Known patient with chronic kidney disease on haemodialysis on top of polycystic kidney disease complaining of chronic bone aches. Laboratory results showed hypercalcemia and elevated parathormone level since one year (~3900 pg/ml), with treatment it currently decreased (~2000 pg/ml). Now she is prepared for surgery (parathyroidectomy).
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Four oval-shaped well-defined hypoechoic soft tissue lesions are noted at the posterior aspect of both thyroid lobes. The upper ones are posterior to the mid-zone of each thyroid lobe and the inferior ones are related to the inferior pole of the thyroid gland (the larger). Each upper one shows peripheral well-defined cystic lesion with turbid fluid and a uniform calcified wall. All the lesions are extracapsular to the thyroid gland which looks normal.
The soft tissue lesions are likely representing asymmetrically enlarged parathyroid glands. Regarding the history, clinical status and laboratory results, the possibility of secondary parathyroid hyperplasia is the prime consideration. Chronic kidney disease is the usual etiology of secondary parathyroid hyperplasia.
Nuclear medicine (Tc-99m MIBI) is the current modality of choice for confirming the diagnosis and identifying ectopic sites of parathyroid tissues. The differential diagnosis is multiple parathyroid adenoma.
Parathyroid cysts are rare and can be functional. They can occur in parathyroid adenoma or hyperplasia or as a rare incidental finding. Fine needle aspiration and fluid analysis for parathyroid hormone content should be done for neck cysts of unknown origin 1.