(4.04) The Complexities of Managing Hypercalcemia-Induced Pancreatitis in a Pregnant Female with Primary Hyperparathyroidism

Hypercalcemia-induced pancreatitis from primary hyperparathyroidism (PHPT) in a pregnant female is a rare entity. This case describes a 14 week pregnant female who presented with symptomatic pancreatitis found to have resistant hypercalcemia from newly diagnosed PHPT, complicating the ability to evaluate and manage the patient.


Case(s) Description :

A 31-year-old female with a past medical history of nephrolithiasis presented to the emergency department with epigastric pain, nausea and vomiting found to have pancreatitis on MRCP without evidence of choledocholithiasis or biliary ductal dilatation. Physical exam revealed epigastric tenderness. Labs showed a corrected calcium of 12.7 mg/dL (8.4-10.5), intact parathyroid hormone (PTH) 99 pg/mL (15-65), 25-hydroxy vitamin D < 6 ng/mL (30-80), 1,25-dihydroxy vitamin D 95.5 pg/mL (19.9-79.3), lipase  >3000 U/L (7-60), serum triglyceride 145 mg/dL (<149) and a GFR >60 mL/min/1.73m². Hypercalcemia in pregnant patients can lead to renal stones, pancreatitis, dehydration, muscle weakness with fetal risks including growth retardation, hypoparathyroidism, prematurity, and fetal loss. Continuous fluids were initiated and effective but limited due to polyuria. Vitamin D 2000 international units (IU) daily for vitamin D deficiency was initiated. Calcitonin was used with some effect but tachyphylaxis developed leaving calcium elevated. Bisphosphonates and denosumab were contraindicated due to pregnancy. Neck ultrasound was unrevealing. The second trimester of pregnancy is optimal for surgery avoiding anesthesia related risks to embryogenesis and was recommended for her PHPT given age less than 50, calcium greater than 1 mg/dL over the upper limit of normal, and history of kidney stones. Discussions with maternal fetal medicine prompted a 4 dimensional computed tomography scan of the parathyroid to minimize intraoperative anesthesia by definitively localizing the parathyroid adenoma which showed 2 lesions, 0.7x0.6x2 cm and 0.4x0.3x0.8 cm suspicious for parathyroid adenomas. The patient underwent a left superior and inferior parathyroidectomy with post-operative PTH measuring 10 pg/mL. The patient was discharged on calcium carbonate 1250 mg three times a day and vitamin D 2000 IU daily with corrected calcium being 9.8 mg/dL on discharge and one month post operatively.


Discussion :

This case illustrates the challenges of managing a rare complication of hypercalcemia, pancreatitis, a diagnosis of exclusion, from PHPT in a pregnant female. Pregnancy made decisions on imaging and medical management of PHPT a challenge. The patient was also hesitant to undergo surgery, under the belief she could be medically managed further complicating treatment.