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Primary hyperparathyroidism — USMLE Step 2 CK MCQ

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HardSurgeryPrimary hyperparathyroidismUSMLE Step 2 CK

A 51-year-old woman has recurrent calcium oxalate nephrolithiasis. Corrected calcium is 11.2 mg/dL (upper reference limit 10.2), phosphorus is low, PTH is elevated, eGFR is 72 mL/min/1.73 m², and DXA shows a T-score of −1.8. Neck ultrasonography is negative for an adenoma. Which management is most appropriate?

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Correct answer: B — Refer for parathyroidectomy despite negative localization imaging

The best answer is “Refer for parathyroidectomy despite negative localization imaging”. Recurrent nephrolithiasis makes this symptomatic primary hyperparathyroidism and is independently an indication for parathyroidectomy. Localization imaging is performed for operative planning, not to establish the diagnosis or determine candidacy; negative ultrasonography therefore does not negate surgery, and additional localization may be pursued by an experienced team. Cinacalcet is generally reserved when surgery is contraindicated or declined, while surveillance or thiazide therapy leaves the causal disease untreated.

Reference: 2022 international workshop guideline: primary hyperparathyroidism. https://academic.oup.com/jbmr/article/37/11/2293/7512381