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Research Report

Primary hyperparathyroidism and urolithiasis: about a coralliform lithiasis case  

Mostafa Jamal YOUSFI , Mohammed El Amine AMANI
Departments of Urology and Endocrinology, 1st November 1954 University Hospital of Oran, Algeria
Author    Correspondence author
International Journal of Clinical Case Reports, 2016, Vol. 6, No. 26   doi: 10.5376/ijccr.2016.06.0026
Received: 04 Aug., 2016    Accepted: 11 Oct., 2016    Published: 12 Oct., 2016
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This is an open access article published under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Preferred citation for this article:

Yousfi M. J., and Amani M.A., 2016, Primary hyperparathyroidism and urolithiasis: about a coralliform lithiasis case, International Journal of Clinical Case Reports, 6(26): 1-4 (doi: 10.5376/ijccr.2016.06.0026)

Abstract

The primary hyperparathyroidism (PHPT) is not uncommon. The lithiasic events are the most common complication of the PHPT. We report the case of a 53-year-old woman, with a heavy urological history with several extracorporeal lithotripsy sessions for a right nephrolithiasis and a semirigid ureteroscopy for a right ureteral lithiasis, as well as a bilateral calcium oxalate coralliform lithiasis with right kidney consequences. This nephrolithiasis was due to a parathyroid macroadenoma. Through this observation, we highlight that the coralliform lithiasis etiology is not always an infectious disease and the PHPT may be responsible of this type of lithiasis as well as the nephrocalcinosis.

Keywords
Coralliform lithiasis; hyperparathyroidism; metabolic tests; surgical treatment

1 Introduction

The primary hyperparathyroidism (PHPT) is, after the thyroid diseases, the most common endocrine disorder in adults especially in women. Its incidence increased in the 90s with a current stabilization at 20.8 / 100.000 (Melton., 2002). The asymptomatic forms detected by a routine calcium dosage account for 80% of the cases (Bilezikian JP., and Potts JT Jr., 2002). Some patients have a PHPT with renal consequences but they are normocalcaemic (Dutta P. K., and al., 2015). The coralliform lithiasis represents the most common clinical manifestation; about 3 to 5% of lithiasic patients have a PHPT. In Patients with persistent urinary hypercalcemia, the PHPT is more common and reached to 10% of the cases (Clark and Duh., 1989). The coralliform lithiasis is a rare urological manifestation of the PHPT and requires a multidisciplinary management.

 

2 Case reports

We report the case of a 53-year-old woman with a heavy urological history, a right ureteral lithiasis (15mm) treated in March 2013 through three sessions of extracorporeal lithotripsy. The patient was readmitted in April 2013 for a pelvic ureteral calculi treated with semirigid ureteroscopy fragmentation with laser. In February 2014, an obstructive left lumbar ureteral calculi (12mm) was diagnosed and treated again with a semirigid ureteroscopy with laser. The morphoconstitutional analysis of the lithiasis by infrared spectrophotometry showed an oxalo-phosphate mixed nature. In September 2015, our patient consulted for a repeated renal colic associated with fatigue and digestive disorders infections (pain and vomiting).A CT urography showed a recurrent left coralliform lithiasis (40mm, density =758 Hounsfield unit) in the pyelic region with middle and lower calices extension (Figure 1). The patient was treated with the third generation cephalosporin and aminoglycosides after a urinary antibiogram. After the negativation of urinary antibiogram, a percutaneous nephrolithotomy (NCCP) was performed with a double surgical approach of the middle and the lower calices in two stages (Figure 2).The morphoconstitutional results of the calculi showed a calcium oxalate structure (Figure 3).

 

  

Figure 1 CT urography: left coralliform lithiasis (40mm) in the pyelic region 

 

  

Figure 2 Percutaneous nephrolithotomy in two stages 

 

  

Figure 3 The morphoconstitutional results of the calculi: calcium oxalate structure 

 

The analysis by the infrared spectrophotometry showed:

-surface: Whewellite (C1)> Weddellite (C2)

-section and central mass: Whewellite (C1)> Weddellite (C2) and trace of carboapatite

-conclusion: oxalo structure and calcium-dependent lithiasis

 

As part of the aetiological investigation, hypercalcemia to 119 mg/l (88 -101), with hypophosphatemia to 14mg/l (27 -45), PTH=508.7pg/ml (15 -65), so the diagnosis of the PHPT was established. The ultrasound cervical scan showed a right heterogeneous hypoechoic parathyroid mass measuring 46x34 mm in contact with the thyroid gland. The parathyroid sestamibi scintigraphy confirmed an isolated enlarged lower right parathyroid gland measuring 5cm. A cervical MRI did not reveal any extension to the surrounding vascular structures. However, there was an extension to the upper mediastinum in relation to the carotid artery. A conventional cervicotomy was performed for the removal of the parathyroid adenoma which measured 5 x 2.5cm with an ipsilateral thyroid lobectomy. The postoperative course was uneventful. A month after the cervicotomy, the patient was asymptomatic and the laboratory tests became normal (calcemia=95mg/ml and PTH=39pg/ml).

