Off-label palopegteriparatide for severe pediatric postsurgical hypocalcemia

Hypoparathyroidism is the most common complication after total thyroidectomy and may be particularly severe in pediatric Graves' disease. We report the case of a 14-year-old boy with Graves' disease who developed profound postoperative hypocalcemia after total thyroidectomy, with serum calcium 5.9 mg/dL, ionized calcium 0.83 mmol/L, and undetectable parathyroid hormone. Despite intravenous and high-dose oral calcium plus calcitriol, biochemical control remained poor, with persistent hypocalcemia, hyperphosphatemia, and ongoing treatment requirements after 16 days. Off-label subcutaneous palopegteriparatide, a long-acting PTH(1-34) prodrug, was started after multidisciplinary assessment and informed family consent. Serum calcium improved within 48 h, intravenous calcium was stopped after 5 days, and calcitriol, sevelamer, and calcium acetate were discontinued within 11 days. Treatment was well tolerated. This case suggests that early PTH replacement may be a useful rescue strategy in selected children with severe refractory post-thyroidectomy hypocalcemia.