BACKGROUND: Hungry bone syndrome (HBS) is defined as prolonged hypocalcemia caused by a sudden decrease in parathyroid hormone (PTH) levels after parathyroidectomy (PTX). Multiple fractures after PTX due to HBS in an end-stage renal disease (ESRD) patient on chronic hemodialysis (HD) are challenging and rare medical conditions presented in this study.
METHODS: A 42-year-old ESRD patient on HD 3 times a week presented to Shariati Hospital, Tehran, Iran, complaining of worsening bone pain and loss of appetite. Laboratory data revealed an intact parathyroid hormone (iPTH) concentration of 2500 pg/mL, an alkaline phosphatase (Alp) level of 4340 IU/L, a phosphorus (P) level of 9 mg/dL, and a calcium (Ca) concentration of 7.2 mg/dL. Sestamibi scintigraphy revealed parathyroid adenoma. The findings suggested tertiary hyperparathyroidism (HPT-III), and the patient was scheduled for total PTX. Approximately one month after surgery, the patient was referred due to convulsions, leg mobility problems, and worsening bone pain. There was bilateral femoral ecchymosis. The Ca concentration was 5.8 mg/dL, and radiological evaluations revealed multiple skeletal fractures. HBS after PTX was suggested for this patient. After several days of hospitalization, he suffered subcutaneous emphysema followed by rib fractures and passed away.
CONCLUSIONS: Multiple fractures after PTX due to HBS following HPT-III in ESRD patients are rare and demanding, highlighting the necessity of timely diagnosis and management of patients with HPT-III. Severe hypocalcemia following PTX can cause skeletal disorders. However, the surgical treatment of parathyroid adenomas may be more important than the risk of complications associated with bone health.

Parathyroid pathologies are suspected based on the biochemical alterations and clinical manifestations, and the predominant roles of imaging in primary hyperparathyroidism are localisation of tumour within parathyroid glands, surgical planning, and to look for any ectopic parathyroid tissue in the setting of recurrent disease. This article provides a comprehensive review of embryology and anatomical variations of parathyroid glands and their clinical relevance, surgical anatomy of parathyroid glands, differentiation between multiglandular parathyroid disease, solitary adenoma, atypical parathyroid tumour, and parathyroid carcinoma. The roles, advantages and limitations of ultrasound, four-dimensional computed tomography (4DCT), radiolabelled technetium-99 (99mTc) sestamibi or dual tracer 99mTc pertechnetate and 99mTc-sestamibi with or without single photon emission computed tomography (SPECT) or SPECT/CT, dynamic enhanced magnetic resonance imaging (4DMRI), and fluoro-choline positron emission tomography (18F-FCH PET) or [11C] Methionine (11C -MET) PET in the management of parathyroid lesions have been extensively discussed in this article. The role of fluorodeoxyglucose PET (FDG-PET) has also been elucidated in this article. Management guidelines for parathyroid carcinoma proposed by the American Society of Clinical Oncology (ASCO) have also been described. An algorithm for management of parathyroid lesions has been provided at the end to serve as a quick reference guide for radiologists, clinicians and surgeons.

BACKGROUND: Parathyroidectomy is recommended for curing primary hyperparathyroidism (PHPT), although uncertainty remains regarding the extent of fracture risk reduction following surgery.
OBJECTIVE: To compare fracture risk and bone mineral density (BMD) changes in patients with PHPT undergoing parathyroidectomy (PTX) versus observation (OBS).
METHODS: We systematically searched PubMed, Embase, and the Cochrane Library until September 2022, including randomized controlled trials (RCTs) and cohort studies, and reviewed citations from previous reviews.
METHODS: Among 1,260 initial records, 48 eligible articles from 35 studies (5 RCTs; 30 cohorts) included PHPT patients receiving PTX or OBS interventions with reported fracture events at any site, including the hip, spine, or forearm, and/or BMD changes at each location.
METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines by two independent reviewers.
RESULTS: In 238,188 PHPT patients (PTX: 73,778 vs. OBS: 164,410), parathyroidectomy significantly reduced fractures at any site (RR, 0.80; 95%CI, 0.74-0.86) compared to observation. In 237,217 patients (PTX: 73,458 vs. OBS: 163,759), the risk of hip fractures decreased (RR, 0.63; 95%CI, 0.52-0.76). No reduction in forearm and vertebral fractures was observed in 3,574 and 3,795 patients, respectively. The annual percentage BMD changes from baseline were higher in the PTX group: femoral neck, 1.91% (95%CI, 1.14-2.68); hip, 1.75% (95%CI, 0.58-2.92); radius, 1.75% (95%CI, 0.31-3.18); spine, 2.13% (95%CI, 1.16-3.10).
CONCLUSIONS: Parathyroidectomy significantly reduced overall and hip fracture risks in PHPT patients. Despite minimal BMD increase, the substantial decrease in fracture risk suggests additional benefits of PTX beyond mineral content enhancement.

