Presentation Of Primary Hyperparathyroidism Research Articles

A Treatable but Commonly Missed Etiology;An Unusual Presentation of Primary Hyperparathyroidism as Acute on Chronic Recurrent Pancreatitis- A Case Report

Introduction: Acute pancreatitis is an identified, but uncommon presentation of Primary hyperparathyroidism with prevalence of 3.6%. Hypercalcemia is a rare but known cause of pancreatitis as it leads to premature intra pancreatic activation of protease and destruction of pancreatic tissue leading to pancreatitis. Here we present a case of primary hyperparathyroidism that went undiagnosed for years, and was finally diagnosed after recurrent episodes of pancreatitis of unclear etiology. Case Presentation: A 46-year-old female with history of recurrent pancreatitis presented to the emergency department due to constant epigastric pain for 6 hours associated with nausea and vomiting. Patient reported recurrent episodes of pancreatitis over the past 4 years. Patient was told that etiology of pancreatitis is unclear despite workup. Patient was frustrated that her pancreatitis attacks were usually labeled as alcoholic pancreatitis as she works as a bartender. She strongly states she only drinks alcohol occasionally. She underwent cholecystectomy 2 years ago in attempt to prevent further pancreatitis attacks. Her vital signs were stable. Physical exam was remarkable for epigastric tenderness. CT abdomen and pelvis with contrast showed chronic pancreatitis, pseudocyst and free fluid in the pancreatic bed characteristic of acute pancreatitis. Abdominal US showed post cholecystectomy changes, with no biliary dilatation or stones. Initial labs showed: lipase 2001 U/L, Alcohol level < 10 mmol/L, Calcium 11.5 mg/dl, ionized calcium 4.9 mg/dl, phosphate 2.7 mg/dl, and Triglycerides 52 mg/dl. Subsequently parathyroid hormone was checked and was 116.8 pg/ml. Vitamin D was normal. NM parathyroid scan showed increased tracer activity demonstrating parathyroid adenoma. Patient was given IVF and supportive treatment and her symptoms improved. Endocrinology recommended parathyroidectomy. Patient elected to be discharged and undergoes parathyroidectomy outpatient. Discusion: In this case we emphasize the importance of considering PHPT in acute pancreatitis of unclear etiology especially when Calcium level is elevated. PHPT was missed as a treatable etiology despite mildly elevated calcium level in prior hospitalizations. It is reported that pancreatitis is frequently associated with hypocalcemia with prevalence of 15–88%. Moreover, hypocalcemia is a component of Ranson’s scoring system for severity of pancreatitis. This is explained by precipitation of calcium soaps, hypoalbuminemia and increased calcitonin secondary to glucagon release. PTHT induced pancreatitis management has the same general principles of supportive management. All these patients, once stable, should undergo parathyroidectomy for definitive treatment. Data suggests nearly 100% improvement in pancreatitis symptoms and prevention of recurrent pancreatitis episodes after the cure of PHPT.

A Unique Case of Primary Hyperparathyroidism

Background: Primary hyperparathyroidism is the most common cause of hypercalcemia. It is more commonly seen in postmenopausal women, but can develop in younger individuals. Brown Tumors are an uncommon finding that can be seen in sever hyperparathyroidism. These bone findings are most often seen in the maxilla or mandible, though can affect any bone. Bone changes are reversible after parathyroidectomy.Clinical Case: An 18 year old male with a PMH of nephrolithiasis presented with a two day history of flank pain and hematuria. Endocrinology was consulted for hypercalcemia and elevated PTH. He had a family history of nephrolithiasis in his maternal uncle and grandfather, but no known family history of hypercalcemia or thyroid cancer. He was not on any medications or supplements. His initial labs were significant for a calcium of 15.0, PTH of 644, and a Vitamin D 25 of 11.7. He had no known history of hypercalcemia. He was treated with aggressive hydration, 4mg of zometa, 30mg of sensipar and two doses of 200mg calcitonin, with improvement in his calcium levels. Imaging of the abdomen and pelvis revealed multifocal solid-cystic lesions in the right superior pubic ramus and the distal femur, with smaller enhancing lesions in the left subtrochanteric, consistent with Brown Tumors. SpectCT was obtained and significant for a 2.1 by 1.4cm lesion in the anterior superior mediastinum. His overall presentation was consistent with primary hyperparathyroidism secondary to an ectopic parathyroid adenoma. Due to his relative young age at presentation and degree of primary hyperparathyroidism, there was concern for MEN1 or possible parathyroid carcinoma. MRI of the pituitary was obtained and showed a 4mm microadenoma in the right side of the pituitary. Prolactin, thyroid hormones, IGF-1, plasma metanephrines and calcitonin were all within normal limits. CDC73, a genetic marker for parathyroid carcinoma, was negative. Genetic work up for MEN1 was also negative. Endocrine surgery was consulted and he underwent a resection of the ectopic parathyroid adenoma.Discusion: Though most patients with primary hyperparathyroidism are asymptomatic, nephrolithiasis and Brown Tumors can be seen with more severe cases. It is important to rule out possible genetic causes for primary hyperthyroidism in patients with abnormal presentations, as it will change the overall long term management.

