Acute necrotizing pancreatitis as first manifestation of primary hyperparathyroidism

Abstract

We report the case of a female patient with severe acute necrotizing pancreatitis associated with hypercalcemia as first manifestation of primary hyperparathyroidism caused by a benign parathyroid adenoma. Initially the acute pancreatitis was treated conservatively. The patient subsequently underwent surgical resection of the parathyroid adenoma and surgical clearance of a large infected pancreatic pseudocyst. Although the association of parathyroid adenoma-induced hypercalcemia and acute pancreatitis is a known medical entity, it is very uncommon. The pathophysiology of hypercalcemia-induced acute pancreatitis is therefore not well known, although some mechanisms have been proposed. It is important to treat the provoking factor. Therefore, the cause of hypercalcemia should be identified early. Surgical resection of the parathyroid adenoma is the ultimate therapy.

Figure 1

Abdominal computed tomography scan at the level of the pancreas. A: On the day of admission showing acute exudative pancreatitis. Note the history of a right nephrectomy; B: On day 20 showing the development of pancreatic pseudocysts and few remnants of normal pancreatic tissue.

Figure 2

99mTc-Sestamibi scintigraphy showing a lower left side parathyroid adenoma. A: Thyroid SKM: SK ELUAAT, -Tc-99mANT; B: Parathyroid SKM: SK MIBI, -Tc-99mH1; C: Normalized subtracted f = 1; D: Registered parathyroid; E: Normalized subtracted f = 1.25; F: Normalized parathyroid f = 1.25; G: Smoothed subtracted f = 1.25.

Figure 3

Abdominal magnetic resonance imaging at the level of the pancreas showing debris in the pancreatic pseudocyst.