title: Parathyroid adenoma with coeliac disease: primary or quaternary hyperparathyroidism?
abstract: Coeliac disease is a gluten-sensitive enteropathy of varying severity. Osteomalacia and hypocalcaemia can result from malabsorption of  vitamin D and calcium, which, in turn, can lead to secondary hyperparathyroidism. If coeliac disease remains untreated for long, tertiary  hyperparathyroidism can also develop through autonomy of the parathyroid glands via chronic stimulation. Primary hyperparathyroidism also has been reported in some cases of coeliac disease. We report the case of an adolescent with coeliac disease presenting with severe hypercalcaemia from a parathyroid adenoma. A 14 year-old girl was admitted to our department for delayed puberty and growth retardation. Laboratory examination revealed iron deficiency anaemia, low 25OH vitamin D level (7 ng/ml), high parathyroid hormone level (PTH) (955 pg/ml), and hypercalcaemia (13.4 mg/dl). Endoscopic biopsy was compatible with gluten enteropathy. Endomysium antibody was positive. A gluten-free diet was started. Her calcium returned to normal after excision of the parathyroid adenoma. After four months of the gluten-free diet, she began to mature, and puberty began with development of breasts and axillary-pubic hair growth. It has been  suggested that autonomous four-gland hyperplasia or tertiary hyperparathyroidism may progress to adenoma formation, and that this  should be termed "quaternary hyperparathyroidism". More studies are required to explain the relationship between coeliac disease and hyperparathyroidism.
authors.affiliation: Department of Endocrinology and Metabolism, Trabzon Numune Education and Training Hospital, Trabzon, Turkey
authors.forename: Inan
authors.initials: I
authors.lastname: Anaforoglu
authors.forename: Kerem
authors.initials: K
authors.lastname: Ersoy
authors.forename: Ekrem
authors.initials: E
authors.lastname: Algun
mesh_terms: D000236:Adenoma / Q000150:complications* / Q000601:surgery; D000293:Adolescent; D018798:Anemia, Iron-Deficiency / Q000097:blood / Q000150:complications / Q000378:metabolism; D002118:Calcium / Q000097:blood / Q000378:metabolism; D002446:Celiac Disease / Q000150:complications*; D055050:Diet, Gluten-Free / Q000379:methods; D005260:Female; D006801:Humans; D006934:Hypercalcemia / Q000150:complications*; D049950:Hyperparathyroidism, Primary / Q000145:classification / Q000150:complications*; D006962:Hyperparathyroidism, Secondary / Q000145:classification / Q000150:complications*; D010281:Parathyroid Hormone / Q000097:blood / Q000378:metabolism; D010282:Parathyroid Neoplasms / Q000150:complications* / Q000601:surgery; D011628:Puberty, Delayed / Q000209:etiology; D013997:Time Factors; D014808:Vitamin D Deficiency / Q000097:blood / Q000150:complications / Q000378:metabolism
chemical_list: D010281:Parathyroid Hormone; D002118:Calcium