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Primary hyperparathyroidism — SCE Rheumatology MCQ

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ModerateNephrolithiasisPrimary hyperparathyroidismSCE Rheumatology

A 59-year-old woman is reviewed after her third calcium oxalate renal stone in 4 years. Renal ultrasonography shows a 7 mm non-obstructing calyceal calculus, for which she is under urological follow-up. She has also had two episodes of acute knee synovitis with calcium pyrophosphate crystals identified in synovial fluid. Albumin-adjusted serum calcium is 2.68 mmol/L and 2.70 mmol/L on separate occasions, with concurrently elevated parathyroid hormone concentrations. Serum phosphate is low, 25-hydroxyvitamin D is replete and eGFR is 82 mL/min/1.73 m². Urinary calcium excretion is not low, making familial hypocalciuric hypercalcaemia unlikely. DXA shows osteopenia without osteoporosis. She has no symptoms attributable directly to hypercalcaemia and is fit for surgery. Which is the most appropriate next step in managing the underlying metabolic disorder?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Refer to a surgeon with expertise in parathyroid surgery

Explanation lettering: C = shown as B · E = shown as C · B = shown as E

The biochemical pattern confirms primary hyperparathyroidism: repeatedly elevated albumin-adjusted calcium with an inappropriately elevated PTH, after vitamin D deficiency and familial hypocalciuric hypercalcaemia have been addressed. Her recurrent nephrolithiasis constitutes end-organ disease. NICE recommends referral to an expert parathyroid surgeon when confirmed primary hyperparathyroidism is associated with renal stones, irrespective of whether adjusted calcium reaches 2.85 mmol/L. A is inappropriate because the apparently modest hypercalcaemia does not negate the surgical indication created by renal end-organ disease. B is inappropriate because cinacalcet is considered when surgery has failed, is unsuitable or is declined, and specified calcium thresholds are met; it is not first-line definitive management in this surgically fit patient. C may reduce fracture risk in selected patients with increased skeletal risk but does not provide definitive treatment for primary hyperparathyroidism or address the stone indication. D reverses the correct sequence: neck ultrasound and sestamibi scintigraphy are localisation studies used to guide an agreed surgical approach, not tests required to establish the diagnosis or determine whether referral is indicated. Calcium pyrophosphate deposition is a recognised clinical clue to hyperparathyroidism, but the decisive management feature is recurrent renal calculi.

Reference: Hyperparathyroidism (primary): diagnosis, assessment and initial management — Recommendations (23 May 2019) — https://www.nice.org.uk/guidance/ng132/chapter/Recommendations Hyperparathyroidism (primary): diagnosis, assessment and initial management — Preoperative imaging and non-surgical management (23 May 2019) — https://www.nice.org.uk/guidance/ng132/chapter/Recommendations