Abraham Benjamin M, Sharkey Elise, Kwatampora Lily, Ranzinger Mark, von Holzen Urs
College of Osteopathic Medicine, Marian University, Indianapolis, USA.
Center for Cancer Care, Goshen Health, Goshen, USA.
Cureus. 2023 Jul 22;15(7):e42306. doi: 10.7759/cureus.42306. eCollection 2023 Jul.
The classic clinical vignette of primary hyperparathyroidism is well described as "bones, stones, abdominal moans, and psychiatric overtones" to reflect the effects of excess parathyroid hormone (PTH) and calcium. Most commonly, primary hyperparathyroidism is due to a functional parathyroid adenoma situated by the thyroid gland. Rarely, the primary focus of autonomously produced PTH is located ectopically within the mediastinum. A 19-year-old Caucasian female with no relevant past medical history presented to the emergency department with tachycardia, nausea, vomiting, and a five-day history of vague, mid-abdominal pain. Initial computed tomography (CT) with contrast of the abdomen and pelvis was negative for acute findings, and she subsequently underwent biochemical screening. The patient was found to have elevated serum calcium and PTH, raising suspicion for the diagnosis of primary hyperparathyroidism. Further evaluation for a parathyroid adenoma was negative by a CT scan of the neck and thyroid ultrasound. A nuclear medicine parathyroid single-photon emission computed tomography (SPECT)/CT with technetium (Tc) 99m sestamibi found an abnormal nodular uptake within the left prevascular mediastinum suggestive of an ectopic parathyroid adenoma. A left-sided, video-assisted thoracoscopic surgery (VATS) with successful excision of the ectopic mediastinal parathyroid adenoma was performed. Surgical pathology revealed that the parathyroid adenoma was completely excised and surrounded by thymus and adipose tissue. The patient tolerated the procedure well and was discharged without further complications. The rarity of mediastinal, intrathymic parathyroid adenomas resulted in delayed diagnosis in this patient, understandably so as errant embryogenesis does not occur commonly. Visualization with SPECT/CT and successful specimen excision by minimally invasive VATS resulted in the accurate diagnosis and ultimate cure of this patient's primary hyperparathyroidism.
原发性甲状旁腺功能亢进的典型临床症状常被描述为“骨痛、结石、腹部不适及精神症状”，以反映甲状旁腺激素（PTH）和钙过量的影响。原发性甲状旁腺功能亢进最常见的原因是位于甲状腺旁的功能性甲状旁腺腺瘤。很少见的情况下，自主分泌PTH的主要病灶位于纵隔内异位。一名19岁无相关既往病史的白种女性因心动过速、恶心、呕吐以及持续五天的中上腹隐痛就诊于急诊科。腹部和盆腔的初次增强计算机断层扫描（CT）未发现急性病变，随后她接受了生化检查。该患者血清钙和PTH升高，这增加了原发性甲状旁腺功能亢进的诊断怀疑。颈部CT扫描和甲状腺超声检查对甲状旁腺腺瘤的进一步评估结果为阴性。核医学甲状旁腺单光子发射计算机断层扫描（SPECT）/CT检查使用锝（Tc）99m甲氧基异丁基异腈发现左前纵隔内有异常结节摄取，提示异位甲状旁腺腺瘤。遂进行了左侧电视辅助胸腔镜手术（VATS），成功切除了异位纵隔甲状旁腺腺瘤。手术病理显示甲状旁腺腺瘤已完全切除，周围被胸腺和脂肪组织包绕。患者对手术耐受良好，出院时无进一步并发症。纵隔内胸腺内甲状旁腺腺瘤罕见，导致该患者诊断延迟，这是可以理解的，因为异常胚胎发育并不常见。SPECT/CT显像以及通过微创VATS成功切除标本，实现了对该患者原发性甲状旁腺功能亢进的准确诊断和最终治愈。
