Life-threatening injuries and a silent gland: Incidental hyperparathyroidism in severe polytrauma

Abstract

Polytrauma from road traffic injury presents unique diagnostic and therapeutic challenges, with priority given to life-threatening injuries. Incidentaloma, or incidental detection of clinically relevant non-traumatic conditions, is rare during the management of acute trauma. We describe a previously healthy 26-year-old female who presented to our unit following a high-velocity road traffic injury in hemorrhagic shock, and was found to have grade IV liver injury, grade III splenic injury, grade II right renal injury, moderate hemoperitoneum, and multiple long-bone fractures. Resuscitation with massive transfusion and selective hepatic artery- and splenic artery-angiographic embolization, staged orthopedic fixation, and intensive care therapy were performed. During the course of stay in the intensive care unit (ICU), the patient’s biochemistry revealed both hypercalcemia and hypophosphatemia. The ICU stay was deemed to be too short to attribute the hypercalcemia to prolonged immobilization. Further evaluation revealed elevated parathyroid hormone (PTH) levels, and ultrasonography of the neck also revealed a hyper vascular mass existed inferior to the right thyroid lobe. All of these findings were compatible with PTH-dependent hypercalcemia of a parathyroid adenoma. However, the degree of injury prevented definitive endocrine surgery, and she was managed conservatively. The patient made a full recovery from her traumatic injuries and was discharged in stable condition with endocrine outpatient follow-up. This case illustrates the importance of maintaining a high index of suspicion of unexplained metabolic derangements in polytrauma patients and using a multidisciplinary approach to manage incidental but meaningful comorbidities without detriment to the acute management of trauma.