Acute Pancreatitis as an Initial Presentation of Primary Hyperparathyroidism

Background: Acute pancreatitis secondary to hypercalcemia is may be the initial presentation of a patient with primary hyperparathyroidism. However, because of its infrequency as a cause of pancreatitis, it can be easily missed during clinical management. Clinical Case: A 56-year old woman initially presented with epigastric pain with radiation to the back. She had no previous comorbidities, did not drink alcohol, and had no previous history of cholelithiasis, nephrolithiasis nor pathologic fractures. The diagnosis was confirmed by an elevated serum lipase level (59117 U/L, reference interval (RI): 73–393 U/L) and contrast-enhanced MRI findings suggestive of acute pancreatitis with hemorrhagic component in the pancreatic body and tail. Hypercalcemia was documented on two separate occasions during her confinement with a serum total calcium level of 10.5 mg/dL (RI: 8.5–10.1 mg/dL) and an ionized calcium level of 1.45 mmol/L (RI: 1.09–130 mmol/L), however, no further workup was done at that time. She was managed conservatively and was sent home with plans to do an ERCP and possible laparoscopic cholecystectomy once her condition had stabilized. However, she had recurrence of the epigastric pain about one month after her initial episode. Her serum lipase showed an interval increase from her last result (1426 U/L from 933 U/L) and contrast-MRI now showed the development of areas of walled-off necrosis in the body and tail of the pancreas. Serum ionized calcium was again elevated (2.17 mmol/L); she also had an elevated intact PTH level (780.6 pg/ml, RI: 18.5–88.0 pg/ml). Parathyroid SPECT-CT showed a sestamibi-avid lesion inferoposterior to the right thyroid lobe, indicating a probable parathyroid adenoma. She was given 1 dose of Denusomab 120 mg subcutaneously and started on Calcitonin nasal spray 200 IU twice a day. She underwent ultrasound-guided drainage of the pancreatic necrosis and was subsequently discharged. Due to difficulty in procurement of the Calcitonin nasal spray, she was maintained on Cinacalcet 30 mg/tablet, 1 tablet once a day upon discharge with plans to undergo parathyroidectomy once she was had fully recovered from her pancreatitis. Conclusion: Primary hyperparathyroidism should always be considered when hypercalcemia is noted during the clinical management of acute pancreatitis. Reference: Misgar RA, Bhat MH, Rather TA, Masoodi SR, Wani AI, Bashir MI, Wani MA, Malik AA. Primary hyperparathyroidism and pancreatitis. J Endocrinol Invest. 2020 Oct;43(10):1493–1498.

P114 Effect of vitamin D on parathyroid hormone, serum calcium and bone mineral density in patients with primary hyperparathyroidism being managed conservatively

