Core Tip: This is the first case of acute pancreatitis caused by primary hyperparathyroidism associated with paraneoplastic syndrome successfully treated with timely surgery and chemotherapy. This further raises concern for women with refractory hypercalcemia and abnormal vaginal bleeding or abdominal symptoms.
INTRODUCTION
Acute pancreatitis is an inflammatory disease of the pancreas[ 1 , 2 ]. Although several causes of acute pancreatitis have been described, including toxins or drugs, neoplastic obstruction of the biliary tract, hyperparathyroidism, hypercalcemia, and trauma[ 3 ], primary hyperparathyroidism with paraneoplastic syndrome is rare and infrequently reported in the literature. Here we report a patient with acute pancreatitis associated with refractory hypercalcemia, hyperparathyroidism, and paraneoplastic syndrome. Due to refractory hypercalcemia, the diagnosis is difficult. Only by fully understanding the characteristics of such diseases, making an accurate diagnosis, and providing timely treatment can we avoid fatal consequences.
CASE PRESENTATION
Chief complaints
A 56-year-old woman visited the emergency department of an affiliated hospital with progressive upper abdominal discomfort, intermittent nausea, and abnormal vaginal bleeding, for 1 wk.
History of present illness
Initially, there was no apparent jaundice or changes in blood pressure. The patient denied any fever, dizziness, headache, or disturbance of consciousness at the beginning of the illness.
History of past illness
The patient had a history of Helicobacter pylori infection for more than 10 years. She had no relevant past interventions.
Personal and family history
She denied family or psycho-social history.
Physical examination
The patient had stable vital signs: body temperature was 37.0 °C, blood pressure was 168/87 mmHg, heart rate was 74 bpm, and respiratory rate was 25 breaths/min, with obvious upper abdominal tenderness, slight rebound pain, and muscle tension.
Laboratory examinations
Laboratory examination results were as follows: white blood cell count 26.5 × 10 9 /L, neutrophil percentage 95%, C-reactive protein 109 mg/L, procalcitonin 4.35 ng/mL, serum amylase 1222.5 U/L, creatinine 172.3 µmol/L, urine amylase 1433.0 U/L, platelet 214 × 10 9 /L, hemoglobin 156 g/L, albumin 26.8 g/L, alanine aminotransferase 19.5 U/L, aspartate aminotransferase 26.6 U/L, lactate dehydrogenase 457.3 U/L, ferritin 747 ng/mL, and 25-hydroxyvitamin D < 3 ng/mL. Serum calcium increased significantly to 4.72 mmol/L, with parathyroid hormone (PTH) rising to 366.90 pg/mL and carbohydrate antigen 125 to 142.5 U/mL. An overview of selected initial laboratory values is shown in Table 1 .
Table 1
Selected initial laboratory values
ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; CA-125: Carbohydrate antigen 125; CRP: C-reactive protein; Hb: Hemoglobin; LDH: Lactate dehydrogenase; PCT: Procalcitonin; PTH: Parathyroid hormone; PLT: Platelet; WBC: White blood cell; 25-OH-VD: 25-hydroxyvitamin D.