Parathyroid lipoadenoma is a rare type of parathyroid adenoma, described as a single parathyroid adenoma with more than 50% fat on histologic examination and an unknown etiology, which is one of the rare causes of primary hyperparathyroidism. The difficulty of parathyroid lipoadenoma is mainly diagnosed by preoperative imaging localization. We hope to arouse attention to the parathyroid adenoma which is difficult to locate through our case report. The patient was a middle-aged male with a body mass index of 38.4 kg/m2 who admitted to our hospital with a 40-day history of an untreated thyroid nodule. We incidentally discovered parathyroid lipoadenoma in his thyroid surgery. His prognosis was good, and there were no signs of recurrence at his 12-month follow-up appointment. We believe that parathyroid lipoadenoma needs to rely on paraffin pathology to make a final diagnosis. This case report serves as a reminder that parathyroid lipoadenomas are also possible in patients who do not have primary hyperparathyroidism preoperatively and who have negative imaging. Clinicians must carefully examine the adipose tissue for the presence of parathyroid lipoadenomas during thyroid surgery to avoid postoperative hypoparathyroidism and persistent hypocalcaemia.

OBJECTIVE: There is no specific recommendation for management in pregnant women: the aim of this review, based on a clinical case study, is to clarify its development, complications, risk factor and treatment.
METHODS: A review of the literature was performed by consulting the Pubmed, Cochrane Library, and Science Direct databases.
RESULTS: Primary hyperparathyroidism is defined as excessive production of parathyroid hormone resulting in hypercalcemia. The prevalence of primary hyperparathyroidism during pregnancy is not known. Indeed, the symptomatology, related to hypercalcemia, is not very specific and easily confused with the clinical manifestations of pregnancy. The physiological changes specific to the pregnant state frequently lead to a slight hypocalcemia which may complicate the diagnosis of primary hyperparathyroidism. Primary hyperparathyroidism results from a parathyroid adenoma in the majority of cases and is detected by ultrasound during pregnancy. Primary hyperparathyroidism in pregnancy causes significant risks to both mother and fetus. The maternal complication rate is 14-67%, however, the most serious complication is hypercalcemic crisis, which requires increased surveillance in the postpartum period. Obstetrical complications are also induced by primary hyperparathyroidism, such as acute polyhydramnios, or intrauterine growth retardation. The fetal complication rate can reach 45-80% of cases with neonatal hypocalcemia as the main complication. If medical treatment is based on hyperhydration, only surgical treatment is curative.
CONCLUSIONS: Surgery should be proposed to symptomatic patients or those with high blood calcium levels, discussed in interdisciplinary committee and should be organized ideally in the second trimester to avoid maternal and fetal complications.

Tuberculosis of the thyroid gland is rare, and tuberculous granulomatous inflammation of the parathyroid glands is even rarer. The present study reports a rare case of primary hyperparathyroidism caused by tuberculous granulomatous inflammation. A 58-year-old female patient presented with generalized body pain persisting for 1 year. She had a history of recurrent renal stones (>20 times) and an incidental finding of multinodular goiter involving the parathyroid on neck ultrasound. A blood analysis revealed elevated levels of serum calcium (11.26 mg/dl) and parathyroid hormone (154.7 pg/ml). The patient underwent the resection of the affected left thyroid lobe under general anesthesia. A histopathological examination revealed parathyroid adenoma with caseating granulomatous inflammation involving the adenoma with focal lymphocytic thyroiditis of the left thyroid gland. Although granulomatous parathyroid disease with parathyroid adenoma causing hypercalcemia is an extremely rare event, it can occur. The treatment of choice is surgical resection.

