Iris Publishers-Open access Journal of Clinical Case Studies | Necrotizing Pancreatitis, an unusual presentation of longstanding Primary Hyperparathyroidism

Authored by M Raghuwanshi

 

Acute Necrotizing pancreatitis can be a rare, but first presentation of longstanding primary hyperparathyroidism. Acute pancreatitis was first described as a rare complication of Primary Hyperparathyroidism in the Annals of Surgery by Cope et al. in 1957, with an incidence rate of pancreatitis of 1.5 % - 7%. We present an interesting case of long-standing primary hyperparathyroidism presenting initially as necrotizing pancreatitis complicated by severe hypocalcaemia in a young woman secondary to hungry bone syndrome after a parathyroidectomy A 38-year-old woman with no past medical history presented with a syncopal episode. A few days prior to the syncopal event, she reported severe abdominal pain and intractable vomiting. These symptoms were a progression of abdominal pain she had experienced for the past 2 months, associated with myalgia and arthralgia. On clinical exam, she appeared in painful distress with epigastric tenderness and voluntary guarding, but no rebounding. On laboratory and imaging studies, she was noted to have severe hypercalcemia of 18mg/dL (n 8.4-10.2mg/dL), intact PTH-1200 pg/mL (n 15-65pg/mL), with initial imaging revealing necrotizing pancreatitis as demonstrated in (Figure 1). On review of previous hospital records, she had hypercalcemia of 13.1 mg/dl dating back to 2003 but was lost to follow up. Based on these clinical findings she was diagnosed with acute necrotizing pancreatitis and started on broad spectrum antibiotics, IV fluids, and taken to the OR emergently for pancreatic debridement. The operative report noted an infected pancreatic necrosis in lesser sac and omental saponification. Due to the patient’s significant abdominal pain post-operatively, she had a repeat CT scan of the abdomen and pelvis with contrast revealing pancreatic drain in the appropriate location and lytic osseous lesions predominantly in the pelvic bones likely representing brown tumors as shown in (Figure 2) [1- 3]. On physical exam patient was noted to have left sided neck mass, which on neck US showed left inferior parathyroid nodule.

 

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