Parathyroid Apoplexy Following Cinacalcet Treatment in Primary Hyperparathyroidism

Challenging Medical and Surgical Management of Ectopic Parathyroid Hormone (PTH) Adenomas in the Elderly

Ectopic parathyroid adenomas (EPAs) are rare and difficult to localize, making surgical cures challenging on the first attempt. However, the management of EPAs in the literature on the geriatric population is limited. Herein, we report two elderly cases of EPAs in atypical locations and challenging management with a mini review of the literature. An 82-year-old English male presented with confusion and constipation, and his tests confirmed primary hyperparathyroidism (PHPT). However, IV fluids and IV bisphosphonate treatment did not treat his hypercalcemia and imaging investigations could not localize parathyroid adenoma (PA); therefore, he underwent explorative left-sided parathyroidectomy, which confirmed normal parathyroid gland. His hypercalcemia improved shortly after surgery; nonetheless, a month later, he was readmitted with recurrent hypercalcemia symptoms. Single-photon emission computed tomography (SPECT) showed a nodule in the mediastinum referring to EPA. But the patient refused the second mediastinal surgery, and after MDT discussion, medical treatment with Cinacalcet was started. Finally, his calcium was normalized under this treatment and remains so. A 69-year-old Turkish female presented with generalized bone pain, and she was diagnosed with PHPT. Her imaging investigations showed only one 1.6cm nodule in the thyroid, and no PA was detected. Further, fine needle aspiration parathyroid hormone (PTH) wash-out from that thyroid nodule showed very high PTH levels, referring to the thyroid's EPA. Meanwhile, she was screened for complications of PHPT, and nephrolitiasis and kyphosis due to severe osteoporosis were found. She underwent minimally invasive surgery under local anesthesia due to severe kyphosis for this EPA, which was confirmed by histopathology. Her PTH and calcium levels normalized shortly after surgery. In limiting imaging results, PTH wash out could be helpful in diagnostic challenges, especially in suspected nodules/lesions in the neck. For the elderly, the value of surgery in achieving a cure is less straightforward than for the young. Thus, treatment of EPAs in the elderly should be decided based on comorbidities, difficult atypical localizations of EPAs and patients' preferences.

Severe Symptomatic Hypocalcemia, complicating cardiac arrhythmia following Cinacalcet (SensiparTM) administration: A Case Report

Clinicians should closely monitor patients on calcimimetics for hypocalcemic symptoms and arrhythmia, even though asymptomatic hypocalcemia typically resolves without intervention.

Mimickers of Hill-Sachs Lesions

The purpose of this article is to describe the imaging appearance, etiology, clinical features, and treatment of rare presentations of common bone and joint diseases known to mimic Hill-Sachs lesions. Knowledge of uncommonly encountered manifestations of ankylosing spondylitis, rheumatoid arthritis, septic joint, hyperparathyroidism, hydroxyapatite deposition disease, malignant bone tumors, and benign bone cysts which mimic traumatic Hill-Sachs lesions is important for radiologists to guide the clinical care of patients who present with shoulder symptoms.

Cinacalcet-Associated Resolution of Primary Hyperparathyroidism in a Patient With Normal Kidney Function

Cinacalcet use is associated with risk of hypocalcemia; however, this risk has been mostly demonstrated in patients with chronic kidney disease. In this article, we describe a case of a 59-year-old male with primary hyperparathyroidism (PHPT), hypercalciuria, osteopenia, and normal kidney function who was started on cinacalcet for the management of recurrent hypercalcemia following prior unsuccessful parathyroidectomy. Within 6 months following cinacalcet commencement, he developed symptomatic and biochemical hypocalcemia requiring discontinuation of the medication and initiation of calcium supplementation. Over more than 3 years of follow-up, his calcium supplementation was gradually tapered off and then discontinued. He is presently eucalcemic and euparathyroid off calcium supplements while also demonstrating normalization of hypercalciuria and bone mineral density. These data indicate that our patient has experienced resolution of PHPT after brief exposure to cinacalcet. We recommend that low starting cinacalcet doses should be considered for treatment of hypercalcemia in patients with PHPT who underwent unsuccessful parathyroidectomy along with close clinical and biochemical follow-up.