Spontaneous Remission Of Recurrent Secondary Hyperparathyroidism

Abstract

calcaemic period if significant swelling did not precede the Spontaneous remission of recurrent secondarynecrosis of the gland.It is very unlikely that our patient had hyperparathyroidism a hypercalcaemic period since the careful biochemical monitoring and absence of symptoms almost exclude it.Sir,An interesting question is the potential role of antico-Spontaneous necrosis of a parathyroid gland is a rare agulation or hypercoagulability.Previous reports have complication that has been described in a few cases of pointed to a possible involvement of heparin in the developprimary [1-3] and secondary hyperparathyroidism [4].We ment of haemorrhage.We do not think anticoagulation plays present a case of parathyroid necrosis which occurred in a primary role in this situation.First, the change of the recurrent secondary hyperparathyroidism following paraclotting time induced by the heparinization used for haemothyroidectomy.dialysis is not important enough to cause bleeding provided there is no local problem.Secondly, although the anticoagul-Case.A 71-year-old man with secondary hyperparathyroidation therapy in our patient consisted of warfarin in addition ism was referred to our clinic for parathyroidectomy.He to the heparin used for dialysis, there was no evidence of had been on haemodialysis since 1991 because of chronic haemorrhage preceding the necrosis of the gland.Therefore, renal failure due to polycystic kidney disease.Other relevant we think that the primary event is gland infarction, and data of his past medical history included multiple vascular following that, anticoagulation may predispose to secondary access thromboses due to protein C deficit, for which he was haemorrhage.The co-existence of focal necrosis and antiadministered warafarin, and previous parathyroidectomy of coagulation may favour haemorrhagic events in the parafour glands in 1994.On that occasion, the histology of the thyroid gland and thereby lead to its destruction, especially glands showed nodular hyperplasia, and the total weight of in cases of permanent anticoagulation.This may not occur the excised glands was 3.6 g.During the postoperative period to the same extent in patients who are not on permanent he developed hungry bone syndrome and required significant anti-coagulation, or who have no permanent anti-coagulation amounts of intravenous and oral calcium supplementation.problems, such as the protein C deficiency of our patient. His Parathyroid hormone (PTH ) levels immediately afterAs necrosis of the parathyroid gland is an uncommon parathyroidectomy were 5 pmol/l.PTH levels gradually complication, the management of it is not well defined.increased over the next 4 years despite treatment with Although some authors have recommended removal of the calcitriol and phosphorus binding agents.When medical remaining parathyroid tissue when haemorrhage is extensive treatment was no longer efficacious (PTH 150 pmol/l, Ca because of potential recurrence [1], we do not support a 9 mg/dl, P 6.3 mg/dl ), he was referred to us for evaluation.generalized recommendation.In our patient there were no This was interpreted as recurrence of his hyperparathyroidserious haemorrhagic or metabolic complications.An unism due to the development of an ectopic gland or an necessary parathyroidectomy would have led to hypoparathyembryonic remmant, and parathyroidectomy was indicated.roidism.Four months later, serum Ca, P and PTH levels Prior to parathyroidectomy, new PTH, Ca and P levels were were well controlled with medical treatment, and there were determined for close biochemical monitoring before and after no local complications.His hyperparathyroidism may recur surgery.Surprisingly, the results were inconsistent with the in the future, but for the moment conservative management diagnosis of recurrent hyperparathyroidism (PTH 2.8 pmol/l, is preferred, although careful monitoring is mandatory in Ca 7.4 mg/dl, P 3.5 mg/dl ) and consistent with hungry bone such cases.syndrome.Partial necrosis of the parathyroid gland was Nephrology Service M. P. Marco suspected and parathyroidectomy was subsequently can-Hospital Universitari Arnau de S. Muray celled.The patient initially required significant amounts of Vilanova E. Ferna ´ndez calcium and calcitriol supplements in order to keep his Ca Lleida levels within normal limits.However, 4 months later his Spain calcium and phosphorus levels were easily controlled with calcium carbonate (3 g daily).At the last analysis PTH levels 1. Natsui K, Tanaka K, Suda M, Yasoda A, Yonemitsu S, Nakao K. were 8.5 pmol/l, Ca 10 mg/dl, and P 5 mg/dl.