 

3 Discussion

The first parathyroidectomy was performed by Vienna Mandle in 1925. The PHPT is one of the main causes of hypercalcemia in non-hospitalized patients and its prevalence is 0.5% to 16.7% (Charopoulas et al., 2006). In the series of Clark and al, the majority of the patients with a PHPT were symptomatic with bone and muscle pain, polydipsia, polyuria, asthenia, anorexia, constipation, pruritus and other complications such as urinary stones in 20%, osteopenia, hypertension and heart disease (Clark and Duh., 1989). The diagnosis of PHPT is confirmed by the association of hypercalcemia, hypophosphatemia and inadequate high PTH in the absence of hypocalciuria. The topographic diagnosis uses the ultrasound technics, imaging by nuclear magnetic resonance, but can only rely on irradiating examinations such as sestamibi scintigraphy (Butler .,and al., 2000). In our case, the parathyroid adenoma was easily detected on scan because of its large size. The radical treatment is an effective way to establish normocalcemia. In 10-15%, the hypercalciuria may persist despite the treatment which reflects an underlying idiopathic hypercalciuria that must be systematically tested in the lithiasic patients away from the parathyroidectomy (Van Heerden and Grant., 1991). Currently, the surgical treatment of coralliform nephrolithiasis with the bivalve nephrotomy is abandoned at the cost of PCNL monotherapy or in combination with extracorporeal lithotripsy or flexible ureteroscopy using several sources of fragmentation, laser or ultrasonic waves. This innovative technic showed satisfactory results in terms of stone-free rate (Saussinea., and  Lechevallierb., 2008). The lithiasic metabolic balance is a real etiological investigation to determine the nature and the origin of the calculi and many authors insisted for it in case of recurrent or bilateral episodes (Simon., and al 2015). The initial tests are based on the calculi morphoconstitutional study recovered with a standard blood and urine laboratory tests (Table 1). In case of multiple stones, bilateral or recurrent, nephrocalcinosis, in children, a solitary kidney, renal failure, a second line exploration in a specialized environment is mandatory, (Table 2), (Traxerb O., and al., 2008).

 

  

Table 1 First line tests 

 

  

Table 2 Second line tests 

 

4 Conclusion

The urolithiasis is a common complication of the PHPT which is manifested by the nephrocalcinosis or the nephrolithiasis and more rarely a coralliform lithiasis. The treatment of the urolithiasis has been revolutionized by the PCNL as minimally invasive approach. The metabolic balance is essential to label any PHPT.

 

References

Bilezikian JP., and Potts JT Jr., 2002, Asymptomatic primary hyperparathyroidism: new issues and new questions--bridging the past with the future, J Bone Miner Res, 17 Suppl 2:N57-67.

 

Butler BM., Cox SM., Ebert EG., and Cunningham FG., 2000, Symptomatic nephrolithiasis complicating pregnancy, Obstetgynecol, 96: 753-6.

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Charopoulas I., Tournis S., Trovas G., Raptou P., Kalrymides P., Skrandavos G., Katnalira K., and Lyritin G.P.,2006, Effect of primary hyperparathyroidismon volumetric bone mineral density & bone geometry assessed by peripheral quantitative computed tomography in postmenopausal women,The Journal of Clinical Endocrinology and Metabolism, 91: 1748-1753

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Dutta P. K., Nishat Jahan and Tharakul Mazid A. H. M., 2015, Normocalcaemic Primary Hyperparathyroidism with Nephrocalcinosis in early Chronic Kidney Disease: a Case Report, International Journal of Clinical Case Reports, 5(39): 1-3 (doi: 10.5376/ijccr.2015.05.0039)

http://dx.doi.org/10.5376/ijccr.2015.05.0039

 

Endres D.B., Villanueva R., Sharp C.R. JR., and Singer F.R., 1991,  Immunochemiluminetric and immunoradiometric determinations of intact and total immunoreactive parathyrin : performance in the differential diagnosis of hypercalcemia and hyperparathyroidism, Clin. Chem,  37 : 162-168.

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Melton LJ 3rd., 2002, The epidemiology of primary hyperparathyroidism in North America, J Bone Miner Res ,17 Suppl 2:N12-7.

 

Saussinea.C., and  Lechevallierb. E., 2008, TraxerCalculscoralliformesoucalculscomplexes :traitement chirurgical. ProgUrol, 18, 12, 966-971.

 

Simon I., Roumeguère T., Devuyst F., Cotton F., Tang BN., Cappello M., and al., 2015.,  Recurrent episodes of brushite nephrolithiasis revealing primary hyperparathyroidism., Rev Med Brux., 36(3):172-6.

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Traxerb O., Lechevallier E., Saussine C., 2008, Bilan métabolique d’un patient lithiasique. Le rôle de l’urologue, Progrès en urologie 18, 849—856.

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