Severe Acute Pancreatitis as the Index Clinical Manifestation of Parathyroid Adenoma in an Elderly Patient

Introduction: Hypercalcemia is a well-documented cause of acute pancreatitis. Patients might develop pancreatitis from hypercalcemia due to primary or secondary hyperparathyroidism. We present this case of an 88-year-woman with acute pancreatitis resulting from hyperparathyroidism due to parathyroid adenoma. Case Presentation: An 88-year-old woman with past medical history of hypertension and hyperlipidemia presented to the Emergency Department with sudden onset epigastric pain and multiple episodes of nonbloody vomiting. Patient was found to have an elevated lipase of 11,916 U/l, lactic acid level of 5.7 mmol/L and white blood cell count of 9.3 × 109/L with 78% neutrophils. Computerized tomography (CT) scan of abdomen (Figure 1) showed an enlarged pancreas with surrounding inflammatory fluid consistent with acute pancreatitis and renal calcifications. Patient denied alcohol consumption or having taken any medications known to cause pancreatitis. Hypertriglyceridemia was not observed and gallstones were not identified on imaging. The patient received IV hydration with lactated ringers solution. Although patient had normal serum calcium levels, hypercalcemia remained a highly probable explanation because of the renal calcifications found on CT. Serum calcium may not have been elevated, as calcium can be precipitated as soap in acute pancreatitis. Thus, to determine if the patient was truly hypercalcemic, ionized calcium levels were drawn and found to be elevated. Parathyroid hormone was also found to be elevated to 210 pg/mL. Patient was diagnosed with severe acute pancreatitis secondary to hyperparathyroidism. Sestamibi scintigraphy (Figure 2) revealed the presence of an adenoma in the left parathyroid gland. Patient had resolution of pancreatitis after treatment of hypercalcemia.Figure: CT showing acute pancreatitis.Figure: Sestamibi scan showing left parathyroid adenoma.Discussion: The most common causes of acute pancreatitis are gallstones (30-60%), alcohol (15-30%), ERCP (5-10%), and hypertriglyceridemia (1.3-3.8%). Hypercalcemia resulting from hyperparathyroidism as a cause of acute pancreatitis is estimated to occur at a prevalence of 1.5-8%. High serum calcium leads to activation of pancreatic enzymes and acute pancreatitis. The case we present here is a particularly interesting one because it demonstrates the unusual systemic effects of an already rare endocrine disorder. Furthermore, it illustrates how pancreatitis can actually predate the diagnosis of underlying parathyroid disease in some patients.