Abstract Background/Aims Vitamin D deficiency is associated with more severe presentation of primary hyperparathyroidism (PTHP) with high parathyroid hormone (PTH) levels and reduced bone mineral density (BMD). We analyzed data to determine if vitamin D levels had any impact on PTH, serum calcium and BMD at diagnosis and 3 years, in patients being managed conservatively. Methods Retrospective analysis of patients presenting with PHPT. Based on vitamin D level at diagnosis, patients were divided into two groups; vitamin D sufficient (≥ 50 nmol/L) and vitamin D insufficient (≤ 50 nmol/L). The two groups were compared for age, serum calcium and PTH levels at diagnosis and after mean follow up of 3 years. BMD at forearm and neck of femur (NOF) was only analyzed in the two groups at diagnosis, due to lack of 3 year’s data. Results There were a total of 93 patients, 17 males, mean age 70; range 38-90. Mean vitamin D level was 73.39 nmol/L in sufficient group (n = 42) and 34.48 nmol/L in insufficient group (n = 40), (difference between means -38.91, 95% confidence interval -45.49 to -32.33, p &amp;lt; 0.0001). There was no significant difference in age, serum calcium and PTH at the time of diagnosis. After three years, there was no significant difference in vitamin D levels between the two groups (mean vitamin D 72.17 nmol/L in sufficient group and 61.48 nmol/L in insufficient group). Despite rise in vitamin D level in insufficient group, no significant change was observed in this group in PTH and serum calcium levels. BMD was lower at both sites in vitamin D sufficient group and difference was statistically significant at NOF. Data were analyzed using unpaired t test and presented as mean ± SEM. Conclusion 50% of patients presenting with PHPT were vitamin D insufficient at diagnosis. Vitamin D was adequately replaced so that at 3 years there was no significant difference in vitamin D status in the two groups. Serum calcium and PTH were no different in the two groups at diagnosis and at three years, despite rise in vitamin D levels in the insufficient group. Interestingly, BMD was lower at forearm and neck of femur in those with sufficient vitamin D levels and the difference was statistically significant at neck of femur. Our data show that vitamin D insufficiency does not have any significant impact on PTH and calcium levels and that vitamin D replacement is safe in PHPT and does not impact serum calcium and PTH levels in the short term. Lower BMD in those with adequate vitamin D levels is difficult to explain and needs further research. Disclosure M. Khalid: None. V. Deshani: None. K. Jadoon: None.

AB120. SOH21AS182. Evaluation of the relationship between primary hyperparathyroidism and concomitant thyroid nodules at a specialist endocrine surgery centre

Background: While it known that thyroid disease is associated with primary hyperparathyroidism (PHPT), it is yet to be determined whether the concomitant presentation of PHPT and thyroid cancer is coincidental, causal, or due to their intimate anatomical relationship. It is known that routine screening of the parathyroid glands simultaneously incorporates evaluation of the thyroid gland and that preoperative diagnostic imaging for localizing parathyroid adenomas can also detect thyroid nodules. The aim of this study was to evaluate the incidence of thyroid cancer in patients with PHPT based on the detection of thyroid nodules from non-invasive imaging.

Primary Hyperparathyroidism with Multiple Fractures and Brown Tumors in a 14-year-old Girl: Case Report &amp; Review of Literature

Primary hyperparathyroidism (PHPT) presenting as pathological fractures with brown tumors is very rare in children. The rarity and variable presentation of PHPT can make its diagnosis a challenge – especially in the developing countries where malnutrition may mask hypercalcemia. We report a case of a 14–year-old girl who presented with muscle pain, multiple fractures and bone pain. Laboratory tests revealed normocalcemia with vitamin D insufficiency. Subsequent biochemical, radiographic and scintigraphic findings were consistent with primary hyperparathyroidism due to a parathyroid adenoma. Tumor resection was done in a local hospital and histopathology confirmed parathyroid adenoma. Following parathyroidectomy, fractures were treated conservatively with supplementation of calcium and vitamin D. We found her quite capable of self-care and walking in good health at 1 year follow up. Though rare, PHPT-causing brown tumors related skeletal fractures is an important differential diagnosis in the evaluation of patients presenting with multiple foci of radiotracer uptake in bone scintigraphy.&#x0D; Bangladesh J. Nuclear Med. 22(2): 130-136, Jul 2019

Hiperparatiroidismo primario: conceptos para el cirujano general

Durante las últimas décadas, la incidencia del hiperparatiroidismo primario ha venido en aumento, muy probablemente relacionado con la mayor accesibilidad a los estudios diagnósticos; sin embargo, la forma más común de presentación clínica del hiperparatiroidismo primario es asintomática, en más del 80% de los pacientes. En la actualidad, es menos frecuente el diagnóstico por las complicaciones renales (urolitiasis) u óseas (osteítis fibrosa quística) asociadas. Un tumor benigno de la glándula paratiroides (adenoma único), es la principal causa de esta enfermedad. Por tanto, su tratamiento usualmente es quirúrgico. A pesar de ello, no es frecuente el manejo de esta patología por el cirujano general. En este artículo se revisan conceptos claves para el diagnóstico y manejo de esta enfermedad para el médico residente y especialista en Cirugía general.

Why is primary hyperparathyroidism more severe in children?

