MEDizzy - A 60-year-old woman is referred to your ofce for evaluation

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A 60-year-old woman is referred to your ofce for evaluation of hypercalcemia. A serum calcium level of 12.9 mg/dL was found incidentally on a chemistry panel that was drawn during a hospitalization for cholecystectomy. Despite fuid administration in the hospital, her serum calcium at discharge was 11.8 mg/dL. The patient is asymptomatic, and her parathyroid hormone level is 95 ng/L (reference value 10–65 ng/L). She is otherwise in good health and has had her recommended age-appropriate cancer screening. She denies constipation or bone pain and is now 8 weeks out from her surgical procedure. Today, her serum calcium level is 12.6 mg/dL, and phosphate is 2.3 mg/dL. Her hematocrit and all other chemistries, including creatinine, were normal. Which of the following would be an indication for surgery in this patient to defnitively treat her underlying diagnosis?

ExplanationPrimary hyperparathyroidism is the most common cause of hypercalcemia and is the most likely cause in an adult who is asymptomatic. Primary hyperparathyroidism results from autonomous secretion of PTH that is no longer regulated by serum calcium levels, usually related to development of parathyroid adenomas. Most patients are asymptomatic or have minimal symptoms at the time of diagnosis. When present, symptoms include recurrent nephrolithiasis, peptic ulcers, dehydration, constipation, and altered mental status. Distinctive bone manifestations include osteitis fbrosa cystica, which histologically results from an increase in the giant multinucleated osteoclasts in scalloped areas on the surface of the bone and a replacement of the normal cellular and marrow elements by fbrous tissue. On x-ray, this will appear as resorption of the phalangeal tufts and replacement of the usually sharp cortical outline of the bone in the digits by an irregular outline. Historically, this fnding was present on presentation in 10%–25% of cases but is rare today due to earlier diagnosis of disease. Laboratory studies show elevated serum calcium with decreased serum phosphate. Diagnosis can be confrmed with measurement of PTH levels. The optimal management of asymptomatic primary hyperparathyroidism has been debated because surgical removal of autonomous adenomas is generally curative. However, it is unclear whether all patients need to be treated surgically. The most recent recommendations suggest that the more aggressive surgical approach be considered in most patients due to concerns of subtle neuropsychiatric symptoms, long-term skeletal efects, and potential for cardiovascular deterioration. The current guidelines recommend surgery for individuals less than 50 years in age or with creatinine clearance <60 mL/min, osteoporosis on bone density scanning, or serum calcium >1 mg/mL above normal. There is no indication for surgery based on 24-hour urine calcium levels or presence of nephrolithiasis. Likewise, presence of cardiovascular disease is not in the guidelines for recommendation of surgical intervention.