Pre- and postoperative levels of parathyroid hormone (PTH) and serum calcium, and effect of autotransplantation.

SAMPLE SIZE

19.

RESULTS

The 13 males and 6 females had a a mean age of 46 days at referral. The mean preoperative parathyroid hormone (PTH) and serum calcium levels were 996 ng/L and 4.54 mmol/L, respectively. Twelve patients underwent ultrasonography preoperatively. Of these, six had prominent glands, while no glands were seen in the other six. A Sestamibi scan was done for 15 patients, of which nine showed negative results and six showed positive results, with three glands observed in the neck and three in the sublingual area. Nineteen patients underwent renal ultrasonography, with nine showing nephrocalcinosis. The mean age at surgery was 5.2 months. Total parathyroidectomy (four glands) was performed in 17 patients, and 15 underwent concurrent auto-transplantation. One patient had three glands removed, in addition to auto-transplantation. Another underwent single gland excision as a redo-surgery after previous surgery elsewhere. The mean postoperative follow-up duration was 6 years. The mean postoperative PTH and calcium levels were 25 ng/L and 1.64 mmol/L, respectively. Ultimately, all the patients were required to initiate calcium and vitamin D supplements, except for two patients who had undergone auto-transplantation. Molecular genetic screening of the calcium-sensing receptor gene reported likely pathogenic/pathogenic mutations in 16 of 19 patients (13 were homozygous, two were heterozygous, one was negative, and data was unavailable for the remaining three patients).

CONCLUSIONS

Surgical treatment of NSHPT is effective. Preoperative radiological localization studies did not impact the treatment plan. Auto-transplantation proved ineffective in maintaining independence from medical supplements.

LIMITATIONS

The retrospective nature of the study may imply inaccuracybut since the data are gathered from electronic medical records, we believe it is highly accurate. The small sample size limits generalizability.

A rare cause of neonatal hypercalcemia: Neonatal severe primary hyperparathyroidism: A case report and review of the literature

•

Neonatal severe primary hyperparathyroidism is an exceedingly rare condition that has high mortality and morbidity if left untreated.

•

Medical therapy must be initiated as soon as the condition is diagnosed, and early surgery must be performed in patients who are refractory to the medical therapy.

•

Scintigraphic studies might sometimes fail to detect ectopic parathyroid glands. Intraoperative parathormone monitoring is particularly important to ensure complete removal of the parathyroid glands.

Introduction

Neonatal severe primary hyperthyroidism is an extremely rare disorder that occurs in the first six months of life. Early recognition and prompt surgical intervention are of vital importance for survival and to avoid neurological sequel. Hypotonia, lethargy, respiratory distress, and growth and developmental delay occur in association with elevated serum parathormone levels and hypercalcemia (Gannon et al., 2014). Definitive therapy involves total parathyroidectomy.

Case presentation

We are presenting a patient with Neonatal severe primary hyperparathyroidism, who successfully underwent total parathyroidectomy. The patient had been followed up with medical therapy until he was seven months old, with no adequate clinical response to medical therapy. Parathormone levels rapidly declined following total parathyroidectomy, and the parathormone level fell to zero after removal of the ectopic tissue with a second surgery, and the patient was discharged with full recovery.

Discussion

Sestamibi scintigraphy might not always show an ectopic parathyroid gland. In such conditions, confirmation of parathyroid glands excised with total parathyroidectomy by frozen biopsy is not sufficient to terminate surgery. Intraoperative parathormone monitoring is particularly important at this point. Persistently elevated parathormone levels should suggest a remnant parathyroid tissue at the surgical site or an ectopic parathyroid gland that needs to be excised.

Conclusion

Neonatal severe primary hyperparathyroidism is a life-threatening condition. Early surgery is life-saving in cases in whom medical therapy fails to control the disease.

Intraoperative parathyroid hormone monitoring in neonatal severe primary hyperparathyroidism

Neonatal severe primary hyperparathyroidism presents in the first days of life with severe life-threatening hypercalcemia. It is associated with an inactivating homozygous mutation of the calcium sensing receptor gene. Total parathyroidectomy is the treatment of choice, so the surgeon must identify all the parathyroid tissue, including supernumerary and ectopic glands. We present the case of an infant who underwent total parathyroidectomy at age 4 months in which intraoperative parathyroid hormone monitoring provided immediate confirmation of surgical cure.

A case of amyloid goiter associated with intrathyroid parathyroid and lymphoepithelial cyst

Diffuse enlargement of the thyroid gland accompanied by an interstitial tissue deposition of amyloid is a special entity termed an amyloid goiter. An amyloid goiter is a rare thyroid lesion, which has been described a long time ago. In this report, we add a new classic case of amyloid goiter that differs from other reported cases in its association with intrathyroid parathyroid and lymphoepthelial cyst involved with amyloidosis. The presence of parathyroid tissue inside the thyroid parenchyma and surrounded by amyloid material elicited a diagnostic problem due to suspected medullary carcinoma. Careful histological examination and immunohistochemical staining for parathormone and calcitonin have largely helped in the differential diagnosis. Bilaterality, diffuse, and homogeneous involvement of the thyroid gland, with absence of definite masses, all direct the diagnosis toward amyloid goiter.

Intrathyroid Parathyroid Adenoma in Primary Hyperparathyroidism: Can It Be Predicted Preoperatively?

INTRODUCTION

The role of cervical ultrasonography (US)-guided surgery for intrathyroid parathyroid adenoma in primary hyperparathyroidism is rarely reported. The aim of this study was to elucidate the role of cervical US in identifying this entity.

METHODS

From 1996 to 2003, cervical explorations were performed in 178 patients (mean age 57 years) with primary hyperparathyroidism. High-resolution cervical US was performed in all of the patients. Patients' characteristics were reviewed to identify predictive factors for intrathyroid adenoma.

RESULTS

Cervical US identified abnormal parathyroid glands in 163 of 178 patients, with a positive predictive value (PPV) of 100%. Six patients (3.4%) were found to have intrathyroid parathyroid adenomas (two in the superior parathyroid and four in the inferior parathyroid). Cervical US predicted this anomaly in four of six patients (67%) in whom the thyroid gland was not nodular and allowed total enucleation of the adenoma to be performed in three and subtotal thyroid loboisthmectomy in three; these operations were performed uneventfully and rapidly. The PPV in this anomaly was 80%. Thirteen patients required postoperative calcium supplementation for 2 to 4 months, and all were normocalcemic at the time of the last clinic visit, with follow-up varying from 12 to 96 months. On multivariable analysis, no factor predicted intrathyroid localization of parathyroid adenoma.

CONCLUSIONS

The PPV of high-resolution cervical US for identifying an abnormal parathyroid gland was 100% in this series. It was 80% for predicting intrathyroid localization of the adenoma. This method allows us to shorten the operating time by guiding the exploration immediately toward the thyroid gland.