The disease presentation of primary hyperparathyroidism (PHPT) is more severe in children. We hypothesize that this difference in disease presentation is a result of several factors including a delay in diagnosis, age-related differences in calcium metabolism and bone turnover, and the influence of the growth hormone (GH)/insulin growth factor-1 (IGF-1) axis. Only the first two explanations for the heightened disease severity of PHPT in children have been previously discussed in the literature. In regards to the potential role GH and IGF-1 may play in this disparity, previous studies have documented decreases in GH and IGF-1 secretion in symptomatic adult PHPT patients potentially influencing the severity of the patients’ disease presentation. While these studies have yet to be replicated in the pediatric population, given that both GH and IGF-1 are important for the achievement of peak bone mass in young individuals, it is logical to infer that the GH/IGF-1 axis may be partly responsible for the severe presentation of PHPT in children.

Gender differences in the presentation, course and outcomes of primary hyperparathyroidism

ObjectiveTo investigate gender-associated differences in the presentation, course, and outcomes of primary hyperparathyroidism (PHPT). Study designA retrospective institutional cohort. MethodsThe database of a tertiary endocrine institute was retrospectively screened for patients treated for PHPT in 2010–2018. Clinical, biochemical, and imaging data were collected. Presentation, management, and outcome variables were compared by gender and by age at diagnosis (<50/≥50 years). ResultsThe cohort included 182 women and 161 men diagnosed with PHPT at age 57.6 ± 12.8 and followed for 6.3 ± 5.5 years. There were no gender differences in age at detection of hypercalcemia and basal levels of serum and urinary calcium, serum PTH, and serum 25-hydroxyvitamin D. Men had a higher prevalence of nephrolithiasis (33 % vs 21 %, p = 0.01). Women had a higher frequency of osteoporosis (65 % vs 45 %, p < 0.001), and a lower mean lumbar spine T-score at PHPT diagnosis. At last follow-up, women had worse bone mineral density (BMD) results in all measured sites (lumbar spine, femoral neck, distal radius) and more fractures (34 % vs 20 %, p = 0.004), despite more frequent and longer pharmacological treatment of osteoporosis. On analysis by age, all these gender-associated differences were statistically significant only in patients diagnosed at age ≥50 years. Parathyroidectomy was performed in 52 % of women and 42 % of men (p = 0.06). ConclusionThe main differences between male and female patients with PHPT are the higher prevalence, more intensive pharmacological treatment, and worse outcomes of osteoporosis in women. Tailoring the optimal medical and/or surgical treatment for fracture prevention in patients with PHPT remains a major challenge, especially in older women.

Osteitis Fibrosa Cystica.

ABSTRACTOsteitis fibrosa cystica is a rare presentation of both primary and secondary hyperparathyroidism. In this perspective, we provide a historical backdrop to this form of parathyroid disease and contend that this clinical presentation of excess parathyroid hormone, particularly in primary hyperparathyroidism, is still seen today. In view of its rarity and the way it typically presents, the diagnosis of metastatic cancer is often the first diagnostic impression. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

A Rare Presentation of Primary Hyperparathyroidism: Generalized Brown Tumors

A Rare Presentation of Primary Hyperparathyroidism: Generalized Brown Tumors

SAT-374 The Many Faces of Parathyroid Carcinoma in the Philippines: A Case Series

Introduction: Parathyroid carcinoma is rare, affecting less than 1% of patients with primary hyperparathyroidism (PHPT). 1 Parathyroid carcinoma with concomitant papillary thyroid carcinoma is also rare, and the etiology is not fully defined. Clinical Case: We present 3 patients with parathyroid carcinoma and discuss their presenting symptoms, characteristics, and treatment. Two women and 1 man (2 Filipinos and 1 Marshallese) with age range 53-68 years old had parathyroid carcinoma. Two had primary hyperparathyroidism, one had non-functioning type of parathyroid carcinoma. Two had concomitant bone or renal disease. All three had concurrent thyroid disease- 2 had papillary thyroid microcarcinoma, one had colloid goiter. Because each one had different indications for neck surgery, different surgical techniques were done. Parathyroid cancer size ranged from 2.0-5.2 cm, with capsular and vascular invasion in all three. One case had double parathyroid carcinoma. No lymph node metastasis was identified. On follow up, the patient with the largest tumor size had tumor recurrence within 1 year from surgery. Conclusion: To the best of our knowledge, this is the first case series on parathyroid carcinoma in the Philippines, and includes the 7th case of double parathyroid carcinoma worldwide. Parathyroid carcinoma is a rare condition, and coupled with its highly variable presentation, as seen in the 3 cases, presents clinicians with a difficulty in arriving at a diagnosis. Histopathology remains the gold standard in diagnosis and is a key in guiding management. Since coexisting thyroid and parathyroid disease may occur, thyroid pathology should be evaluated in the presence of PHPT.

