A patient with fatigue, recurrent ureteric stones, bone pain, severe hypercalcemia, and a 2‑cm parathyroid adenoma—what is the most appropriate next step in management?

Management of Primary Hyperparathyroidism with Parathyroid Adenoma

Parathyroidectomy is the definitive and most appropriate next step for this patient with symptomatic primary hyperparathyroidism, severe hypercalcemia (3.50 mmol/L), and a 2-cm parathyroid adenoma. 1, 2

Rationale for Immediate Surgical Intervention

This patient presents with the classic triad of primary hyperparathyroidism complications:

• Renal manifestations: Recurrent ureteric stones 1, 3
• Skeletal manifestations: Bone pain 1, 3
• Systemic symptoms: Fatigue 1, 3

The calcium level of 3.50 mmol/L represents severe hypercalcemia (normal range 2.15-2.25 mmol/L), which is 0.25 mmol/L above the upper limit—a threshold that mandates surgical intervention. 4, 5 The presence of a 2-cm parathyroid adenoma confirms the diagnosis of primary hyperparathyroidism and provides a clear surgical target. 1, 3

Why Surgery Over Medical Management

Parathyroidectomy is the only curative treatment for primary hyperparathyroidism caused by parathyroid adenoma. 1, 2 Medical therapies are temporizing measures at best:

• Bisphosphonates may be considered only in patients who meet surgical criteria but are not surgical candidates, not as primary therapy. 4 They do not address the underlying autonomous PTH hypersecretion and provide no long-term benefit. 5

• Calcium restriction (reducing dietary calcium) is contraindicated and potentially harmful, as it would worsen bone disease without controlling the hypercalcemia driven by autonomous PTH secretion. 6

• Increasing calcium intake would exacerbate the already severe hypercalcemia and is completely inappropriate. 6

Surgical Indications Met

This patient meets multiple absolute indications for parathyroidectomy:

• Symptomatic disease (bone pain, recurrent stones, fatigue) 1, 3, 4
• Severe hypercalcemia >0.25 mmol/L above upper limit of normal 4, 5
• Renal complications (recurrent nephrolithiasis) 1, 3
• Skeletal complications (bone pain suggesting osteitis fibrosa cystica) 1, 3

Expected Outcomes

Surgical resection provides:

• Immediate normalization of calcium and PTH levels within 2 days post-operatively 1, 3
• Complete resolution of symptoms including bone pain and prevention of further stone formation 1, 3
• Reversal of bone mineral density loss over several years without need for bisphosphonates 5
• Excellent prognosis when performed before development of parathyroid crisis 2

Critical Timing Consideration

With calcium at 3.50 mmol/L, this patient is at risk for parathyroid crisis (also called parathyroid storm), a life-threatening complication with 100% mortality if untreated and 20% mortality even with surgery. 2 Early diagnosis and aggressive surgical treatment are essential. 2

Perioperative Management

While awaiting surgery, the patient may require:

• Aggressive hydration to manage hypercalcemia 7
• Temporary bisphosphonates or calcitonin for acute calcium lowering 7
• Correction of vitamin D deficiency if present 5

Post-operatively, monitor for:

• Hungry bone syndrome: Expect transient hypocalcemia requiring calcium and vitamin D supplementation 7, 5
• Calcium normalization typically occurs within 48 hours 1, 3

Answer: D. Parathyroidectomy