(094) Rapid remission of catatonia after Parathyroidectomy: A Case Report and Review of Literature

Abstract:

Background: Neuropsychiatric symptoms (NPS) are well recognized in primary hyperparathyroidism (PHPT) (Serdenes et al., 2021), but parathyroidectomy (PTX) is yet to be considered the definitive treatment for patients with predominant NPS (Bilezikian et al., 2014; Nilsson et al., 2019). We report a case of catatonia with rapid remission after PTX in the context of prolonged PHPT and hypercalcemia (HC).

Case report: Ms. M is a 67-year-old woman, with a long-standing psychiatric history since 2002. At the onset, mild HC was noted which was explained in 2006 by PHPT due to a left active parathyroid adenoma. She had around 20 lengthy inpatient medical and psychiatric hospitalizations over 20 years with a deteriorating course. Her diagnosis evolved from major depressive disorder with psychotic features, to bipolar disorder, schizoaffective disorder, and catatonic schizophrenia, then to advanced dementia. Ms. M lost her decisional capacity over years and her son was appointed as her legal guardian. Patient and her son had refused PTX. She had failed multiple trials of antidepressants, antipsychotics, mood stabilizers, and multiple sessions of electroconvulsive therapy. The length of her hospitalizations kept getting longer up to 10 months, and she eventually required care in a nursing home. During her most recent hospitalization, patient was admitted for failure to thrive, her Bush-Francis score (BFS) was 22. HC was corrected using IV calcitonin and cinacalcet, with partial improvement in her NPS. However, this improvement only lasted for 2 weeks after she resisted further treatment. Patient’s son eventually approved PTX which successfully achieved normocalcemia. Her BFS improved to 7 on postoperative day 1 with an improvement in mental status. Patient was stable for discharge on post-operative day 10.

Discussion: Untreated PHPT and mild HC clearly contributed to this patient’s presentation. Her clinical course is consistent with prior studies reporting improvement of NPS after PTX for PHPT. However, patients with predominant NPS remain excluded from the selection criteria for PTX. Based on these cases reports, we strongly recommend more advocacy for PTX when NPS are primarily due to PHPT and HC.

Conclusion: The remission of catatonia after PTX highlights the pivotal role of PHPT/HC in the pathogenesis of NPS. The rapid improvement suggests that PTH/HC seems to have an acute but reversible effect on cerebral dysfunction. This case also indicates that severe NPS can result from mild and prolonged HC.

References:

1. Serdenes R et al.: A Clinical Review of the Psychiatric Sequelae of Primary Hyperparathyroidism. Cureus 2021; 13(10): e19078

2. Bilezikian JP et al.: Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab 2014; 99:3561–3569

3. Nilsson I-L: Primary hyperparathyroidism: should surgery be performed on all patients?: J Intern Med. 2019 Feb;285(2):149-164.