Thyrotoxicosis after parathyroidectomy mimicking myocardial infarction: a case report and review of the literature

Abstract

Sirs: A 55-year-old female patient was presented to our surgical department for elective parathyroidectomy for sHPT following terminal kidney failure due to a minimal change glomerulonephritis with Ig-M sedimentation. An open operation through a Kocher’s cut was performed, and two hypertrophic parathyroid glands were removed. Intraoperative parathyroid hormone (PTH) test revealed a significant decrease of serum PTH levels by *760 pg/ml after parathyroidectomy. The following stationary course was uneventful and patient was discharged 3 days after surgery. Three days after discharge, patient was admitted to the local Emergency Centre suffering from angina pectoris and dyspnoea. An instantly performed ECG showed tachycardia (120/min) and ST elevations (Fig. 1a) associated with elevated hs-cTnT concentrations (180.9 pg/ml; normal range \14.0 pg/ml; Fig. 1b). Assuming a STEMI, an urgent coronary angiography was performed, but no signs of arteriosclerotic coronary artery changes could be detected (Fig. 1c). Tako-Tsubo syndrome was ruled out via echocardiography revealing normal left ventricular function. Additional serum analyses finally revealed an extreme elevation of thyroid hormones fT3 (11.4 pg/ml; normal range 2.3–4.2 pg/ml) and fT4 (5.15 ng/dl; normal range 0.89–1.76 ng/dl), and a simultaneous reduction of TSH (0.04 lIU/ml; normal range 0.55–4.78 lIU/ml). Consequently, thyrotoxicosis following parathyroidectomy was diagnosed and a therapy with ivabradine was started. Genesis of the cardiac symptoms was thought to be induced most likely secondarily to the thyrotoxicosis. Thyroid hormone levels regressed to normal range during the next few days, ECG changes reversed and the patient was discharged 7 days after admission. Herein, we describe a case of thyrotoxicosis as a postoperative complication after an—from surgical viewpoint—uneventful parathyroidectomy. Thyrotoxicosis manifested with clinical signs of a myocardial infarction with corresponding changes in ECG. Symptomatic treatment with limitation of heart rate was followed by spontaneous normalization of thyroid hormone levels. Parathyroidectomy is a standard surgical procedure mainly for pHPT, but also in cases of failure of conservative treatment of secondary or tertiary hyperparathyroidism, parathyroidectomy might be a treatment option to overcome musculoskeletal pain, pathological fractures and pruritus. Parathyroidectomy is classically performed via Kocher’s cut. Nowadays, technical advances have lead to novel concepts for minimally invasive parathyroid surgery, such as endoscopic parathyroidectomy, minimally invasive video-assisted parathyroidectomy (MIVAP) with median access, or a lateral approach (VAPLA), and open minimally invasive parathyroid surgery using a central or a lateral approach. Besides these cervical approaches, there are further surgical approaches to the parathyroid glands (e.g., transoral, transaxillary). Besides formation of visible cervical scars, which shall be reduced or be at least invisible using alternative than cervical approaches, main complications after parathyroidectomy are lesions of the recurrent nerves [1], intraoperative hypokalemia, as well as A. Kauffels M. K. Schilling J. E. Slotta (&) Department of General, Visceral, Vascular, and Pediatric Surgery, Saarland University Hospital, 66421 Homburg/Saar, Germany e-mail: jan.e.slotta@uks.eu