An 83-year-old male, dependent for daily life activities due to dementia, was admitted with prostration and asthenia lasting for a few days. Blood tests showed hypercalcaemia (12.9 mg/dL) and hypophosphatemia at 1.7 mg/dL. Further investigation revealed increased serum parathyroid hormone levels (321 pg/ml) compatible with primary hyperparathyroidism, with normal levels of Vitamin D.
CT scan of the neck detected a right paraesophageal 18 mm mass with tissue density (Figure 1).
Figure 1: Cervical CT scan: Right paraesophageal 18 mm mass with tissue density (arrows)
Upper gastrointestinal endoscopy showed no relevant findings. Endoscopic ultrasound showed a hypoechoid 17x11x27 mm mass with heterogeneous structure, apparently extrinsic to the esophagus located 20 cm from the dental arcade (Figure 2).
Figure 2a & 2b. Endoscopic ultrasound: Hypoechoid 17x11x27 mm lesion with heterogeneous echostructure.
Endoscopic-guided fine-needle aspiration of the lesion was done through a transesophageal approach. The histological findings were compatible with ectopic parathyroid tissue, without dysplasia (Figure 3).
Figure 3a-c. Histological findings (a- Hematoxylin and eosin; b- Chromogranin; c- Synaptophysin).
The patient was referred for surgery, for ectopic parathyroidectomy procedure.
The incidence of ectopic parathyroid glands in patients with primary hyperparathyrodism ranges from 9% to 20%. The ectopic parathyroid glands are more often derived from the inferior glands because of their longer migration path, granting them a higher probability of being ectopic. However, ectopic parathyroid glands in the paraesophageal space are derived from the superior gland precursors.
Ectopic gland surgical excision is advised for patients with prominent hypercalcaemia.
Pedro Russo, Diana Carvalho, Mariana Costa, Ricardo Rio-Tinto, Gonçalo Ramos
Department of Gastroenterology, Hospital de Santo António dos Capuchos – Centro Hospitalar de Lisboa Central, Lisbon, Portugal