bluuebunny/crossref_metadata_2025_split huggingface dataset:
SAT193 Double Trouble: A Case of Ipsilateral Double Parathyroid Adenoma
Authors: Perez Suelto Jeremy Anne , Dimayuga Wassmer Gia 
Published: October 2023

Abstract
Disclosure: J.P. Suelto: None. G.D. Wassmer: None.
Background: Eighty percent of the cases of Primary Hyperparathyroidism is caused by a single adenoma and only about 15% are multiglandular adenoma. Parathyroid imaging like Sestamibi is less sensitive in detecting multiglandular disease. Clinical Case: A 63 year-old female presented with intermittent left lower back pain for 7 years. There was no joint pain, weakness, urinary symptoms, constipation and abdominal pain. In 2019, due to persistence of left back pain, abdominal ultrasound done showed a right non-obstructing nephrolithiasis. Ionized and total calcium were elevated at 1.53 meq/L (NV 1.12-1.32 meq/L) and 11.35 ng/dl (NV 8.42-10.23 ng/dl) respectively with normal creatinine, phosphorus and albumin. PTH was elevated at 116.6 pg/ml (NV 10-65 pg/ml). Primary Hyperparathyroidism probably secondary to parathyroid adenoma was considered. Thyroid ultrasound showed right thyroid cyst but no enlarged parathyroid gland. Parathyroid imaging using Dual Isotope Subtraction Method neither showed evidence of adenoma. Patient was advised parathyroidectomy but did not consent hence started on Cinacalcet. In 2021, ionized calcium was still elevated to 1.58 meq/L with elevated PTH 151 pg/ml and low Vitamin D level 22.76 ng/ml (&gt;30 ng/mL). Patient was given Vitamin D3 2000 IU daily and Cinacalcet was up-titrated to 60mg daily. Sestamibi/SPECT CT showed faint focus of radioactivity in the right thyroidal bed area suspicious for parathyroid adenoma or hyperplasia. She then agreed to have parathyroidectomy. There was no decrease in PTH after removal of the right inferior parathyroid gland (measuring 1.8x0.6x0.6cm, weighs 500mg), hence re-exploration was done. It was only after the removal of the right superior parathyroid gland (measuring 2.8x0.9x0.7cm, weighs 1 gram) when the 5 and 10 minute post excision PTH decreased to 123.91 and 76.01 pg/ml respectively from preincision PTH of 407.19 pg/ml. Histopathology showed Parathyroid adenoma of right inferior and superior parathyroid glands. No further evidence of hypercalcemia was noted at 6-month follow-up. Conclusion: Double adenoma is reported in 2% to 12% of patients with primary hyperparathyroidism. This occurs predominantly as bilateral superior in 45% and on same side of the neck in 18%. Sestamibi scanning is poor in the presence of multiglandular disease. It was observed that the presence of oxyphil cells may cause longer sestamibi retention in parathyroid tissues. Given the same amount of oxyphil cells in ipsilateral adenomas, the tracer may be distributed hence faintly seen on imaging. Addition of SPECT/CT/4D CT may improve the anatomical localization. Another reason for false negative imaging in this patient can be due to use of Cinacalcet which may decrease scintigraphy uptake of parathyroid adenoma. The combination of preoperative imaging localization and intraoperative PTH monitoring permits successful surgical outcome.
Presentation: Saturday, June 17, 2023
SAT199 Intrathyroidal Parathyroid Adenomas: A Case Series
Authors: Bowens Brendan K , LaChance David , Shakir Mohamed K M , Duc Hoang Thanh 
Published: October 2023

Abstract
Disclosure: B.K. Bowens: None. D. LaChance: None. M.K. Shakir: None. T.D. Hoang: None.
