Presentation
Generalized bone pains.
Patient Data
Laboratory tests
S. phosphorus 2.6 mg/dL (N 2.5 to 4.5 mg/dL)
S. ionized calcium 6.3 mg/dL (N 4.64 to 5.28 mg/dL)
Calcium 12.6 mg/dL (N 8.6 to 10.3 mg/dL)
Vitamen D 9 ng/mL (N>12 ng/mL)
S. creatinine 0.82 mg/dL (N<1.2 mg/dL)
An oval-shaped homogeneous hypoechoic nodule is seen posteroinferior to the lower pole of left thyroid lobe measuring 1 x 1.2 x 2 cm in dimensions showing avid vascularity with high peak systolic velocity. There is prominent feeding vessel at the medial aspect (polar vessel sign). No calcifications or cystic degeneration.
Normal thyroid gland.
Bilateral suprarenal gland lesions with low homogeneous density and mild postcontrast enhancement, largest on the right measuring 1.5 cm and on the left side measuring 3 x 2.5 cm. The largest lesion shows absolute washout of 64% (>60%) and a relative washout of 64 (>40%) in keeping with adrenal adenoma.
The pancreas shows two enhancing soft tissue lesions with coarse calcifications and hypodense core, the largest at the head region and uncinated process measuring 2.2 x 4.4 cm in axial dimensions, and the other is at the distal body measuring 2 x 2.5 cm, suggestive of pancreatic neuroendocrine tumors.
Case Discussion
Enlarged left lower parathyroid gland with laboratory findings suggestive of primary hyperparathyroidism due to a parathyroid adenoma. The patient has normal kidneys ultrasound and renal function tests excluding parathyroid hyperplasia. The patient was referred to do a parathyroid hormone level and surgical consultation.
The presence of parathyroid adenoma, pancreatic lesions and adrenal adenomas is suggestive of multiple endocrine neoplasia type I, which is an autosomal dominant genetic disease. Primary hyperparathyroidism is the most common presentation, as in this case.
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