Overt metabolic bone failure as the initial manifestation of neglected primary hyperparathyroidism: An unusual presentation and review of current practice guidelines.

Varied symptomatology exists in hyperparathyroidism. The current approaches and evaluation of altered calcium homeostasis have led to the practice of early identification and subsequent management of the adenomas. Hence, bony manifestations (deformities, lesions, and fractures) termed to be end stage of bone metabolism failure, have rarely been encountered in the last two decades. We report this infrequent presentation in a 47-year-old female, who visited the emergency department following a trivial fall. Her background history recorded left superior parathyroidectomy three months prior to fall. The clinical and radiological evaluations were suggestive of insufficiency fractures of right proximal humerus and right shaft of femur, multiple lytic lesions and other bony manifestations pathognomonic of hyperparathyroidism. Metabolic profile revealed a primary cause despite prior adenectomy, and targeted scintigraphy demonstrated a hyper-functioning right inferior parathyroid gland. The high resolution ultrasound used before the prior surgery failed to localise additional hyper-functioning glands. Post-parathyroidectomy, the hungry bone disease was adequately managed. The femur fracture required surgical stabilization. In conclusion, bony manifestations of hyperparathyroidism can be disabling and difficult to treat. Although a rare clinical presentation, the severity of bony manifestations arise from a preventable cause and that the initial evaluation of hyperparathyroidism should also include parathyroid scintigraphy, and not limited to screening of the neck with ultrasonography, for its combined additive information and improved diagnostic value.