Background: Primary hyperparathyroidism (PHPT) is a relatively common condition which affects 1-7 people per 1000. However, intrathyroidal parathyroid adenomas (ITPA) have a prevalence of 1.3% to 6.7%. In this case series, we report 3 cases of ITPA. Case 1: 66-year-old male with a history of PHTP without intervention at initial diagnosis presented to Endocrinology several years after initial diagnosis due to an incidental thyroid nodule on routine CT lung cancer screening. Parathyroid hormone (PTH) level found to be 109.3 from a previous level of 80 (ref 10-55pg/mL) in the setting of mild hypercalcemia and osteopenia. Initial bedside thyroid ultrasound was suggestive of a right ITPA. Parathyroid scan, formal thyroid US and CT gated scan revealed a 1.5cm parathyroid adenoma (PA) posterior to the right superior aspect of the thyroid gland. Fine Needle Aspiration (FNA) was completed with PTH washout of 399.40 pg/mL. Right superior parathyroidectomy confirmed ITPA due to an intrathyroidal parathyroid adenoma Case 2: 44-year-old female presented with 9 months of fatigue and was diagnosed with PHPT. Her PTH level was 167 with a serum calcium of 10.9 (ref 8.5-10.4 mg/dL). CT SPECT with tech-99M sestamibi was positive for a right parathyroid adenoma. Explorative surgery did not localize parathyroid adenoma. Thyroid ultrasound revealed a 9mm hypoechoic lesion in the right inferior lobe with polar artery. FNA of this lesion was completed with PTH washout of 4737 pg/mL. Right hemi-thyroidectomy was completed with resolution of PHTP.
Case 3: 54-year-old male with history of PHPT and carcinoma of the right kidney s/p nephrectomy presented with persistent hypercalcemia. Serum calcium of 10.2-11.0 mg/dL and PTH of 160-186 pg/mL. Thyroid US showed a 1.1cm hyperechoic, cystic nodule in the left inferior thyroid lobe. Sestamibi was consistent with ITPA. FNA of left thyroid mass with PTH washout of 2602 pg/mL. Parathyroidectomy with left thyroid lobectomy was completed with resolution of hypercalcemia. Discussion: PHPT is a common endocrinopathy with 85% of cases due to PAs, 15% due to parathyroid hyperplasia, and &lt;1% due to carcinoma. ITPAs have an incidence of 1.3% to 6.7% and are due to improper embryologic migration. Sestamibi parathyroid scan allows for localization of PA and for minimally invasive procedures. Other imaging modalities include SPECT, US, SPECT-CT, and MRI. PTH washout with more than 101 pg/mL confirms the presence of parathyroid tissue or adenoma. Conclusion: This is a rare presentation of a common endocrinopathy. These patients were noted to have PHTP. Initial exploratory neck dissections did not localize. FNA and US were able to confirm IPTAs and hemi-thyroidectomy was needed for definitive management with resolution of PHTP.
Presentation: Saturday, June 17, 2023
SAT201 A Rare Case Of A Mediastinal Atypical Parathyroid Adenoma Resulting In Severe Hypercalcemia And Brown Tumor
Authors: Aluko Oluwatomisin A , Franey Daniel , Quiros Roderick , Burfeind William , Amori Renee E 
Published: October 2023

Abstract
Disclosure: O.A. Aluko: None. D. Franey: None. R. Quiros: None. W. Burfeind: None. R.E. Amori: None.
