PMC6308315_01
Neck ultrasound and 99mTc-sestamibi scintigraphy performed on admission and 8 months after parathyroid apoplexy. (A) Baseline neck ultrasound showed a solid and hypoechoic 8 mm nodule located behind the right thyroid lobe (arrow). (B) Baseline 99mTc-sestamibi scintigraphy showed an area of increased uptake (arrow). (C) Follow-up neck ultrasound performed 8 months later notice the near complete disappearance of the nodule. (D) Follow-up 99mTc-sestamibi scintigraphy performed 8 months later showing a marked reduction of the uptake, although residual activity was still noticeable.
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F1
Neck ultrasound revealed a 9-mm, hypoechoic mass behind the right lobe of the thyroid gland (Figure 1A). Technetium 99m (99mTc)-sestamibi scintigraphy showed a focal area of increased uptake (Figure 1B), corresponding to the ultrasound finding, thus suggesting a parathyroid adenoma. Neck ultrasound performed at the same time no further identified the parathyroid lesion (Figure 1C). Repeated 99mTc-sestamibi scintigraphy showed a minute area of increased uptake, which we interpreted as a remnant adenoma, although a local inflammatory reaction could not be excluded (Figure 1D).
Serum levels of total calcium and parathyroid hormone (PTH). The x-axis shows the calendar time and the boxes above the graph show the treatments. Assessments were made at several time points before, during and after cinacalcet treatment. Note the marked decline in PTH and total calcium (arrow) occurring about a month after cinacalcet reached the 180 mg/dl daily dosage.
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F2
This dosage was gradually increased, in the following months, to 60 mg 3 times a day as to normalize the serum calcium levels (Figure 2, left panel; Table 1). Serum calcium, surprisingly, did not rise after cinacalcet cessation, remaining around values of 6 mg/dL for about 10 days (Figure 2, arrow). Three months later, serum calcium normalized and PTH remained normal (44.0 pg/ml) (Figure 2).
Morphological appearance of the fine-needle aspirate of the patient's parathyroid nodule. Note the presence of necrotic debris and inflammatory cells mainly consisting in neutrophils (black arrow), macrophages (white arrow), and lymphocytes (arrowhead). Original magnification 20X.
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F3
Cytological examination revealed basophilic amorphous material, neutrophils (Figure 3, black arrow), macrophages (Figure 3, white arrow), and lymphocytes (Figure 3, arrowhead), consistent with necrosis and inflammation.