Hyperparathyroid crisis: use of bisphosphonates as a bridge to parathyroidectomy

Abstract

Background: Hyperparathyroid crisis is an uncommon, potentially lethal condition for which emergent parathyroidectomy has been advocated.

Study design: The manifestations of hyperparathyroid crisis and outcomes of bisphosphonate-based therapy and delayed parathyroidectomy were determined and compared with cases from a review of the literature. Laboratory indices and gland weights were compared with those from patients with primary hyperparathyroidism without crisis.

Results: Of the 292 patients operated on for hyperparathyroidism, 8 (2.8%) had hyperparathyroid crisis, consistent with rates of 1.6% to 6% reported in the literature. Hyperparathyroid crisis was manifested by vomiting, nausea, or both (n=6); abdominal pain (n=3); mental status changes (n=3); pancreatitis (n=2); bone pain, osteolytic lesions, or both (n=2); electrocardiogram changes (n=1); and an acute conversion disorder (n=1). Isotonic sodium chloride and furosemide, in combination with a bisphosphonate drug in 7 of 8 patients, resulted in a calcium decline from 16.2+/-1.6 mg/dL to 11.8+/-1.6 mg/dL, with resolution of electrocardiogram and mental status changes, and pancreatitis before resection of an adenoma (n=7) or carcinoma (n=1). Patients with hyperparathyroid crisis had higher parathyroid hormone levels (691.7 +/-662.4 pg/mL versus 172.6 +/-147.5 pg/mL; p=0.062), larger tumor weights (7.5 +/-8.4 g versus 1.6 +/-2.1 g; p=0.085), and lower postoperative calcium levels (7.3 +/-1.6 mg/dL versus 8.7+/-0.9 mg/dL; p=0.035) than patients without crisis. Four (50%) of the 8 tumors were found in ectopic locations. There was no mortality from hyperparathyroid crisis, compared with a 7% mortality rate for cases reported in the literature since 1978.

Conclusions: Rehydration, calciuresis, and bisphosphonate therapy are effective in correcting life-threatening manifestations of hyperparathyroid crisis, providing an effective bridge to parathyroidectomy.