Recurrent hyperparathyroidism: A sixth mediastinal parathyroid gland.

Area of Science:

• Endocrinology
• Surgical Pathology
• Medical Imaging

Background:

• Primary hyperparathyroidism can present with multi-glandular disease.
• Ectopic parathyroid glands pose diagnostic and surgical challenges.
• Recurrent hyperparathyroidism necessitates thorough investigation for missed or supernumerary glands.

Observation:

• A 71-year-old woman with a history of subtotal parathyroid resection and thyroidectomy for primary hyperparathyroidism presented with recurrent disease.
• Imaging revealed a sixth parathyroid gland in the aortopulmonary window, missed during prior videomediastinoscopic attempts.
• The patient also had terminal renal insufficiency, a common comorbidity in advanced hyperparathyroidism.

Findings:

• Initial surgery revealed parathyroid hyperplasia and an incidental fifth gland within the thyroid.
• A subsequent parathyroid adenoma was identified as the cause of recurrent hyperparathyroidism.
• Sestamibi scintigraphy and CT scan were crucial in localizing the mediastinal ectopic gland.

Implications:

• This case underscores the importance of comprehensive imaging and surgical exploration for recurrent hyperparathyroidism.
• Manubriotomy can be a viable approach for resecting mediastinal parathyroid glands when less invasive methods fail.
• Understanding parathyroid embryology is key to managing complex cases of hyperparathyroidism with ectopic glands.