A two-month-old male child was referred with history of lethargy, irritability and poor feeding. The child was full term delivery, fourth in birth order born out of consanguineous marriage. On investigations, he was found to have hypercalcemia (serum calcium 25 mg/dL), a low serum phosphate and high serum parathyroid levels. The serum proteins, liver enzymes, serum electrolytes and urinary calcium levels were normal. Echocardiography was normal and no bone changes were seen on X-ray. Ultrasound of the abdomen was normal. The maternal serum calcium and parathyroid levels were low. The child was considered to have transient neonatal parathyroidism due to maternal hypocalcemia and initially treated conservatively with hydrocortisone. There was no response to treatment. A spiral CT scan of the neck was done which showed a 3 × 3 mm adenoma originating from the right inferior parathyroid gland. On exploration of the neck, an adenoma of the inferior parathyroid gland was found, and a right inferior parathyroidectomy was performed. The other three parathyroid glands appeared normal. Histopathological examination of the gland was suggestive of parathyroid adenoma. The child had an uneventful recovery, and has remained normocalcemic during six months of follow up.

Fewer than 100 cases of childhood hyperparathyroidism have been reported in the literature. Of the two large series of childhood hyperparathyroidism published in the last decade, Allo, et al.(1) reported 17 cases and Rapaport, et al.(2) reported seven cases in which the disease manifested before 18 years of age. Neonatal hyperparathyroidism uniformly presents in the first three months of life, usually or shortly following birth.

The presentation of childhood hyper-parathyroidism is nonspecific with vague symptoms like anorexia, nausea, vomiting, constipation, irritability, polyuria and polydipsia(3). Primary hyperparathyroidism in infancy is extremely rare. Fifty per cent of the patients have a family history.

For differentiation of parathyroid hyperplasia and parathyroid adenoma, localization studies are of great importance. Invasive methods for localization have been replaced by imaging modalities like high fre-quency ultrasound, CT scan, and subtraction scintigraphy. Technetium 99m-Sestamibi scanning is the most sensitive and specific(4). Surgical exploration is almost always indicated with options of local lobe excision, subtotal parathyroidectomy or total para-thyroidectomy with parathyroid reimplanta-tion. An accurate preoperative localization results in a high surgical success rate. Patients may need postoperative calcium or vitamin D supplements for a few days if they become symptomatic.

Amar A. Shah,
Anirudh V. Shah,
Department of Pediatric Surgery,
K.M. School of Postgraduate
Medicine and Research,
N.H.L. Municipal Medical College,
V.S. Hospital, Ahmedabad,
India.
E-mail: [email protected]

1. Allo M, Thompson NW, Harness JK, Nishiyama RH. Primary hyperparathyroidism in children, adolescents, and young adults. World J Surg 1982; 6: 771-776.

2. Rapaport D, Ziv Y, Rubin M, Hubiner D, Dintsman M. Primary hyperparathyroidism in children. J Pediatr Surg 1986; 21: 395-397.

3. Rogers PN, Seright W. Pancreatitis associated with parathyroid adenoma in childhood. Br J Surg 1984; 71: 38.

4. Dijkstra B, Healy C, Kelly LM, Mcdermott EW, Hill AD, O’Higgins N. Parathyroid localization–current practice. J R Coll Surg Edinb 2002; 47: 599-607.