Raheja Ronak, Wolfish Erica B, Huded Jill M
Internal Medicine, Kempegowda Institute of Medical Sciences, Bangalore, IND.
Family Medicine, Case Western Reserve University School of Medicine, Cleveland, USA.
Cureus. 2019 Jan 26;11(1):e3966. doi: 10.7759/cureus.3966.
Primary hyperparathyroidism is the third most commonly encountered endocrine disorder after diabetes and thyroid diseases. There has been a constant debate between medical and surgical management of the disorder. Guidelines clearly indicate surgical management over medical management in symptomatic patients and asymptomatic patients below 50 years of age. The problem is identification of symptoms can be difficult as there is a large overlap in the presentation of symptomatic and asymptomatic patients. Here, a 74-year-old veteran presented with scrotal edema and a perineal abscess. He had urinary incontinence secondary to urological procedures which were done for nephrolithiasis, which were detected incidentally on imaging. He had multiple vertebral compression fractures and required referral to neurosurgery. He had worsening renal function and cognitive impairment. On review of his medical records he was found to have a long-standing history of medically managed hyperparathyroidism, which was complicated due to non-compliance to follow-up outpatient visits. He constantly declined elective parathyroidectomy but unfortunately had to undergo several other invasive procedures with multiple hospital visits due to the complications of hyperparathyroidism. Safe medical management of hyperparathyroidism requires a religious follow-up and compliance to outpatient visits. He was started on Denosumab which we attribute to be contributory to his skin infections although evidence to support the same is insufficient.
原发性甲状旁腺功能亢进是继糖尿病和甲状腺疾病之后第三常见的内分泌疾病。对于该疾病的医学治疗和手术治疗一直存在争议。指南明确指出，有症状的患者以及50岁以下无症状的患者应采用手术治疗而非医学治疗。问题在于，由于有症状和无症状患者的临床表现有很大重叠，识别症状可能很困难。在此，一名74岁的退伍军人出现阴囊水肿和会阴部脓肿。他因肾结石接受了泌尿外科手术，术后出现尿失禁，这些结石是在影像学检查中偶然发现的。他有多处椎体压缩性骨折，需要转诊至神经外科。他的肾功能恶化且有认知障碍。查阅他的病历发现，他有长期接受医学治疗的甲状旁腺功能亢进病史，由于未按要求进行门诊随访，病情变得复杂。他一直拒绝择期甲状旁腺切除术，但不幸的是，由于甲状旁腺功能亢进的并发症，他不得不接受其他几次侵入性手术并多次住院。甲状旁腺功能亢进的安全医学管理需要严格的随访和遵守门诊就诊要求。他开始使用地诺单抗，我们认为这是导致他皮肤感染的原因之一，尽管支持这一观点的证据并不充分。