Parathyroid adenomas are benign proliferative disorders of parathyroid glands. Patients typically exhibit hyperparathyroidism and elevated serum calcium levels due to elevated levels of parathyroid hormone (PTH). We report a newly diagnosed case of a rare pathological osteolytic lesion. Radiological evaluation revealed multiple bony lesions in multiple parts of the pelvis, vertebral body, and spinous process, suggesting hematological neoplasms or bone marrow metastatic carcinoma. The morphology revealed many abnormal cells in the bone marrow smear. Furthermore, serum calcium and PTH levels were significantly increased compared to normal levels. Doppler color ultrasound showed a thyroid mass (left), suspected parathyroid adenoma, thyroid, and isthmus nodular goiter (right). The patient underwent bilateral neck exploration with parathyroidectomy, and serum calcium and PTH levels significantly decreased on the second day after surgery and had a surgical cure.

Primary hyperparathyroidism is a common endocrine disorder, with 80% of all cases usually caused by one single hyperfunctioning parathyroid adenoma. Conventional imaging modalities for the diagnostic work-up of primary hyperparathyroidism (PHPT) include ultrasound of the neck, 99mTc-sestamibi scintigraphy, and four-dimensional computed tomography (4D-CT). However, the role of other imaging modalities, such as 11C-methionine PET/CT, in the care pathway for PHPT is currently unclear. Here, we report our experience of the diagnostic utility of 11C-methionine PET/CT in a single-center patient cohort (n = 45).
Retrospective single-center cohort study.
The data of eligible patients that underwent 11C-methionine PET/CT between 2014 and 2022 at Addenbrooke\'s Hospital (Cambridge, UK) were collected and analyzed. The clinical utility of imaging modalities was determined by comparing the imaging result with histopathological and biochemical outcomes following surgery.
In patients with persistent primary hyperparathyroidism following previous surgery, 11C-methionine PET/CT identified a candidate lesion in 6 of 10 patients (60.0%), and histologically confirmed in 5 (50.0%). 11C-methionine PET/CT also correctly identified a parathyroid adenoma in 9 out of 12 patients (75.0%) that failed to be localized on other imaging modalities. 11C-methionine PET/CT had a sensitivity of 70.0% (95% CI 55.8 - 84.2%) for the detection of parathyroid adenomas.
This study highlights a diagnostic role for 11C-methionine PET/CT in patients that have undergone unsuccessful prior surgery or have equivocal or negative prior imaging results, aiding localization and a targeted surgical approach.

Primary HPT (PHPT) is a common disorder, affecting approximately 1% of the general population. Parathyroid adenomas emerge as non-familial sporadic in 90% of cases. The aim of this review is to give a detailed update of molecular genetics of sporadic parathyroid adenoma reported in international literature.
A bibliographic research was conducted in PubMed, Google Scholar, and Scopus.
Seventy-eight articles were included in our review. CaSR, MEN1, CCND1/PRAD, CDKI, angiogenic factors like VEGF, FGF, TGFβ, and IGF1, and apoptotic factors are important genes in parathyroid adenomas pathogenesis that have been established by several studies. A huge list of proteins is differently expressed in parathyroid adenomas measured by Western Blotting, MALDI/TOF, MS spectrometry, and immunohistochemistry. These proteins take part in several cell processes such as cell metabolism, cytoskeleton structural stability, cell oxidative stress regulation, cell death, transcription, translation, cell connection, and cell signaling transmission, while they can be found over- or underexpressed in abnormal tissues.
This review gives a detailed analysis of all reported data on genomics and proteomics of parathyroid adenoma. Further studies should be applied on understanding parathyroid adenoma pathogenesis and introducing new biomarkers for early detection of primary hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is the leading cause of incidentally detected hypercalcaemia in asymptomatic individuals. Rarely, PHPT may present with severe hypercalcaemia or even hypercalcaemic crisis. We describe a case of a 53-year-old male who presented with acute severe hypercalcaemia as the index manifestation. Complete clinical, biochemical and radiological evaluation led to an eventual diagnosis of PHPT. He had a challenging clinical course as hypercalcaemia did not improve significantly despite undergoing multiple sessions of haemodialysis and other supportive measures. Furthermore, the presence of acute kidney injury precluded the use of bisphosphonates. In the end, he received subcutaneous denosumab injection and his serum calcium levels improved dramatically afterwards. Subsequently, he underwent successful parathyroidectomy. Denosumab therapy can play a critical role in managing such patients especially when other therapeutic modalities cannot adequately control hypercalcaemia.