8082 Primary Hyperparathyroidism or Familial Hypocalciuric Hypercalcemia? Why Not Both?
Authors: Zmijewski C A , Greenberg P D , Saul S R 
Published: October 2024

Abstract
Disclosure: C.A. Zmijewski: None. P.D. Greenberg: None. S.R. Saul: None.
Background: Although considered two separate entities, primary hyperparathyroidism (PHPT) and familial hypocalciuric hypercalcemia (FHH) can present concurrently. Case: A 68-year-old male with hypertension was referred to Endocrinology for hypercalcemia and osteoporosis. The patient reported a long-standing history of intermittent hypercalcemia, first diagnosed at age 30 with a strong family history, both his father and son. He denied symptoms of hypercalcemia, history of nephrolithiasis and fractures, and was not taking calcium supplementations. Labs were notable for intermittent elevations in calcium, the highest being 10.9 mg/dL (8.5-10.5 mg/dL), in addition to phosphorus levels as low as 1.7 mg/dL (2.5-4.5 mg/dL). Vitamin D was replete at 50 ng/mL (32-100 ng/mL) and the highest parathyroid hormone (PTH) was 124 pg/mL (10-66 pg/mL). The 24-hour urine for calcium was 117 mg (100-300 mg) with a Ca/Cr 0.01. DEXA scan showed T scores -2.2 at the right femoral neck and -3.4 at the distal radius (Z score -2.3). Due to the significant osteoporosis, a work-up for secondary causes was completed and was unremarkable. The differential diagnosis for the osteoporosis, elevated parathyroid hormone, and intermittent hypercalcemia included PHPT vs FHH or possibly, a combination. Additional imaging included a renal ultrasound which was negative for nephrolithiasis, Sestamibi and 4D-CT which were both negative for a parathyroid adenoma. Genetic testing confirmed a mutation in the CASR gene. Due to the inability to localize a possible lesion, the decision was made to treat the osteoporosis with zoledronic acid. Conclusion: PHPT is a common endocrine disorder; approximately 100,000 people in the United States develop PHPT annually. Conversely, FHH is a rare endocrine disorder with an incidence rate of 1 in 78,000. PHPT occurs due to the over-secretion of PTH by one or more parathyroid glands. FHH is an inherited autosomal dominant disorder, most commonly due to an inactivating mutation in the calcium-sensing receptor (CASR) gene. Distinguishing PHPT from FHH is important because PHPT is cured with surgery while FHH does not require treatment. Hypercalcemia from FHH, as opposed to PHPT, is suggested by the absence of symptoms, a positive family history, normal or high PTH, and hypocalciuria. However, it can be challenging to separate the two especially in atypical presentations (PTH can be normal in PHPT and elevated in FHH, and Ca/Cr can be &lt; 0.01 in PHPT). But what if these two conditions were to co-exist? Case reports have described patients with concurrent PHPT and FHH (parathyroid adenoma confirmed with pathology and CASR gene mutation confirmed with genetic testing). In these cases, parathyroidectomy can still be considered in co-existing PHPT and FHH to alleviate symptoms and prevent complications of hypercalcemia. Though a rare occurrence, PHPT and FHH have been shown to co-exist in prior case reports.
Presentation: 6/1/2024