Introduction: Primary hyperparathyroidism is most often from parathyroid adenomas located usually in close association to the thyroid gland. Ectopic parathyroid glands result in significant variability in the position of the gland, however rarely in the mediastinum. We report a case of a patient with severe hypercalcemia from a large, ectopic mediastinal parathyroid adenoma. Case Report: A 53-year old male with a past medical history of hypercalcemia and nephrolithiasis was sent to the ER for evaluation of hypercalcemia after he was found to have a corrected calcium of 12.5 mg/dl (n8.4 - 10.2 mg/dl) on routine labs. Repeat blood work at presentation confirmed hypercalcemia with a corrected calcium 11.9 mg/dl and elevated ALP of 211 U/l (n 43 - 122 U/L), elevated initial PTH of799 pg/ml (n 18.4 - 80.1 pg/ml), Vit D 32.7 ng/ml (n 30 - 100 ng/ml), and low phosphorus 2.4 mg/dl (n2.7 - 4.5 mg/dl). Calcium slightly improved to 11.7 mg/dl after IV hydration. Chest CT showed a large mediastinal mass compressing trachea and esophagus, suspicious for parathyroid origin, with a smaller left sided lesion suspicious for parathyroid adenoma. CT also showed multiple bone lesions likely brown tumors. He underwent complete robotic resection of the mediastinal mass. Immediately prior to surgery, PTH was 1002.8 pg/ml, and fell to 131.1 pg/ml and 44.1 pg/ml following removal of the mediastinal mass. Adherence of the mass to surrounding structures made resection challenging, resulting in a right vocal cord paralysis. After surgery, he was empirically started on IV calcium and calcitriol for high clinical concern for hungry bone syndrome, both later discontinued as serum calcium remained within normal limits. Pathologic findings reported as highly suspicious, however not definitive for parathyroid carcinoma with no evidence of perineural or lymphovascular invasion. Given rarity, he was referred to a tertiary cancer center where he was diagnosed with Atypical parathyroid Adenoma (APA). He underwent a right pubic biopsy with pathology diagnosis of brown tumor of hyperparathyroidism. He started on cinacalcet 30 mg daily after surgery. There is a future plan for resection of the smaller left sided parathyroid adenoma. Conclusion: This case highlights two rare entities; a mediastinal ectopic parathyroid and atypical parathyroid adenoma. Atypical Parathyroid Adenoma is a not-well defined entity which could mimic a parathyroid carcinoma as seen in our case. The location of the mass in the superior mediastinum is unusual, making it more difficult to diagnose, and could increase risk of complications during resection. Delayed diagnosis of these entities can lead to severe hypercalcemia and skeletal complications infrequently seen in common primary hyperparathyroidism cases.
Presentation: Saturday, June 17, 2023
SAT202 A Case Of Primary Hyperparathyroidism Secondary To Ectopic Intrathymic Parathyroid Adenoma
Authors: Pandiri Shruti 
Published: October 2023

Abstract
Disclosure: S. Pandiri: None.
Introduction: Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia. Majority of cases are due to a single adenoma. In about 6-16% of cases, the parathyroid adenoma is in an ectopic location. Accurate preoperative imaging is key in localizing ectopic parathyroid adenomas. Clinical Case: 64 year old man with hypercalcemia was referred to endocrinology for further evaluation. His symptoms included fatigue, nausea, polydipsia and polyuria. There was no history of fractures, radiation therapy or family history of hypercalcemia. The patient’s past medical history is significant for nephrolithiasis, thyroid nodules and hypertension. He was started on Cinacalcet 30 mg, twice daily, by his primary care physician about 6 weeks prior to the initial visit. Physical exam was unremarkable. Lab studies were significant for elevated albumin-corrected calcium: 11.2 mg/dl (8.6-10.3 mg/dl), elevated PTH: 578.1 pg/ml (12-88 pg/ml), 25-OH vitamin D: 17 ng/ml (&gt;30 ng/ml), phosphorus: 2 mg/dl (2.5-4.5 mg/dl) TSH: 0.54 mIU/L (0.40-4.50 mIU/L), 24 hr urine calcium: 429 mg (&lt;250 mg/24 hr). The lab findings were consistent with hypercalcemia due to primary hyperparathyroidism. Neck Ultrasound showed bilateral thyroid nodules but no parathyroid adenoma. Tc-99m sestamibi scintigraphy was significant for 2.8 x 1.5 x 3.4 cm mass in the anterior mediastinum but did not show uptake in the neck. CT Neck showed a mass in the anterior mediastinum measuring 1.6 x 2.7 cm. Bone density was significant for osteopenia. He underwent robot assisted mediastinal mass excision two months after the initial evaluation. The pathology was significant for ectopic, intrathymic parathyroid adenoma, watery cell type with nuclear atypia, measuring 3.8 x 3.1 x 1.3 cm. Labs at the follow up visit showed normal albumin-corrected calcium of 8.6 mg/dl, improved PTH of 110.3 pg/ml. His symptoms improved significantly after surgery. Conclusion: This case demonstrates that preoperative localization of an ectopic parathyroid adenoma can prevent recurrent surgeries and persistent hypercalcemia. It is important for physicians to be aware of the various ectopic locations of parathyroid adenomas during the diagnostic workup of PHPT. Reference: Roy M, Mazeh H, Chen H, Sippel RS. Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients. World J Surg. 2013 Jan;37(1):102-6. doi: 10.1007/s00268-012-1773-z. PMID: 22968537.
