Case Presentation in

Endocrinology
Sittichai Pinyopodjanard
9/9/2558

History
Case 51 , No U/D, , ,
refer .
CC : 9
PI : 9

8 kg/9

7-8

1
.
x-rays osteolytic lesion femur,
pelvis refer

Past History


, ,

,
,

Physical Examination
Good consciousness, Mild dehydration
BT 37 C PR 75/min RR 20/min BP 110/75 mmHg
HEENT : Not pale, no jaundice, no thyroid
enlargement, no cervical lymphadenopathy, No neck
mass
Lungs : Clear
Heart : Normal S1S2, no murmur, regular HR
Abdomen : Soft, impalpable liver and spleen, no mass
liver span 9 cm, splenic dullness negative
Ext : No edema, no rash, no groin lymphadenopathy
MS : Tender Rt. groin at hip joint area, Anvil &
Rolling test positive
Neuro : Grossly intact, No visual field defect

Investigation

BONE SCINTIGRAPHY (Tc-99m

MDP)
FINDINGS: The study reveals increased
radiotracer uptake involving nearly
the entire skeleton including at skull,
entire mandible, sternum, bilateral
clavicles, bilateral humeri, bilateral femora,
bilateral tibiae and both feet. Only faint
soft tissue and renal radiotracer activity is
noted; these findings are a 'super scan'
due to metabolic bone disease.
IMPRESSION: Metabolic bone disease is
suggested.

BONE SURVEY
FINDINGS:
- Diffuse osteopenia is found.
- Multiple osteolytic lesions at shaft of left tibia and right ilium
are found. The lesions are well define and contain thin
sclerotic border.; Brown tumor is likely.
- Multiple osteolytic lesions are detected with endosteal
scalloping at bilateral femoral shaft. Sclerotic border is noted.
- Blurring of bilateral SI joints is noted.; Bone resorption is
likely.
- Loss of lamina dura is found around the teeth.
IMPRESSIONS:
Overall findings are suggestive of hyperparathyroidism and
pathological fracture of right femoral neck.

BOTH HANDS
Findings:
- Osteopenia is observed.
- Terminal tuft resorption is seen.
- A well define lytic lesion is observed at distal
phalangeal bone of the 4th finger, left hand.
- Subperiosteal and endosteal bone
resorption is detected.
- No significant joint space narrowing is
observed.
- No calcified soft tissue is demonstrated.
IMPRESSION:
Hyperparathyroidism is likely.

Calcium to Cr clearance ratio > 0.01

PARATHYROID SCINTIGRAPHY
(Dual phase technique with
SPECT/CT)
The study reveals radiotracer uptake at bilateral thyroid bed
which has washed out in the delayed image without
significant retention.
The SPECT/CT image at the neck region reveals radiotracer
uptake within the thyroid gland without extra-thyroid lesion.
There is a focus of intense increased radiotracer uptake
seen at the mediastinum which the SPECT/CT images
located that the uptake is in a large AP-window mass,
measured about 5.7x3.5x3.5 cm. The visualized lung
shows no definite pulmonary lesion.
IMPRESSION:
1. No evidence of hyperfunctioning parathyroid tissue
at bilateral neck position. Note that hyperfunctioning
parathyroid gland with size smaller than 500 mg may cause
false negative study.
2. A large ectopic parathyroid adenoma is suspected
at the AP window of mediastinum.

Pamidronate
30 mg (eGFR
CKD-EPI = 21)

Overnight 1 mg dexamethasone suppression test

MRI OF PITUITARY
GLAND
FINDINGS

- The study reveals well-defined oval shape intrasellar

mass, measured about 0.8 x 0.5 cm, with mild
enlargement of the sella turcica. This lesion shows
isointense signal intensity on T1WI and slightly high
signal intensity on T2WI. There is no evidence of
posterior pituitary bright spot.
- After contrast administration, delayed
enhancement of lesion in dynamic contrast study
when compare to the rest pituitary gland is
observed. Overall findings suggest pituitary
microadenoma.
- Paranasal sinuses show mucous retention cyst in
sphenoid sinus and right maxillary sinus.
IMPRESSIONS:

- Suggest a pituitary microadenoma 0.8 x 0.5 cm.

 Problem Lists
1. R/O MEN I -> Ectopic PTH adenoma,
Microprolactinoma
Plan
CT whole abdomen w/u Pancreatic
tumour
Genetic testing
Set index case for familial testing

 Problem Lists
2. Ectopic PTH adenoma with Hypercalcemia
with pathologic fx
Plan
S/P Pamidronate 30 mg
Consult CVT for minimal invasive surgery
IoPTH
Beware post-op Hungry bone syndrome
Femoral Neck Fracture on skin traction ->
plan OR post parathyroidectomy

 Problem Lists
3. Microprolactinoma
Plan
Medical treatment -> Dopamine agonist