In a patient with fatigue, recurrent ureteric stones, bone pain, marked hypercalcemia (serum calcium 3.5 mmol/L) and a 2‑cm parathyroid adenoma, what is the most appropriate next step in management?

Parathyroidectomy is the Most Appropriate Next Step

This patient requires urgent parathyroidectomy—surgery is the only curative treatment for primary hyperparathyroidism and should be performed promptly in symptomatic patients with target organ damage (recurrent nephrolithiasis, bone pain) and severe hypercalcemia. 1, 2

Why Parathyroidectomy is Indicated

This patient has clear indications for surgical intervention:

• Symptomatic disease with target organ involvement: Recurrent ureteric stones (nephrolithiasis) and bone pain indicate significant end-organ damage from chronic hypercalcemia 1
• Severe hypercalcemia: Serum calcium of 3.5 mmol/L meets criteria for severe hypercalcemia (>3.5 mmol/L), which can progress to life-threatening hypercalcemic crisis 3, 4
• Identified parathyroid adenoma: The 2 cm parathyroid adenoma is the source of autonomous PTH overproduction causing the hypercalcemia 1, 2
• Surgery is definitive: Parathyroidectomy is the only curative therapy for primary hyperparathyroidism, and delaying surgery for medical management in symptomatic patients with clear target organ damage is not recommended 1, 2

Why Other Options are Inappropriate

Bisphosphonates (Option A)

• Bisphosphonates are temporizing measures only for acute hypercalcemia management, not definitive treatment 5
• While they can lower calcium acutely, they do not address the underlying autonomous parathyroid overproduction 3
• Medical management alone (including bisphosphonates, denosumab, calcitonin) often fails to control severe hyperparathyroid-induced hypercalcemia, as demonstrated in cases where patients deteriorated despite aggressive medical therapy 3

Calcium Restriction (Option B - "Calcium meteics")

• Dietary calcium restriction has minimal impact on hypercalcemia driven by autonomous PTH secretion 1
• The hypercalcemia results from increased bone resorption and renal calcium reabsorption mediated by excess PTH, not dietary intake 2

Increased Calcium Diet (Option C)

• This is completely contraindicated—increasing calcium intake would worsen the patient's already dangerously elevated calcium levels 1
• This option demonstrates a fundamental misunderstanding of the pathophysiology

Surgical Approach

Minimally invasive parathyroidectomy (MIP) is appropriate for this patient with a single localized adenoma:

• Preoperative imaging (99mTc-sestamibi scan and/or ultrasound) should be performed for localization 1, 2
• MIP offers shorter operating times, faster recovery, and decreased costs compared to bilateral neck exploration 2
• Intraoperative PTH monitoring confirms adequate removal of hyperfunctioning tissue 1

Critical Post-Operative Management

After parathyroidectomy, hungry bone syndrome is a significant risk given the chronic severe hypercalcemia and bone pain:

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours post-operatively 1
• If ionized calcium drops below 0.9 mmol/L, initiate calcium gluconate infusion at 1-2 mg elemental calcium/kg/hour 1
• Transition to oral calcium carbonate 1-2 g three times daily plus calcitriol up to 2 μg/day when oral intake is possible 1
• Phosphate binders may need to be discontinued or reduced based on serum phosphorus levels 1

Urgency Considerations

Given the severe hypercalcemia (3.5 mmol/L) and symptomatic presentation, this case borders on hypercalcemic crisis, which can cause:

• Cardiac arrhythmias including complete heart block 4, 6
• Acute kidney injury 4
• Neurocognitive disturbances and altered mental status 3, 4
• Multi-system organ failure if untreated 4

Surgery should not be delayed—temporary medical measures (IV hydration, bisphosphonates) may be initiated while preparing for urgent parathyroidectomy, but definitive surgical treatment is required 3, 4

Answer: D. Parathyroidectomy