Presentation: Saturday, June 17, 2023
SAT210 A Case Of Recurrent Metastatic Parathyroid Cancer Complicated By Multiple Brown Tumors
Authors: Elmaaz Ahmed , Bustamante Eilyn , Batra Manav 
Published: October 2023

Abstract
Disclosure: A. Elmaaz: None. E. Bustamante: None. M. Batra: None.
Introduction: Parathyroid cancer is a rare malignancy with about 25 % incidence of metastasis. Brown tumors are benign bone lesions caused by excessive bone turnover which are rarely associated with parathyroid carcinoma. Here, we present a case of recurrent metastatic parathyroid cancer complicated by multiple brown tumors. Case Presentation: A 63-year-old male presented with back pain, generalized weakness, and significant weight loss. Laboratory findings showed hypercalcemia 14.4 mg/dl, Alkaline phosphatase 253 U/L, and phosphorus 2.3 mg/dl. He was admitted to the hospital for hypercalcemia workup. MRI spine showed a heterogeneous mass arising from the left thyroid lobe and conglomerate lymph node, along with extensive metastatic sclerotic lytic lesions throughout the spine. MRI brain revealed multiple metastatic lesions in the skull base, facial bones, and the right angle of the mandible. Further workup revealed normal PSA, normal serum levels of free lambda and kappa light chains, and normal urine and serum protein electrophoresis. PTH levels, 2435.1 (8.7-77.1) pg/ml, and PTH-rP levels &lt;1.1 pmol/l were noted. Ultrasound-guided FNA of the thyroid mass showed solid growth of malignant parathyroid cells strongly stained for PTH. Biopsy of the body of the T12 vertebra and mandibular lesions showed giant cell lesions of the bone with fibrous dysplasia, consistent with brown tumors. IV hydration, calcitonin, cinacalcet, and IV zoledronic acid started, followed by left hemithyroidectomy and left inferior parathyroidectomy. Surgical pathology was positive for parathyroid carcinoma invading the thyroid gland. His calcium and PTH levels post-surgery significantly improved. A few months later, the patient presented again with hypercalcemia and high levels of PTH. Sestamibi parathyroid scan showed no evidence of parathyroid adenoma. Because of enlarging left neck mass, confirmed by MRI neck, he then underwent excision of the left subcutaneous cervical lesion involving the left sternomastoid muscle. Surgical pathology was consistent with parathyroid carcinoma involving soft tissue. His calcium and PTH levels improved on subsequent follow-up visits. Conclusion: Parathyroid carcinoma is not a common cause of hypercalcemia. Though a rare entity, parathyroid cancer should be considered in the differentials of hypercalcemia and extremely high levels of PTH. Metastasis either locally or remotely should not be overlooked. Brown tumors could mimic bone metastasis and giant cell tumors; therefore, the clinical presentation is important for the diagnosis.
Presentation: Saturday, June 17, 2023
SAT211 PTH-secreting Endometrial Carcinoma: A Rare Cause of Hypercalcemia
Authors: Fanous Ereeny , Park Patricia , Rakhlin Luba 
Published: October 2023

Abstract
Disclosure: E. Fanous: None. P. Park: None. L. Rakhlin: None.