| WBC (4-10) (× 10 9 /L) | 26.5 |
| Neutrophil percentage (50-70) (%) | 95 |
| PLT (100-300) (× 10 9 /L) | 214 |
| Hb (113-151) (g/L) | 156 |
| Albumin (35-53) (g/L) | 26.8 |
| ALT (4-40) (U/L) | 19.5 |
| AST (4-40) (U/L) | 26.6 |
| CRP (0-10) (mg/L) | 109 |
| PCT (0-0.5) (ng/mL) | 4.35 |
| Serum amylase (0-200) (U/L) | 1222.5 |
| Urine amylase (0-1000) (U/L) | 1433.0 |
| Creatinine (44-97) (μmol/L) | 172.3 |
| Serum calcium (2.13-2.65) (mmol/L) | 4.72 |
| PTH (15-65) (pg/mL) | 366.90 |
| CA-125 (0-35) (U/mL) | 142.5 |
| LDH (80-250) (U/L) | 457.3 |
| Ferritin (11-306) (ng/mL) | 747 |
| 25-OH-VD (20-100) (ng/mL) | < 3 |
Imaging examinations
Non-contrast enhanced computed tomography (CT) of the abdomen showed exudation around the pancreas (Figure 1A and B ). Ultrasound examination of the neck revealed an inferior thyroid nodule and mild hyperplasia of the parathyroid gland. Head magnetic resonance imaging (MRI) was performed, and abnormal signals were found in the bilateral fronto-parietal-temporal-occipital cortex-medullary junction area and bilateral paraventricular area, which were likely due to metabolic encephalopathy related to pancreatitis (Figure 1C and D ). A repeat non-contrast enhanced CT scan of the abdomen (Figure 1E and F ) and head MRI (Figure 1G and H ) showed a reduction in pancreatic exudation and abnormal head signals after effective treatment. Contrast enhanced CT of the neck (Figure 1I and J ) showed nodules located at the junction of the left lobe of the thyroid and parathyroid gland. MRI of the pelvis (Figure 1K and L ) suggested malignant lesions of the uterus and multiple uterine fibroids.
MULTIDISCIPLINARY EXPERT CONSULTATION
Due to the unknown nature of the disease and refractory hypercalcemia, a multidisciplinary expert consultation was conducted, and further workup was proposed. General practitioners believed that refractory hypercalcemia might be caused by parathyroid disease, and exploratory resection of the parathyroid gland was necessary.
FINAL DIAGNOSIS
Moderately severe acute pancreatitis with refractory humoral hypercalcemia caused by primary hyperparathyroidism associated with paraneoplastic syndrome.
TREATMENT
Based on the above laboratory and imaging examinations (initially we did not consider gynecological disease and did not perform pelvic MRI), the preliminary diagnosis was acute pancreatitis secondary to hypercalcemia caused by primary hyperparathyroidism. She was transferred to the emergency intensive care unit and treated with salmon calcitonin, zoledronic sodium, and anti-infection and intravenous fluids. During the hospitalization period, the patient became more lethargic with dry mucous membranes and mild coma. Early use of imipenem and extensive resuscitation effectively controlled her inflammation. As serum calcium treatment was not satisfactory, hemofiltration was then performed twice. Although acute pancreatitis and consciousness gradually improved, serum calcium did not return to normal level (Figure 2 ).
To determine the cause of the elevated calcium, a multidisciplinary expert was consulted, and further workup was proposed. Finally, although the nature of the parathyroid lesions was not yet clear, to reduce serum calcium, exploratory parathyroidectomy was performed on April 14, 2020 (Figure 2 ). The pathological result of the removed tissue suggested nodular goiter.
Unexpectedly, removal of the parathyroid gland did not decrease serum calcium; therefore, we speculated that high calcium might not be caused by hyperparathyroidism alone. To verify this hypothesis, an MRI of the pelvis was performed, and the results showed ambiguous, irregular masses and multiple uterine fibroids in the uterine/cervix region. There were multiple peritoneal and omental masses, and the pelvic and para-aortic lymph nodes were enlarged. The pathological results of the vaginal curettage suggested poorly differentiated uterine cancer (Figure 3 ). She was immediately transferred to the gynecological ward. She was treated with cytoreductive surgery and neoadjuvant chemotherapy (Figure 2 ). After surgery, supportive care was provided in the intensive care unit (ICU) and she received 3 cycles of carboplatin and paclitaxel.
OUTCOME AND FOLLOW-UP
She did not experience any serious complications or neurologic deficits in the ICU. The patient’s serum calcium eventually decreased to normal levels, and she was successfully discharged from hospital 2 mo later.
