Endocrinol Metab.  2012 Jun;27(2):163-168. 10.3803/EnM.2012.27.2.163.

A Case of Parathyroid Apoplexy of Primary Hyperparathyroidism Presenting as Auditory Hallucinations Accompanied with Hypocalcemia

• Jeon EJ
• Jeong JY
• Kim JG

• KMID: 1497659
• DOI: http://doi.org/10.3803/EnM.2012.27.2.163

Abstract

The natural history of primary hyperparathyroidism, due to parathyroid adenoma, is unknown. Furthermore, spontaneous resolution of parathyroid necrosis or hemorrhage is rare and usually asymptomatic. Here, we report a case of parathyroid apoplexy of primary hyperparathyroidism, presenting as auditory hallucinations, accompanied with hypocalcemia. A 39-year-old man who was incidentally diagnosed with primary hyperparathyroidism, and waiting surgery for parathyroidectomy presented to psychiatric service with auditory hallucinations. He developed tetany, while taking psychiatric drugs. On a follow-up investigation, his serum calcium level fell from 11.8 to 5.8 mg/dL. His intact parathyroid hormone level also decreased from 1,017 pg/mL to 71.1 pg/mL. The parathyroid apoplexy was confirmed after a surgical removal of the infarcted adenoma. The auditory hallucinations disappeared, and serum calcium level was returned to within the normal range.

Keyword

Auditory hallucination; Hypocalcemia; Parathyroid apoplexy; Primary hyperparathyroidism

MeSH Terms

Adenoma
Adult
Calcium
Follow-Up Studies
Hallucinations
Hemorrhage
Humans
Hyperparathyroidism, Primary
Hypocalcemia
Natural History
Necrosis
Parathyroid Hormone
Parathyroid Neoplasms
Parathyroidectomy
Reference Values
Stroke
Tetany
Calcium
Parathyroid Hormone

Figure

• 

  Fig. 1 A. Thyroid ultrasound sonogram shows an approximately 1.72 × 1.74 × 2.71 cm-sized hypoechoic mass (arrow) surrounded by a hyperechogenic wall in the right inferior thyroid. B. Neck computed tomography shows an approximately 1.5 × 2.4 cm-sized mass (arrow) with internal low density on the inferior and posterior aspects of the right lobe at the enhanced phase.

• 

  Fig. 2 Parathyroid scan. ANT, anterior; RAO, right anterior oblique; LAO, left anterior oblique.

• 

  Fig. 3 Follow-up images. A. Thyroid ultrasound sonogram shows an approximately 1.85 × 1.55 × 2.57 cm-sized hypoechoic mass (arrow) surrounded by hyperechogenic wall in the right inferior thyroid. B. Neck computed tomography shows an approximately 1.8 × 2.9 cm-sized mass (arrow) on the inferior and posterior aspects of the right lobe at the enhanced phase. The low-density lesion was enlarged.

• 

  Fig. 4 Gross findings of the resected parathyroid gland. A, B. Parathyroid adenoma specimen of a 3.2 × 2.0 × 1.5 cm mass.

• 

  Fig. 5 Microscopic findings of parathyroid adenoma. A. Proliferative parathyroid cells, the presence of fibrous tissue with hemosiderin deposition (arrow), and a cavity surrounded by fibrous walls are shown (H&E stain, × 40). B. The remaining parathyroid adenoma (arrow) with fibrous capsule in the peripheral area (H&E stain, × 40).

Reference

1. Geffken GR, Ward HE, Staab JP, Carmichael SL, Evans DL. Psychiatric morbidity in endocrine disorders. Psychiatr Clin North Am. 1998. 21:473–489.

2. Feldman F, Mitchell W, Soll S. Psychosis, Cushing's syndrome and hyperparathyroidism. Can Med Assoc J. 1968. 98:508–511.

3. Efremidou EI, Papageorgiou MS, Pavlidou E, Manolas KJ, Liratzopoulos N. Parathyroid apoplexy, the explanation of spontaneous remission of primary hyperparathyroidism: a case report. Cases J. 2009. 2:6399.

4. Wootten CT, Orzeck EA. Spontaneous remission of primary hyperparathyroidism: a case report and meta-analysis of the literature. Head Neck. 2006. 28:81–88.

5. Fraser WD. Hyperparathyroidism. Lancet. 2009. 374:145–158.

6. Silverberg SJ, Shane E, Jacobs TP, Siris E, Bilezikian JP. A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery. N Engl J Med. 1999. 341:1249–1255.

7. Petersen P. Psychiatric disorders in primary hyperparathyroidism. J Clin Endocrinol Metab. 1968. 28:1491–1495.

8. Cope O. Hyperparathyroidism: diagnosis and management. Am J Surg. 1960. 99:394–403.

9. Joborn C, Hetta J, Palmér M, Akerström G, Ljunghall S. Psychiatric symptomatology in patients with primary hyperparathyroidism. Ups J Med Sci. 1986. 91:77–87.

10. Walker MD, McMahon DJ, Inabnet WB, Lazar RM, Brown I, Vardy S, Cosman F, Silverberg SJ. Neuropsychological features in primary hyperparathyroidism: a prospective study. J Clin Endocrinol Metab. 2009. 94:1951–1958.

11. Devaris DP, Mehlman I. Psychiatric presentations of endocrine and metabolic disorders. Prim Care. 1979. 6:245–265.

12. Guisado R, Arieff AI, Massry SG, Lazarowitz V, Kerian A. Changes in the electroencephalogram in acute uremia. Effects of parathyroid hormone and brain electrolytes. J Clin Invest. 1975. 55:738–745.

13. Bilezikian JP. Primary hyperparathyroidism. Drug Ther. 1982. 7:41–48.

14. Norris EH. Primary hyperparathyroidism; a report of five cases that exemplify special features of this disease (infarction of a parathyroid adenoma; oxyphil adenoma). Arch Pathol (Chic). 1946. 42:261–273.

15. Nylen E, Shah A, Hall J. Spontaneous remission of primary hyperparathyroidism from parathyroid apoplexy. J Clin Endocrinol Metab. 1996. 81:1326–1328.

16. Natsui K, Tanaka K, Suda M, Yasoda A, Yonemitsu S, Nakao K. Spontaneous remission of primary hyperparathyroidism due to hemorrhagic infarction in the parathyroid adenoma. Intern Med. 1996. 35:646–649.

17. Mir R, Gerold T, Khan S, Weitz J. Spontaneous infarction of parathyroid adenoma: case report and literature review. Head Neck. 1993. 15:566–568.

18. Kovacs KA, Gay JD. Remission of primary hyperparathyroidism due to spontaneous infarction of a parathyroid adenoma. Case report and review of the literature. Medicine (Baltimore). 1998. 77:398–402.

19. Govindaraj S, Wasserman J, Rezaee R, Pearl A, Bergman DA, Wang BY, Urken ML. Parathyroid adenoma autoinfarction: a report of a case. Head Neck. 2003. 25:695–699.