Introduction: Hypercalcemia of malignancy (HCM) is a common occurrence in advanced cancer, but it is rare for gynecological malignancies to be the cause (1). Case Presentation: Our patient is a 48-year-old postmenopausal female with diabetes mellitus and obesity who presented with pelvic pain and vaginal spotting over the course of 2 months. She also reported unintentionally losing approximately 60 lbs over the past year. A CT scan of the pelvis revealed a 6.1 cm uterine mass and thickening of the endometrium up to 2.4 cm. Her electrolyte levels were normal at the time of presentation. A biopsy of the endometrium was performed, and the pathology report indicated endometrial carcinoma. The patient was scheduled for a total hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO). A few weeks prior to her scheduled surgery, the patient reported increased thirst and urination, which she attributed to her diabetes and intake of an SGLT2 inhibitor. On the day of surgery, she was found to have a calcium level of 15.4 mg/dl and an albumin level of 3.6 g/dl. She denied taking calcium supplements or Vitamin D3. The workup for hypercalcemia revealed a PTH level of 338 pg/ml, an undetectable PTH-rp level, and normal levels of Vitamin D1,25 and Vitamin D25. Additional imaging showed numerous pulmonary nodules, which were later confirmed to be metastases from endometrial carcinoma. The thyroid gland and surrounding soft tissue were noted to be unremarkable on available CT images. The patient received a single dose of zolendronic acid and was started on cinacalcet 30 mg twice a day. The calcium gradually normalized. She was initiated on chemotherapy with paclitaxel and carboplatin and underwent a palliative TAH/BSO. Cinacalcet was discontinued after several cycles of chemotherapy. Two months later, the PTH level was checked and found to be 34 pg/ml, with a normal calcium level of 9.5 mg/dl and an albumin level of 4.1 g/dl. Given that the hypercalcemia resolved and the PTH level normalized after chemotherapy and hysterectomy, it is believed that the endometrial carcinoma was the source of ectopic PTH. Conclusion: Approximately 5% of gynecological malignancies are associated with paraneoplastic hypercalcemia [1]. We present a rare case of PTH-secreting endometrial carcinoma, in which surgery and chemotherapy resulted in complete resolution of hypercalcemia and normalization of PTH. Clinicians should consider ectopic PTH production as part of the differential diagnosis in patients who present with malignancy and hypercalcemia.
References: 1. Savvari P, Peitsidis P, Alevizaki M, et al. Paraneoplastic humorally mediated hypercalcemia induced by parathyroid hormone-related protein in gynecologic malignancies: A systematic review. Onkologie. September. 2009;32:517-23.
Presentation: Saturday, June 17, 2023
SAT214 A Rare Case Of Biopsy-proven Non-uremic Calciphylaxis In A Patient With Secondary Hyperparathyroidism
Authors: Annabel Ogar Ufeh , Gbenga Olafimihan Ayobami , Asemota Iriagbonse , Krishnaraju Ellil , Okafor Akuchi 
Published: October 2023

Abstract
Disclosure: U.A. Ogar: None. A.G. Olafimihan: None. I. Asemota: None. E. Krishnaraju: None. A. Okafor: None.
