What is the most appropriate management for a patient with symptomatic primary hyperparathyroidism (fatigue, recurrent ureteric stones, bone pain, serum calcium 3.5 mmol/L) and a 2‑cm parathyroid adenoma?

Management of Symptomatic Primary Hyperparathyroidism

The most appropriate management is D. Parathyroidectomy, which is the only definitive curative therapy for this patient with symptomatic primary hyperparathyroidism presenting with recurrent nephrolithiasis, bone pain, and significant hypercalcemia (3.5 mmol/L) due to a 2 cm parathyroid adenoma. 1

Rationale for Surgical Management

This patient has clear indications for immediate parathyroidectomy based on symptomatic disease with target organ damage:

• Recurrent ureteric stones represent definitive renal involvement requiring surgical intervention 1
• Bone pain indicates ongoing bone demineralization from chronic PTH excess 1
• Serum calcium of 3.5 mmol/L (approximately 14 mg/dL) represents severe hypercalcemia, well above the surgical threshold of 0.25 mmol/L above the upper limit of normal 2
• Identified 2 cm parathyroid adenoma provides a clear surgical target 1

Surgery is indicated even in asymptomatic patients given the negative long-term effects of hypercalcemia, making it unequivocally appropriate in this symptomatic case. 1

Why Other Options Are Inappropriate

A. Bisphosphonates - Incorrect

• Bisphosphonates may temporarily address bone symptoms but do not treat the underlying autonomous PTH hypersecretion 3
• They are reserved only for patients who meet surgical criteria but cannot undergo surgery due to contraindications 2
• Delaying definitive surgery for medical management in symptomatic patients with clear target organ damage is not recommended 1

B. Calcimimetics (Calcium Mimetics) - Incorrect

• Calcimimetics inhibit PTH secretion but are not curative 3
• They are appropriate only when patients meet surgical guidelines but are not surgical candidates 2
• This patient has no contraindications to surgery mentioned and requires definitive treatment 1

C. Increased Calcium Diet - Completely Contraindicated

• Increasing dietary calcium is absolutely contraindicated in hypercalcemia, as it would dangerously worsen the patient's already elevated calcium levels 1
• This option could precipitate acute hypercalcemic crisis

Surgical Approach

Minimally invasive parathyroidectomy (MIP) with intraoperative PTH monitoring is the appropriate surgical technique:

• The single 2 cm adenoma makes this a straightforward surgical case amenable to focused exploration 1
• Preoperative localization with sestamibi scan and/or ultrasound facilitates minimally invasive surgery 4
• Intraoperative PTH monitoring confirms adequate removal of hyperfunctioning tissue, with expected PTH drop of approximately 70% 5
• Success rates exceed 95-98% with experienced parathyroid surgeons 3

Expected Outcomes

Post-parathyroidectomy, this patient should experience:

• Resolution of recurrent nephrolithiasis 1
• Improvement in bone pain as bone metabolism normalizes 1
• Normalization of serum calcium and PTH levels 6, 5
• Average calcium decrease of approximately 20% post-operatively 5

Critical Postoperative Management

Monitor for hungry bone syndrome, particularly given the severe preoperative hypercalcemia and bone involvement:

• Check ionized calcium every 4-6 hours for the first 48-72 hours 1
• If ionized calcium falls below 0.9 mmol/L, initiate IV calcium gluconate 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 resumes 1

Common Pitfall to Avoid

Do not delay surgery to correct vitamin D deficiency if present. Vitamin D-deficient patients actually have similar or better surgical outcomes, are more likely to be cured with single adenoma excision, and have equivalent rates of postoperative hypocalcemia compared to vitamin D-replete patients. 7 Restoring vitamin D should not delay appropriate surgical treatment. 7