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 immediate parathyroidectomy—surgery is the only curative therapy for symptomatic primary hyperparathyroidism with clear target-organ damage (recurrent kidney stones, bone pain) and marked hypercalcemia. 1, 2

Why Surgery is Indicated Now

This patient meets multiple criteria for urgent surgical intervention:

• Symptomatic disease with target-organ involvement: The presence of recurrent ureteric stones (nephrolithiasis) and bone pain indicates established end-organ damage from chronic hypercalcemia 1, 2
• Severe hypercalcemia: A calcium level of 3.5 mmol/L is considered severe (>3.5 mmol/L threshold) and can cause vomiting, polyuria, dehydration, and progressive renal impairment 3
• Identified adenoma: The 2 cm parathyroid adenoma confirms autonomous PTH overproduction from a single source, making this a straightforward surgical case 1, 2
• Delaying surgery is not recommended: Medical management in symptomatic patients with clear target-organ damage is inappropriate—parathyroidectomy should be performed promptly 1, 2

Why Other Options Are Incorrect

Option A: Bisphosphonates

• Bisphosphonates serve only as temporizing agents for acute hypercalcemia and do not provide definitive treatment of primary hyperparathyroidism 2
• They may be used as a bridge to surgery in hypercalcemic crisis, but surgery remains the definitive treatment 4

Option B: Calcimimetics (Cinacalcet)

• Calcimimetics may have value only if the patient meets surgical guidelines but is not a surgical candidate 5
• This patient is symptomatic with a localized adenoma—there is no indication to defer surgery for medical management 1, 2

Option C: Increased Calcium Diet

• Completely contraindicated in hypercalcemia—increasing calcium intake would worsen the patient's already elevated calcium levels 1, 2
• Dietary calcium restriction (not supplementation) has minimal effect on hypercalcemia driven by autonomous PTH secretion 2

Surgical Approach

Preoperative Planning

• Obtain preoperative localization with 99mTc-sestamibi scintigraphy and/or neck ultrasound to facilitate minimally invasive parathyroidectomy (MIP) 1, 2
• MIP with intraoperative PTH monitoring is appropriate for single adenoma cases, offering shorter operative times and faster recovery 1, 2

Postoperative Management

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours to detect hungry-bone syndrome 1, 2
• If ionized calcium falls below 0.9 mmol/L, initiate calcium gluconate infusion at 1-2 mg elemental calcium/kg/hour 1, 2
• Transition to oral calcium carbonate 1-2 g three times daily plus calcitriol up to 2 μg/day once oral intake is tolerated 1, 2

Clinical Pitfalls to Avoid

• Do not delay surgery for medical optimization in symptomatic patients—this patient has already developed complications (stones, bone disease) 1, 2
• Do not confuse this with asymptomatic hyperparathyroidism—the presence of fatigue, recurrent stones, and bone pain makes this clearly symptomatic disease requiring surgery 1, 2
• Ensure adequate postoperative calcium monitoring—severe, longstanding hyperparathyroidism increases risk of hungry-bone syndrome after adenoma removal 1, 2