Severe Renal Compromise Associated with Hypercalcemic Crisis Due to Giant Parathyroid Adenoma in a Woman with Bilateral Adrenal Incidentalomas

Introduction:
Parathyroid or hypercalcaemic crisis is a rare presenting manifestation of primary hyperparathyroidism (PHPT). We present a woman with severe hypercalcaemia due to giant parathyroid adenoma presenting as exacerbated chronic kidney disease, who was also found to have non-functioning bilateral adrenal adenomas.

Case Description:
A 74-year-old woman, a history of arterial hypertension 10 years ago and lumbar spine scoliosis, usual medication irbersartan 150 mg/day, was admitted by emergency with a 1-week illness time characterized by lower limb weakness, severe low back pain, nausea and vomiting , which intensified the day of admission. Examination revealed BP 120/60 mmHg, heart rate 89 beats/min, weight 75 kg, height 1.72 cm, dry oral mucosa, no lymphadenopathy or nodules palpable at neck level.

Laboratory tests: Arterial gases pH: 7.3, HCO₃: 17 mmol/L, Calcium: 3.8 meq/L; hemoglobin: 10.1 g/dl, creatinine: 7.32 mg/dl, urea: 181 mg/dl, sodium: 140 mmol/L, potassium: 5 mmol/L, calcium: 14.1 mg/dl, phosphorus: 5.6 mg/dl, magnesium: 2.18 mg/dl. Renal ultrasound showed: signs of bilateral chronic kidney disease. Given the suspicion of malignancy and awaiting the result of parathormone (PTH), the body CT in the emergency room showed a solid lesion at the neck level, located posteriorly and in contact with the left thyroid lobe, measuring 39 x 14 x 30 mm, contacted the trachea and partially displaced the esophagus to the right without infiltrating them, it maintained interface with the left carotid and jugular, suggesting parathyroid dependence; and incidentally, both adrenal glands were diffusely thickened, the left showed a nodular formation of 20 x 15 mm, with an attenuation of -10 HU.

She was hospitalized, received hydration, furosemide and pamidronate, did not require renal replacement therapy. Intact PTH was 1114 pg/mL; it was possible to normalize the levels of calcium, phosphorus, magnesium, creatinine decreased to 2.53mg/dl. Sestamibi scintigraphy showed an image compatible with lower left parathyroid adenoma and bone densitometry showed osteoporosis with a high risk of fracture (left forearm (1/3): bdm= 0.475 g/cm2, Tscore= -5.3, hip: bdm= 0.435 g/cm2, tscore= -4.5).

The patient underwent a lower left parathyroidectomy, where a 5 x 3.5 cm parathyroid tumor was reported with an increased consistency of brown coloration; the pathology reported giant adenoma of the parathyroid gland with apoplexy.

In the postoperative period, the intact PTH was 57 pg/ml, at the same time the functionality of the adrenal adenoma was ruled out. She developed hungry bone syndrome for which she receives calcium and calcitriol to this day.

Discussion:
Some studies provided an unclear definition of hypercalcemic crisis as a serum calcium concentration >3.5 mmol/L, accompanied by signs and symptoms. A hypercalcemic crisis was first described in 1939 by Hanes, and is considered as an endocrine emergency and fatal in the absence of optimal treatment. The acute effects of PHPT on renal function are not well understood. Furthermore, non-oliguric acute kidney injury caused by refractory hypercalcemia requires emergent hemodialysis, which was not necessary in our patient.