Acute Pancreatitis and Band Keratopathy as Initial Manifestations of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine disorder characterized by hypercalcemia and concurrently elevated or inappropriately normal parathyroid hormone (PTH) levels. More than 80% of patients with PHPT in the developed countries are asymptomatic (1.1), however, in some developing countries symptomatic forms which include skeletal, renal and gastrointestinal manifestation are still frequently encountered (1.2). An association between serum calcium concentration and pancreatitis was suspected as early as 1903, when a patient with a hyperparathyroid gland adenoma was described as having a necrotic pancreas at autopsy. (2) Despite numerous case reports and case series published during the last century where PHPT was suggested as etiological factor of acute pancreatitis causal relation between those conditions is still controversial. Band keratopathy as a presenting sign of PHPT syndrome is however, rarely described. A 34 years old man was admitted to our hospital with clinical signs of acute pancreatitis. At admission, he was presented with severe upper abdominal and back pain. Blood analysis showed significant leukocytosis with tenfold and twentyfold increase in serum amylase (911 U/L) and serum lipase (1600 U/L) respectively. Conservative treatment in the intensive care unit was initiated, however a severe form of acute pancreatitis was developed. The most common etiological factors for pancreatitis, including gallbladder calculosis, alcohol ingestion and hyperlipidemia were excluded; a diagnosis of idiopathic pancreatitis was established. After three weeks of treatment the patient's condition significantly improved. All laboratory parameters returned to normal values only hypercalcemia persisted. Neck ultrasound showed large adenoma of the left inferior parathyroid gland and PTH value was 1230 pg/ml (ref. 14-60 pg/ml). The patient was discharged and parathyroid surgery was scheduled in three weeks. One week before planned surgery the patient was readmitted due to ocular symptoms including bilateral eye pain, lacrimation and blurred vision. After detailed ophthalmological examinations diagnosis of band keratopathy caused by hypercalcemia was established. Surgical procedure was performed according to schedule and 3 cm adenoma of the left inferior parathyroid gland was removed. He was discharged from hospital on the third postoperative day with PTH and calcium level in normal range. Four years following surgery, the patient is asymptomatic without recurrent episodes of pancreatitis and ocular symptoms. To the best of our knowledge this is the third described case in literature of concurrent acute pancreatitis and band keratitis as presenting signs of PHPT.

Author(s): Kovacevic Bojan

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