A Rare Case of Giant Parathyroid Adenoma in a Rural Tertiary Hospital of North Bengal

A 30-year-old euthyroid male patient presented with a gradually progressive, painless mass in the neck that moved with deglutition, associated with generalized weakness, needing assistance for activities of daily life, and a pathological fracture. Biochemical reports revealed hyperparathyroidism and hypercalcemia. Radiological investigations revealed a complex mass in the postero-medial aspect of the left thyroid lobe, generalized bone resorption with healed pathological fracture, and nephrolithiasis. FNAC was unable to rule out parathyroid neoplasm. The patient underwent a left hemithyroidectomy and a parathyroidectomy. Aggressive IV calcium therapy managed the post-operative hungry bone syndrome. Post-operative histopathology suggested giant parathyroid adenoma of the left superior parathyroid gland. Parathormone, secreted from the parathyroid glands, is responsible for the maintenance of calcium homeostasis in the body.[1] Increased secretion of parathyroid hormone results in primary hyperparathyroidism (or PHPT), causing symptoms characterized by the mnemonic “stones, bones, groans, thrones, and psychiatric overtones’’.[2,3] Osteoporosis and bone fractures are the most common symptoms of primary hyperparathyroidism. Calcium deposits in the renal parenchyma and recurrent nephrolithiasis lead to decreased kidney function and phosphate retention.[4,5] PHPT has been reported in 1% of the adult population and in 2% after the age of 55 years in Western series.[6] In an Indian series, the male: female ratio was 1.7: 1. Almost three quarters (71.5%) of cases were less than 40 years of age, lower than the fifth and sixth decades reported from developed nations.[7] The common causes of primary hyperparathyroidism are sporadic, solitary adenomas (80-85%), parathyroid hyperplasia (10%), and parathyroid carcinoma (2-5%).[8,9] Parathyroid adenomas (PTAs) are usually small, measuring < 2 cm and weighing < 1 gm. GPTAs (Giant PTAs) are adenomas that weigh more than 3.5 gm and are usually rare. Both PTA and GPTA present with the syndrome of primary hyperparathyroidism.[10] Most hyperparathyroidism patients are asymptomatic or have nonspecific symptoms such as fatigue, pain, and weakness that are generally missed in the initial phases. Most patients with hypercalcemia are discovered incidentally on routine laboratory screening. The present case report shows a delay in the diagnosis of a symptomatic case of hyperparathyroidism, caused by parathyroid adenoma, due to the difficulty in the diagnosis of such cases in rural areas.