Introduction: Calciphylaxis, also known as calcific uremic arteriolopathy, is a rare, lethal, metastatic calcification involving cutaneous microvasculature that presents as painful necrotic skin lesions. It typically occurs in patients with end-stage kidney disease (ESKD), renal transplant, or acute kidney injury requiring renal replacement therapy. Calciphylaxis occurring without these comorbidities is termed non-uremic calciphylaxis (NUC), which is rarer. NUC’s etiology is unclear but it has been associated with hyperparathyroidism, malignancies, alcohol liver disease, and connective tissue disorders. There are only a few reported cases of biopsy-proven NUC in patients with secondary hyperparathyroidism, as in our patient. Clinical Case: A 63-year-old female with a history of COPD on home oxygen therapy, smoking, and alcohol use disorder presented with a four-day history of severe, painful, purplish left thigh rash. She had no recent trauma or insect bite. Her physical exam showed a large (6x10 cm), tender, distal anterior left thigh bruise. Laboratory findings were significant for elevated creatine of 4.3 mg/dL from a normal baseline creatinine (0.6 mg/dL), normal serum corrected calcium (10.1 mg/dL) and elevated phosphate (4.7mg/dL). Three days following her admission, the skin lesion had progressed into multiple brown coalescing bullae with central ulceration, collarette, surrounding erythema, warmth, and induration. Due to concern for possible skin and soft tissue infection, empiric vancomycin therapy was started. However, the overall clinical picture was not convincing of an infection, necessitating consultation with the Dermatology team. A skin biopsy was recommended, and this was diagnostic of calciphylaxis. Further testing revealed hyperparathyroidism (202pg/ml), low 25 hydroxy Vitamin D (12ng/ml), and negative autoimmune and thrombophilia workup. Her treatment plan included wound care with debridement, analgesia, and interdisciplinary clinic follow-up. During outpatient follow-up, her wound was seen to be slowly healing with daily wound dressing, and her elevated serum creatinine had resolved. Conclusion: NUC has a high mortality rate (52%) and requires a high index of clinical suspicion to ensure prompt diagnosis and initiation of treatment. Differential diagnoses include atherosclerotic vascular disease, vasculitis, hypercoagulable disorders, and cellulitis as in our patient. Skin biopsy is diagnostic. Aggressive wound care and analgesia are pivotal to treatment, in addition to addressing underlying precipitating conditions. Other treatment options like sodium thiosulphate exist but with uncertain outcomes. Efforts geared at definitive therapeutic modalities are needed.
Presentation: Saturday, June 17, 2023
SAT244 Hypercalcemia Induced By Inconspicuous Histoplasmosis Infection
Authors: Alkhathlan Mujahed , Li Yulong , Siddiqui Ayesha , Goud Sarita 
Published: October 2023

Abstract
Disclosure: M. Alkhathlan: None. Y. Li: None. A. Siddiqui: None. S. Goud: None.
Background: Hypercalcemia is a common condition with a variety of etiologies. In general, it can be categorized as either parathyroid hormone (PTH) dependent or independent. In those with non-PTH mediated hypercalcemia, elevated 1, 25 vitamin D is one of the causes and among pathologies behind it are sarcoidosis, malignancy, and to less extent infectious process. An important determinant in the management of elevated 1,25vitD is to identify the source of 1,25vitD overproduction as the choice of treatment can affect the outcomes and increase the risk of mortality. Clinical Case: Our patient is an 81-year-old man who had been admitted to the hospital for nonspecific fatigue and weakness for two months. He was discharged from another hospital with similar complaints without resolution. At the time of admission, he was noted to have elevated total calcium 12.5 mg/dL (8.4-10.2) with albumin 3.0 g/dL (3.5-5.2), subacute kidney injury with creatinine 3.46 mg/dL (0.7-1.3), suppressed parathyroid hormone (PTH) and markedly elevated 1,25-dihydroxy vitamin D (1,25OH2D) 128 pg/mL (19.9-79.3). His calcium and kidney function were normal 4 months ago. The hypercalcemia was refractory to intravenous fluid, loop diuretic or calcitonin administration. Extensive workup eventually revealed disseminated histoplasmosis infection with blood and urine positive for histoplasmosis antigens. Bone marrow aspiration showed scattered non-necrotizing granulomas. With antifungal treatment, his calcium level returned to the normal range in two weeks (8.9 mg/dL) and was maintained in the normal range. Conclusion: Hypercalcemia is a rare presentation of histoplasmosis. Pubmed keyword search of hypercalcemia and histoplasmosis returned 18 clinical case reports from 1977 to 2021. The case review showed a striking similarity in atypical clinical presentation and diagnosis challenges. Hypercalcemia is most developed in histoplasmosis disseminated cases with elevated 1,25vitD levels and pathology identification of granulomas in some of the cases. With successful antifungal treatment, patients will have prompt recovery of hypercalcemia. Steroid treatment is a well know and effective treatment by suppressing 1-alpha hydroxylation of 25-vitD. However, treatment with steroids before establishing diagnosis due to Inconspicuous presentations or delay in diagnosis may lead to mortality quickly.
Presentation: Saturday, June 17, 2023