A 55-year-old woman consults for fatigue and polyuria of two years' evolution. Laboratory tests reveal hypercalcemia, increased PTH and increased bone turnover markers. The radiographic study shows subperiosteal resorption and osteoporosis. Sestamibi scintigraphy revealed a parathyroid adenoma. Parathyroidectomy was performed with minimally invasive surgery. Postoperatively, the patient developed severe hypocalcemia and tetany, with PTH below 5 ng/l. The patient responds well to initial treatment with intravenous calcium and later with oral calcium and vitamin D. What is the most likely diagnosis?
Question of very high difficulty, I would not worry about having failed it. It is easy to get confused with the hypoparathyroidism answer. Permanent post-surgical hypoparathyroidism after parathyroidectomy of an adenoma with minimally invasive surgery is rare. I write a brief summary of the hungry bone syndrome that I have found in a clinical case in the Annals of Internal Medicine [1]: "The pathophysiology of the hungry bone syndrome (HBS) is related to an imbalance between bone formation and bone resorption, which is associated with hypocalcemia, hypophosphatemia and hypomagnesemia (1). This syndrome can be observed after surgery in patients with primary hyperparathyroidism (HPT), as well as in tertiary HPT of chronic renal failure, and to a lesser extent after treatment of processes with excess of circulating thyroid hormones (2). In PTH, there is an excess of parathyroid hormone (PTH) which stimulates osteoclastic activity causing demineralization of the bone matrix and releasing calcium into the bloodstream. After parathyroidectomy, serum PTH levels drop dramatically, thus, PTH-induced bone resorption ceases, while osteoblastic activity continues resulting in increased bone uptake of calcium, phosphate and magnesium, thus SHH appears (3)."
Permanent surgical hypoparathyroidism.
Transfusion of citrated blood.
Vitamin D insufficiency.
Hungry bone syndrome.
Osteomalacia.
Permanent post-surgical hypoparathyroidism after parathyroidectomy of an adenoma with minimally invasive surgery is rare.
"The pathophysiology of the hungry bone syndrome (HBS) is related to an imbalance between bone formation and bone resorption, which is associated with hypocalcemia, hypophosphatemia and hypomagnesemia