Recurrent secondary hyperparathyroidism and calciphylaxis due to a retro-oesophageal gland

Valeria Rathaus1,3 and Mauro Rathaus2,3

1 Department of Diagnostic Imaging and 2 Department of Nephrology, Meir Hospital, Sapir Medical Center, 44281 Kfar Saba, Israel and 3 The Sackler Faculty of Medicine, Tel Aviv University, Israel

Correspondence and offprint requests to: Mauro Rathaus, Department of Nephrology, Meir Hospital, Sapir Medical Center, 44281 Kfar Saba, Israel. Email: rathaus{at}bezeqint.net

Keywords: calciphylaxis; hyperparathyroidism; recurrent; retro-oesophageal gland

A 77-year-old woman, treated with haemodialysis for 7 years, underwent neck exploration because of severe secondary hyperparathyroidism. Only three parathyroid glands were found and excised. Parathyroid hormone (PTH) levels decreased from 586 to 309 pg/ml (normal <65 pg/ml). One year later, PTH levels had returned to 506 pg/ml, and the CaxP product averaged 48 mg2/dl2. A necrotic skin lesion appeared on the lateral aspect of the left calf. Biopsy showed changes typical of calciphylaxis. A Tc-99m sestamibi scan demonstrated a zone of uptake near the thyroid isthmus, but ultrasound examination was negative. An MRI disclosed a suspected parathyroid gland in the retro-oesophageal space (Figure 1, arrow). A compression fracture of C6 was also seen (asterisk). The patient underwent a successful parathyroidectomy, PTH levels fell to 7 pg/ml and CaxP product to 50 mg2/dl2. The extended skin lesion completely healed 2 months after surgery.



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Fig. 1. MRI shows a suspected parathyroid gland in the retro-oesophageal space (arrow). A compression fracture of C6 is also seen (asterisk).

 
Calciphylaxis (mural calcification of small vessels leading to severe ischaemia and necrosis) carries a severe prognosis in dialysis patients. Parathyroidectomy remains indicated, despite the fact that it often fails to be of benefit in patients with elevated serum PTH levels. Retro-oesophageal glands are found in ~3% of cases of primary hyperparathyroidism.

Conflict of interest statement. None declared.





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