DISCUSSION
Acute pancreatitis is a common disease associated with significant morbidity and mortality. Alcohol and biliary disease are the causes of almost all such cases, with an incidence of approximately 80%-90%[ 4 ]. Additionally, uncommon causes include toxic substances, trauma, infection, autoimmune diseases, or metabolic disorders secondary to hypercalcemia, such as primary hyperparathyroidism or malignant tumors[ 3 ]. Generally, acute pancreatitis is associated with a decrease in serum calcium, but pancreatitis caused by primary hyperparathyroidism or malignancies is usually associated with hypercalcemia. These two causes are rare in hypercalcemia. Although the relationship and the pathophysiology are unclear, it is possible that the connection between them is not accidental. Inappropriate activation of digestive enzymes in the pancreas, especially trypsinogen in the acetabulum may play an important role in the development of acute pancreatitis[ 5 , 6 ]. An excessive increase in intracellular calcium concentration can lead to over-activation of digestive enzymes and block the pancreatic ducts, causing inflammatory exudation of the pancreas[ 7 ].
The above two rare, but well-known causes of hypercalcemia, are discussed in the literature. Many cases of acute pancreatitis caused by hyperparathyroidism with parathyroid adenoma or adenocarcinoma have been described[ 8 - 11 ]. With regard to paraneoplastic syndrome, several cases have shown that pancreatitis was related to Zollinger-Ellison syndrome[ 12 - 14 ]. Four cases diagnosed as pancreatitis were associated with lung cancer[ 15 - 18 ]. One case had pancreatic adenocarcinoma[ 19 ]. One case with myelodysplastic syndromes finally led to pancreatitis[ 20 ]. One case had breast cancer[ 21 ]. One case was associated with an intraductal papillary neoplasm of the bile duct[ 22 ]. Another case of Hodgkin lymphoma with paraneoplastic hypercalcemic pancreatitis was reported[ 23 ]. Two similar cases of autoimmune-like pancreatitis with a thymoma and myasthenia gravis were described[ 24 , 25 ]. In addition, two rare cases of pancreatitis and ovary carcinoma were reported, where pancreatitis was caused by the gynecological malignancies[ 26 , 27 ]. An overview of previously described cases of pancreatitis associated with malignant paraneoplastic syndromes is shown in Table 2 .
Table 2
Overview of previously described cases of paraneoplastic syndrome and pancreatitis
PTH: Parathyroid hormone.
| Ref. | Cancer | Along with increased PTH |
| Danne et al [ 12 ], 1985 | Gastrinoma | No |
| Yamamoto et al [ 13 ], 2003 | Zollinger-Ellison syndrome | No |
| Baffy et al [ 14 ], 2000 | Zollinger-Ellison syndrome | No |
| Belhassen-García et al [ 15 ], 2009 | Lung cancer | No |
| Saliba et al [ 16 ], 2006 | Lung carcinoma | No |
| Akinosoglou et al [ 17 ], 2014 | Lung cancer | No |
| Casadei Gardini et al [ 18 ], 2016 | Lung cancer | No |
| Leone et al [ 19 ], 1998 | Pancreatic adenocarcinoma | No |
| Tanvetyanon et al [ 20 ], 2005 | Myelodysplastic syndrome | No |
| Lekakis et al [ 21 ], 2012 | Breast cancer | No |
| Miyazaki et al [ 22 ], 2019 | Intraductal papillary neoplasm of bile duct | No |
| Mittra and Davidzon[ 23 ], 2014 | Hodgkin lymphoma | No |
| Colaut et al [ 24 ], 2002 | Thymoma | No |
| Tomiyama et al [ 25 ], 2008 | Thymoma | No |
| Wynn et al [ 26 ], 2004 | Ovarian carcinoma | No |
| Seifert and Seemann[ 27 ], 1967 | Ovarian carcinoma | No |
On the one hand, primary hyperparathyroidism is rare, with a documented incidence of 1.5%-8%[ 8 ]. Compared with healthy individuals, patients with hyperparathyroidism have an increased risk of acute pancreatitis. The prevalence of pancreatitis among patients with primary hyperparathyroidism is between 1.5% and 13%[ 28 ]. Acute pancreatitis caused by hyperparathyroidism can now be diagnosed by the continuous increase in serum calcium and elevated PTH levels[ 10 ]. Primary hyperparathyroidism is mainly associated with a solitary parathyroid adenoma (85%-90%), but it is also associated with parathyroid carcinoma (< 1%)[ 9 ]. Malignant tumors of the parathyroid gland are usually rare, with an incidence of less than 0.5%[ 29 ]. The clinical manifestations are traditionally secondary to hypercalcemia, including non-specific gastrointestinal symptoms and cardiovascular or neuromuscular dysfunction[ 30 , 31 ]. Imaging studies including ultrasound imaging, radionuclide scanning, CT, and MRI have advantages in detecting ectopic parathyroid lesions and are helpful in diagnosis[ 32 ]. Surgery is the most effective and only way to treat parathyroid carcinoma, which provides the best chance for cure and long-term survival[ 33 , 34 ].
