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Case description A 31 year old white female presented with symptoms of tetany with her bloods revealing hypocalcaemia of 2.05mmol/L, increased ALP (263IU/L) and increased PTH(1100ng/L). She had normal 25-hydroxycholecalciferol. The hand radiograph suggested osteitis fibrosa. Secondary hyperparathyroidism was excluded and diagnosis of pseudohypoparathyroidism was made and patient was commenced on vit D2 and calcium supplements. Twenty five years later she presented with hypercalcaemia, raised PTH and borderline low vit D levels and was switched from calcitriol to alphacalcidiol which she stopped as she couldn’t tolerate the preparation. Her Calcium levels remained elevated, vit D became undetectable and PTH soon exceeded 150pmol/L. The DEXA scan showed L1L4 osteopenia and US KUBmarked bilateral cortical thinning. US neck suggested left lower parathyroid adenoma confirmed by a Sestamibi scan which revealed a well defined 2x1cm left inferior parathyroid adenoma and possibly a second intrathyroid 8mm parathyroid adenoma. Patient was eventually established on 2200 units of cholecalciferol OD and weekly alendronate with normalisation of calcium and vitamin D levels and gradual decline in PTH levels. A decision was made not to proceed with parathyroidectomy as this could potentially lead to hyperplasia of remaining parathyroid glands. PTH (pmol/l) Vit D (nmol/l)

Tertiary hyperparathyroidism: a long-term complication of pseudohypoparathyroidism type 1b?