title: Transient hypercortisolism and symptomatic hyperthyroidism associated to primary hyperparathyroidism in an elderly patient: case report and literature review.
abstract: BACKGROUND
  Primary hyperparathyroidism (PHPT) is often found on routine blood tests, at a relatively asymptomatic stage. However many studies suggest different systemic effects related to PHPT, which could be enhanced by an abnormal cortisol release due to chronic stress of hyperparathyroidism. Being PHPT frequently found in the 6(th) to 7(th) decade of life, a careful and multifaceted approach should be taken.
  
  
  METHODS
  We report the case of an elderly patient with symptomatic PHPT and incidental pulmonary embolism. He was treated with hydration, zoledronic acid, cinacalcet and high-dose unfractionated heparin. Parathyroid surgery was successfully performed, but patient's conditions suddenly worsened because of a transient thyrotoxicosis, probably induced by a previous exposure to iodine load and/or thyroid surgical manipulation. A short-term treatment with beta-blockers was introduced for symptomatic relief. The patient also presented a transient hypercortisolism with elevated ACTH, likely due to stress related not only to aging and hospitalization but also to PHPT, resolved only four months after parathyroid surgery.
  
  
  CONCLUSIONS
  Chronic hyperparathyroidism has been linked with increased all-cause mortality. A functional chronic hypercortisolism could be established, enhancing PHPT related disorders. Only parathyroid surgery has been demonstrated to cure PHPT and complications related, showing similar outcome between older and younger patients. However, the management of post-operative period should be more careful in fragile patients. In particular, the early diagnosis and treatment of a transient post-operative thyrotoxicosis could improve recovery. Due to the increase in prevalence and the evidence of many related complications even in asymptomatic PHPT, expert opinion-based guidelines for surgical treatment of PHPT should be developed especially for elderly patients.
authors: Department of Medicine-Endocrinology, University of Padua, Via Ospedale 105, 35128, Padua, Italy. chiara.sabbadin.1@studenti.unipd.it.
authors: Chiara
authors: C
authors: Sabbadin
authors: Department of Molecular Medicine-Biological Chemistry, University of Padua, Padua, Italy. gabriella.dona@unipd.it.
authors: Gabriella
authors: G
authors: Donà
authors: Department of Molecular Medicine-Biological Chemistry, University of Padua, Padua, Italy. luciana.bordin@unipd.it.
authors: Luciana
authors: L
authors: Bordin
authors: Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy. maurizio.iacobone@unipd.it.
authors: Maurizio
authors: M
authors: Iacobone
authors: Department of Medicine-Endocrinology, University of Padua, Via Ospedale 105, 35128, Padua, Italy. valentina.camozzi@unipd.it.
authors: Valentina
authors: V
authors: Camozzi
authors: Department of Medicine-Endocrinology, University of Padua, Via Ospedale 105, 35128, Padua, Italy. caterina.mian@unipd.it.
authors: Caterina
authors: C
authors: Mian
authors: Department of Medicine-Endocrinology, University of Padua, Via Ospedale 105, 35128, Padua, Italy. decio.armanini@unipd.it.
authors: Decio
authors: D
authors: Armanini
mesh_terms: D000369:Aged, 80 and over; D050071:Bone Density Conservation Agents / Q000627:therapeutic use; D057966:Calcimimetic Agents / Q000627:therapeutic use; D000069449:Cinacalcet / Q000627:therapeutic use; D003480:Cushing Syndrome / Q000209:etiology*; D004164:Diphosphonates / Q000627:therapeutic use; D005440:Fluid Therapy; D006801:Humans; D006934:Hypercalcemia / Q000209:etiology*; D049950:Hyperparathyroidism, Primary / Q000150:complications* / Q000628:therapy; D006980:Hyperthyroidism / Q000209:etiology*; D007093:Imidazoles / Q000627:therapeutic use; D008297:Male; D016105:Parathyroidectomy; D000077211:Zoledronic Acid
chemical_list: D050071:Bone Density Conservation Agents; D057966:Calcimimetic Agents; D004164:Diphosphonates; D007093:Imidazoles; D000077211:Zoledronic Acid; D000069449:Cinacalcet
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