SAT-LB65 A Rare Existence

Primary hyperparathyroidism is a common endocrine disorder of metabolism usually due to a parathyroid adenoma. Although, the clinical presentation of primary hyperparathyroidism has changed from Albright’s description of a disease of bones and stones, the central target organs affected by this disorder continue to be the skeleton and kidneys. With the advent of routine biochemical screening, the typical diagnosis of primary hyperparathyroidism is no longer accompanied by overt skeletal and renal involvement. Majority of the cases of primary hyperparathyroidism are due to parathyroid adenomas. Giant glands were defined as greater than the 95th percentile, characterized as glands weighing > 3.5 grams.This present case in a 54-year old female is a rare case of primary hyperparathyroidism secondary to a giant parathyroid adenoma measuring 10.7 x 8.0 x 40.0 cm and weighing 145 grams, the largest giant parathyroid adenoma reported to date, with co-existent silent thymoma, multinodular goiter and osteosclerosis of the vertebral spine, metaphorically known as the “rugger-jersey spine”. The association between thymoma and parathyroid adenoma is rare, and only 3 cases have been reported in the literature. We characterized the correlation of preoperative imaging, intraoperative location, and postoperative course, including significant postoperative hypoparathyroidism, as compared to other patients with PHPT to determine whether giant adenomas represent a clinical entity with distinct clinical characteristics.Keywords: primary hyperparathyroidism, giant parathyroid adenoma, rugger-jersey spine, thymomaAbbreviationPHPTPrimary hyperparathyroidism

Chronic urticaria as a rare presentation of primary hyperparathyroidism

Chronic urticaria as a rare presentation of primary hyperparathyroidism

СПОСОБ ВЕРИФИКАЦИИ ПЕРВИЧНОГО ГИПЕРПАРАТИРЕОЗА

A method is proposed for the integral biochemical diagnostic of primary hyperparathyroidism to obtain reliable information about the functional state of the parathyroid glands, which allows one to assess changes in phosphorus-calcium metabolism, to predict the presence or absence of primary hyperparathyroidism, and also to control the pathological process and the effectiveness of the treatment. To determine a single integral indicator - the index of primary hyperparathyroidism (IPHPT), the ratio of calcium and phosphorus to parathyroid hormone was determined. Measurements were performed in volunteers who don’t suffer from any endocrine pathology (19 patients) and in the group of patients with primary hyperparathyroidism before and after surgical treatment (19 patients). As a result of the study, it was found that the value of IPHPT ≤ 2.46 reliably indicates the presence of primary hyperparathyroidism, and the value of IHPT &gt; 2.46 is a measure for the absence of the parathyroid glands pathology. Thus, the proposed method for the integral biochemical diagnosis of primary hyperparathyroidism could be a reliable quantification technique of the parathyroid glands function, allowing the assessing changes in phosphorus-calcium metabolism, to predict the presence or absence of primary hyperparathyroidism, and also to be used as an objective measure for the effectiveness of the treatment.

PROFILE OF PATIENTS OPERATED ON FOR PRIMARY HYPERPARATHYROIDISM AT CHRIS HANI BARAGWANATH ACADEMIC HOSPITAL.

Introduction: The presentation of primary hyperparathyroidism is protean, making the early diagnosis difficult. The routine use of automated calcium analyser has solved the problem where it is available. This is not the case for Chris Hani Baragwanath Academic hospital (CHBAH), where, according to our observations, the diagnosis is still a challenge and often made in the complication-related stage. Worldwide, women are more affected than men, especially after menopause. The morbidity associated with hyperparathyroidism can be disastrous for a condition that can be readily treated. The aim of this study is to assess the profile of patients operated on for primary hyperparathyroidism. Objective: To determine the clinical presentation, the calcium level, and the cause of primary hyperparathyroidism Method: Review of all patients operated on for primary hyperparathyroidism at CHBAH from 2013 to 2019. Results: Most patients presented with various conditions not directly related to hyperparathyroidism and had mild to moderate hypercalcemia. Over 90% of hypercalcemia resolved post-parathyroidectomy, and parathyroid adenoma was the most common histopathological report. Conclusion: Primary hyperparathyroidism was mainly established in the workup of patients who presented with various conditions and was associated with significant comorbidities. Most cases were due to parathyroid adenoma that was successfully treated with parathyroidectomy.

