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Case 4

Tertiary Hyperparathyroidism

The neck of a young female with renal failure

Ken Wong

This 34 year old female patient has a long history of chronic renal failure, complicated by hypercalcaemia. Her thyroid function tests were within normal limits. US of the neck was performed.

Transverse US of right lobe of thyroid

Sagittal US of right lobe of thyroid

Findings

Examination of the neck shows two solid nodules behind the lower pole of the right lobe of the thyroid measuring 8 x 7 x 16 mm and 16 x 8 x 10 mm.

Diagnosis

Tertiary hyperparathyroidism, parathyroid adenomata.

Discussion

The parathyroid glands lie posterior to the thyroid gland. There are usually four such glands, and measure only a few millimetres in diameter. The normal gland is not usually visible on ultrasound of the neck. Ectopic parathyroid tissue can occur, from cricoid to anterior mediastinum.

In hyperparathyroidism the increased levels of parathyroid hormone (PTH) release calcium from bone, causing an elevation in ionised serum calcium.

Primary hyperparathyroidism is usually caused by a parathyroid adenoma. Hyperplasia or ectopic production by bronchial carcinoma are rarer causes.

Secondary hyperparathyroidism is a physiological response to hypocalcaemia, such as occurs in chronic renal failure, and does not cause an elevated serum calcium.

Tertiary hyperparathyroidism, as here, results from prolonged secondary hyperparathyroidism, when hyperplastic tissue becomes autonomous, or an adenoma develops. The ultrasound appearances of primary and tertiary forms due to an adenoma will be the same; the history is what differentiates them.

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