1. Primary Hyperparathyroidism presenting with Pancreatitis Prof. Aasem Saif MD, MRCP(UK), FRCP(Edin) Workshop A (Calcium and Bone) Friday 25 October 2013 14:15 – 15:45

2. Patient History Fifteen-year-old female patient presented with recurrent vomiting for two weeks associated with fever and severe upper abdominal pain radiating to the back. No change in bowel habits was reported. No urinary, respiratory, cardiovascular or neurological symptoms. Past and family history were irrelevant. No report of similar complaints in the family. The patient did not use any medications apart from analgesics and anti-emetics. On examination: She had low grade fever and normal blood pressure Abdomen was lax with epigastric tenderness but no rebound tenderness. Cardiovascular, chest and neurological assessment showed no significant clinical signs.

3. Investigations Laboratory : Lipase 1395 U/L (N: 73 – 393) Amylase 140 U/L (N: 25 – 115) Calcium 3.77 mmol/L (N: 2.12 – 2.52) Potassium 3.2 mmol/L (N: 3.5 – 5.1) PTH 1629 pg/ml (N: 14 - 72) Vit D 8.4 ng/ml (N: 15 – 65) CT abdomen Bulky pancreas with peri-pancreatic collection (11.4 X 9.1 cm). Osteopenia and lytic areas in the left iliac bone, the femoral neck bilaterally as well as the right pubic bone with old non united fracture in the right pubic rami. CT Neck with IV contrast Left parathyroid adenoma (3.5 X 1.7 X 1.2 cm) + erosions of medial ends of clavicles and mandible. Investigations to rule out possible MEN were all negative.

4. Imaging

5. Questions for the Audience Can primary hyperparathyroidism present with pancreatitis? How common? Can preoperative treatment with bisphosphonates prevent postoperative hungry bone syndrome? Can primary hyperparathyroidism be the presenting condition in MEN?

6. Case Resolution / Follow Up The patient was diagnosed to have hypercalcemia-induced pancreatitis due to primary hyperparathyroidism caused by a parathyroid adenoma Medical management: IV fluids (D5NS + KCL) + IV furosemide managed to lower serum Calcium to 2.84 mmol/L. IV Biphosphonate could not be given (Zoledronic acid is contraindicated below 18 years and Pamidronate was not available). Surgical Management: Left inferior parathyroidectomy was done removing a large parathyroid adenoma. Postoperative ICU management: serum calcium dropped to 2.57 mmol/L within 30 minutes and later it dropped gradually to 1.59 mmol/L. PTH dropped to zero, then it went up again to 126 pg/ml within 24 hours after surgery. The patient was kept for 5 days in ICU and maintained on IV calcium infusion (8 g/day). Oral calcium (3 g/day) was started with gradual withdrawal of IV calcium. She was also given alfacalcidol 2 mcgm / day. Serum calcium improved gradually (up to 1.88 mmol/L)