Comparative prospective study on the presentation of normocalcemic primary hyperparathyroidism. Is it more aggressive than the hypercalcemic form?

BackgroundSome patients with primary hyperparathyroidism (PHPT) have an elevated PTH that does not always correlate with high blood calcium levels. We aimed to compare the clinical presentation between normocalcaemic and hypercalcaemic forms using ionized calcium levels as an inclusion criterion. MethodsWe included all patients referred for surgery for PHPT between January 2015 and December 2017. Patients were divided into 2 groups (hypercalcaemic (hPHTP)/normocalcaemic (nPHPT)). Results104 patients were included.64% of the patients who were initially classified as normocalcaemic had high ionized calcium levels. There were no differences between groups except in terms of bone resorption parameters:patients with hypercalcaemia had higher osteocalcin (37.4vs23.5 ng/mL,P = .02), collagen amino-terminal propeptide (73.5vs49.2 ng/mL,P = .005), and beta-CTX levels (0.68vs0.38 ng/mL,P = .001). Bone involvement as measured by densitometry was similar. ConclussionsWhen these patients’ diagnosis and classification is accurate, their clinical presentation and symptoms are similar to those of the classical form. Since the only difference is in terms of bone resorption parameters, in most cases it seems to be an attenuated form or even similar to the classical presentation. The improvement in diagnostic sensitivity supports the use of ionized calcium levels in patients suspected to have nPHPT.

Clinical Presentation of Primary Hyperparathyroidism in Older Adults.

BackgroundThe clinical presentation of primary hyperparathyroidism (PHPT) has changed greatly during the past few decades. Our aim was to evaluate whether the clinical presentation at diagnosis differed according to age.MethodsWe evaluated retrospectively a monocentric series of 462 consecutive patients with PHPT, dividing them according to a cutoff of 65 years of age.ResultsNo differences were found in the mean serum PTH, calcium, or vitamin D levels. In older patients (n = 212; 45.9%), the urinary calcium levels were significantly lower (median, 205 mg/24 hour; interquartile range, 220 mg/24 hour) compared with those in younger patients (median, 308 mg/24 hour; interquartile range, 233 mg/24 hour). In addition, renal involvement was significantly less frequent (25% vs 49.2%), and bone involvement significantly more frequent (58% vs 44%) in older patients compared with younger patients. The clinical presentation was significantly different between the two age groups, with a lower frequency of symptomatic forms and a greater frequency of asymptomatic forms not meeting surgical criteria in the older patients (44.4% vs 57.2% and 18.4% vs 5.6%, respectively). Osteoporosis was significantly more frequent in the older adults than in their younger counterparts. The most affected bone site was the forearm in older adults and the lumbar spine in younger ones (50.3% and 50.5%, respectively).ConclusionThe clinical presentation of PHPT differs according to age, and this difference can affect the selection of management modalities.

PARATHYROID ADENOMA IN A YOUNG FEMALE PRESENTING WITH CRANIOFACIAL BROWN TUMOR AND ACUTE PANCREATITIS – A CASE REPORT

Solitary Parathyroid adenomas have a diverse clinical presentation. They may be asymptomatic or may sometimes lead to extensive bony resorption and replacement of bone by fibrous tissue, also known as a brown tumor. Brown tumor is a relatively rare presentation of primary hyperparathyroidism and is even rarer in a younger age group. Here, we report the case of a 20-year-old female presenting with craniofacial brown tumor and during the course of hospital stay; she also developed an attack of acute pancreatitis due to hyperparathyroidism. This case report emphasizes the importance of a complete investigative work up in patients presenting with maxillofacial bony lesions for early diagnosis and planning of definitive management.

Stones, Bones, Groans, and Psychic Moans: Primary Hyperparathyroidism Presenting as Surgical Emergency

Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder after diabetes and thyroid disease. Most cases of hyperparathyroidism remain clinically silent. The clinical manifestations of hypercalcemia captured in the classic medical student mnemonic of “stones, bones, groans, and psychic moans” are often not found. Sometimes patients can present with unique complications. This case describes perforated peptic ulcer as the first presentation of primary hyperparathyroidism.