Spontaneous cervical-mediastinal hematoma caused by hemorrhage into parathyroid adenoma: A clinical case

Abstract

Introduction: Spontaneous cervical-mediastinal hematoma caused by extracapsular rupture of parathyroid gland occurs extremely rarely. There are no standard treatment approaches because of the peculiarities of each case.

Presentation of case: We report herewith about a rare case of spontaneous cervical-mediastenal hematoma occured by hemorrhage in parathyroid adenoma, which was detected in an previously absolutely healthy female patient in the age of 29. This woman was hospitalized in 2 days after the manifestation, complaining about a neck ache. Indirect laryngoscopy: right-side larynx paresis. Blood test: parathyroid hormone 843pg/ml (norm 15-65), ionized calcium 1.8mmol/l (norm 0.9-1.1). Positive dynamics was observed throughout 8 days of anti-inflammatory therapy. Symptoms of neck organs compression increased acutely at the 9th day. The patient was operated - hematoma lancing with resection of walls. Histological examination discovered the fragments of parathyroid adenoma in the hematoma's wall. Level of ionized blood calcium got normal approximately in 24h after the surgery. The patient was examined 6 months after the surgery. The patient had no disphagy, voice quality was intact, breathing was not restricted. Level of parathyroid hormone in blood got normal.

Discussion: A rareness of this pathology and treatment variability does not allow to choose a unified medical and diagnostic tactics.

Conclusion: Our case demonstrates that radical correction of primary hyperparathyroidism by excision of hematoma and its fibrous capsule with preservation of thyroid gland is possible in conditions of tense cervical-mediastinal hematoma with inflammation process in the hemorrhage area.

Keywords: Acute neck diseases; Extracapsular parathyroid hemorrhage; Hypercalcemia; Hyperparathyroid gland disease; Larynx paresis; Tumors of parathyroid glands.

Fig. 1

Transcutaneous echography. Sagittal section. (a) A nonhomogenous structure in cervical-mediastenal area, to the right of the thyroid gland. (b) An isoechoic nonhomogenous structure sized up to 3 cm is adjacent to the posterior surface of thyroid gland, with an apparent capsule (1) (parathyroid gland adenoma with hemorrhage). A hypoechoic to echonegative area spreads from the structure into mediastenal septum and into the anterior neck surface (2) (a cervical-mediastenal hematoma).

Fig. 2

Multi-slice CT scan with angiography: (a) 3D reconstruction. Deformation of the anterior neck surface with shift of thyroid gland by a non-vascular lesion (hematoma) and (c) axial scan. A mass lesion compressing the tracheal lumen is located to the right of the thyroid gland. Extravasation of contrast media into hematoma volume is observed in the bifurcation zone of inferior thyroid artery. (b) Multi-slice CT scan: Frontal scan. A mass lesion is located to the right of the thyroid gland, propagating into mediastenal septum and compressing the tracheal lumen.

Fig. 3

Microphotography of operative material. Tinted with hematoxylin and eosine. Magnification ×400. (a) Hematoma wall is composed of fibrous connective tissue, sediment of hemosiderin, fragment of fat tissue, lymphoplasmocitary infiltration. (b) Hematoma wall is composed of fibrous connective tissue, vessels, small fragments of parathyroid gland tissue in fibrous tissue. (c) Tissue of parathyroidgland adenoma with focal hemorrhage.