On the other hand, paraneoplastic hypercalcemia occurs in patients with malignant tumors, with an incidence of about 0.3%-4.0%, which means that the immune system’s abnormal response to normal tissues is either through the production of autoantibodies or T cell attack. Dysfunction of immune regulation and cross-reactivity of the immune system to tumor and normal tissues are involved in the pathogenesis of such reactions[ 21 ]. It can occur in different types of malignant tumors, and the most common types are lung cancer, head and neck cancer, renal cancer, or multiple myeloma, but it rarely occurs in gynecological malignancies[ 35 , 36 ]. There are also reports in ovarian cancer, sarcoidosis, and multiple endocrine neoplasia syndrome[ 37 ]. Timely surgery and appropriate chemotherapy are necessary[ 36 ].
In our patient, examinations initially suggested that moderately severe acute pancreatitis was caused by primary hyperparathyroidism. Firstly, the major etiologies of acute pancreatitis include alcohol consumption and biliary stones, which were not present in this patient. Secondly, she did not have a family history of pancreatitis. In addition, PTH and serum calcium were significantly increased, and treatment did not decrease refractory serum calcium. In addition, ultrasound and contrast enhanced CT of the neck revealed nodules located at the junction of the left lobe of the thyroid and parathyroid gland. Therefore, these findings suggested that the pathogenesis of acute pancreatitis was the result of hypercalcemia caused by hyperparathyroidism. Although no adenoma or adenocarcinoma was found, an exploratory resection was performed to decrease refractory serum calcium. Pathological findings of the removed tissue suggested nodular goiter.
Due to this surprising finding, we conducted a further diagnostic workup and finally found gynecological malignancy. A literature review indicated that some malignant tumors might secrete parathyroid hormone-related protein (PTHrP), instead of PTH, causing pancreatitis. The amino terminus of PTHrP has a similar structure to that of PTH. Both activate PTH/PTHrP receptor 1 and decrease the renal clearance of calcium[ 36 ].
According to the results of the above analysis, the final diagnosis was moderately severe acute pancreatitis caused by primary hyperparathyroidism associated with paraneoplastic syndrome. Timely surgery and neoadjuvant chemotherapy were performed which extended the survival time of this patient. She was satisfied with the treatment outcome and was successfully discharged from hospital.
CONCLUSION
To our knowledge, this is the first case of moderately severe acute pancreatitis caused by primary hyperparathyroidism associated with paraneoplastic syndrome. Despite its rare occurrence, hypercalcemia secondary to primary hyperparathyroidism or malignancies usually manifests in the advanced stage of malignancy and has a poor prognosis. Early accurate management can avoid fatal consequences and extend survival time. Therefore, more attention should be paid to the differential diagnosis in women with hypercalcemia and abnormal vaginal bleeding or abdominal symptoms.
Informed consent statement: Informed consent was obtained from the patient.
