Difficulties Of Case Management: Giant Parathyroid Adenoma With Cystic Appearance And Presentation Amid COVID-19 Pandemic

Abstract

Primary hyperparathyroidism (PH) – related parathyroid tumours, usually adenomas (regardless typical or atypical, solid or with cystic transformation) with a good outcome after surgical removal, might embrace the entire area of complications due to high parathormone (PTH) – related hypercalcemia, and rarely local compressive complications, since adenomas are usually of small dimensions. We introduce a challenging adult male case with a large parathyroid tumour who was admitted during the first year of COVID-19 pandemic. A 58-year old, non-smoking male patient was admitted as an emergency for a large anterior cervical mass in July 2020. Despite local compressive symptoms, he delayed the presentation due to pandemic circumstances. Blood tests revealed normal renal and liver function and high calcium. Bone metabolism exploration confirmed PH and high turnover status. Anterior cervical ultrasound revealed a posterior hypoechoic mass to the right thyroid lobe of very large dimensions (by 10/8.54/4.85 cm), with inhomogeneous consistence (both solid and cystic pattern with a cystic predominance), a tumour that is well shaped and has mass effect (left tracheal deviation). After fluid replacement and 5 mg zolendronic acid to correct hypercalcemia, upper right parathyroidectomy was done. The confirmation of a giant parathyroid adenoma (40 g) with cystic transformation (a total of 170 g) was done. The patient had a good clinical evolution for the following year when he was re-assessed; normal calcium levels were maintained as well as an improvement of bone mineral density parameters according to central DXA (Dual -Energy X-Ray Absorptiometry). Challenges of the case management include late presentation, most probably amid pandemic burst, the fact that a giant parathyroid tumour is expected to be a carcinoma or have some atypia (which were not confirmed), the cystic transformation that contributed to increased size and more difficult surgery, and the question if such an impressive parathyroid tumour is actually on the ground of a genetic anomaly as seen in familial PH.