Spontaneous Parathyroid Hemorrhage in a Hemodialysis Patient

Dr. J. Roma, Nephrology Service, Hospital Creu Roja, Dos de Mayo 301, Barcelona 25 (Spain) Dear Sir, Spontaneous parathyroid hemorrhage has been reported in a few cases of primary hyperparathyroidism due to adenoma [1] or hyperplasia [2], but to our knowledge, it has not been described in secondary hyperparathyroidism. We wish to report a woman with chronic renal failure who developed spontaneous hemorrhage of the parathyroid glands during a hemodialysis session. Case Report A 43-year-old woman had been on hemodialysis for 18 months because of chronic renal failure of undetermined etiology, discovered 3 years before. Throughout her stay on dialysis she was found on several occasions to be moderately hypocalcemic and hyperphosphatemic and her immunoreactive serum parathyroid hormone levels were elevated. In addition, she had increased serum alkaline phosphatase values and radiologic evidence of subperios-teal resorption in the distal phalanxes of both hands. She had received aluminum hydroxide 5 g/day and 25hydroxycholecalcif-erol (0.78 mg/week) for 27 months and 1,25-dihydroxycholecalcif-erol (0.25 μg/day) for 1 month. Her dialysis fluid contained 0.9 mmol/l of calcium and 0.75mmol/l of magnesium; the prothrombin time was 11/11 s, platelets 200,000 × mm3 and the Ivy bleeding time 4 min. During a hemodialysis session, she suddenly developed hoarseness, dysphagia, enlargement of the neck and hypercalcemia (3 mmol/l). Later on, a large hematoma appeared in the anterior chest area and over both breasts (fig. 1). Since the patient was also known to have two cold nodules in the thyroid gland (functionally euthyroid), a presumptive diagnosis of thyroid hemorrhage was made. At surgery, a large hematoma surrounding the parathyroid glands was found. The thyroid contained two foci of papillary carcinoma, but otherwise there were no areas of hemorrhage, either macroscopically or microscopically. A parathyroid gland was massively enlarged (8.7 g) and contained several areas of hemorrhagic necrosis and chief cell hyperplasia; the gland was removed. The other parathyroid gland (775 mg) with chief cell hyperplasia was removed as well. Fig. 1. Enlargement of the neck and hematoma on chest and both breasts. The postoperative course was benign, with transient hypocal-cemia. Since then the patient has required calcitriol and her clinical course has been uneventful for 1 year.