Conflict-of-interest statement: All authors have no conflict of interest related to the manuscript.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Manuscript source: Unsolicited manuscript
Peer-review started: June 10, 2021
First decision: June 25, 2021
Article in press: July 30, 2021
Specialty type: Critical care medicine
Country/Territory of origin: China
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1 Khoo TK Vege SS Abu-Lebdeh HS Ryu E Nadeem S Wermers RA Acute pancreatitis in primary hyperparathyroidism: a population-based study J Clin Endocrinol Metab 2009 94 2115 2118 19318456 10.1210/jc.2008-1965 PMC2730346
2 Bai HX Giefer M Patel M Orabi AI Husain SZ The association of primary hyperparathyroidism with pancreatitis J Clin Gastroenterol 2012 46 656 661 22874807 10.1097/MCG.0b013e31825c446c PMC4428665
3 Egea Valenzuela J Belchí Segura E Sánchez Torres A Carballo Alvarez F Acute pancreatitis associated with hypercalcemia. A report of two cases Rev Esp Enferm Dig 2009 101 65 69 19335036 10.4321/s1130-01082009000100009
4 Tun-Abraham ME Obregón-Guerrero G Romero-Espinoza L Valencia-Jiménez J [Acute pancreatitis associated with hypercalcaemia] Cir Cir 2015 83 227 231 26123156 10.1016/j.circir.2015.05.006
5 Gerasimenko JV Peng S Tsugorka T Gerasimenko OV Ca 2+ signalling underlying pancreatitis Cell Calcium 2018 70 95 101 28552244 10.1016/j.ceca.2017.05.010
6 Watanabe T Kudo M Strober W Immunopathogenesis of pancreatitis Mucosal Immunol 2017 10 283 298 27848953 10.1038/mi.2016.101
7 Otsuka Y Kamata K Minaga K Takenaka M Watanabe T Kudo M Acute Pancreatitis with Disturbed Consciousness Caused by Hyperparathyroidism Intern Med 2018 57 3075 3078 29877272 10.2169/internalmedicine.0552-17 PMC6262715
8 Biondi A Persiani R Marchese M Cananzi F D'Ugo D Acute pancreatitis associated with primary hyperparathyroidism Updates Surg 2011 63 135 138 21286893 10.1007/s13304-011-0048-9
9 Yang J Dong MJ Chen F A rare lethal case of severe acute necrotizing pancreatitis due to a parathyroid adenoma in a third-trimester pregnant woman BMC Endocr Disord 2019 19 82 31357974 10.1186/s12902-019-0409-9 PMC6664735
10 Ma YB Hu J Duan YF Acute pancreatitis connected with hypercalcemia crisis in hyperparathyroidism: A case report World J Clin Cases 2019 7 2367 2373 31531333 10.12998/wjcc.v7.i16.2367 PMC6718780
11 Bansal S Kaushik RM Kaushik R Modi S Raghuvanshi S Kusum A Primary hyperparathyroidism presenting as severe hypercalcemia with acute pancreatitis in pregnancy Gynecol Endocrinol 2020 36 469 472 31793366 10.1080/09513590.2019.1698028
12 Danne PD Buls JG Connell J Bennett RC A case of pancreatitis associated with gastrinoma Aust N Z J Surg 1985 55 213 215 3862397 10.1111/j.1445-2197.1985.tb00888.x
13 Yamamoto M Mine H Maehara Y Sugimachi K The Zollinger-Ellison syndrome with acute bleeding pancreatitis Hepatogastroenterology 2003 50 430 431 12749240
14 Baffy G Boyle JM Association of Zollinger-Ellison syndrome with pancreatitis: report of five cases Dig Dis Sci 2000 45 1531 1534 11007101 10.1023/a:1005500708405
15 Belhassen-García M Velasco-Tirado V Carpio-Pérez A Soler-Fernández MC López-Bernús A Pardo-Lledias J Fuentes-Pardo L Iglesias-Gómez A [Acute pancreatitis and obstructive jaundice secondary to metastases from lung cancer] Gastroenterol Hepatol 2009 32 697 701 19800149 10.1016/j.gastrohep.2009.07.013
16 Saliba WR Dharan M Bisharat N Elias M Eosinophilic pancreatic infiltration as a manifestation of lung carcinoma Am J Med Sci 2006 331 274 276 16702798 10.1097/00000441-200605000-00008
17 Akinosoglou K Siagris D Geropoulou E Kosmopoulou O Velissaris D Kyriazopoulou V Gogos C Hyperamylasaemia and dual paraneoplastic syndromes in small cell lung cancer Ann Clin Biochem 2014 51 101 105 24048720 10.1177/0004563213500658
18 Casadei Gardini A Mariotti M Lucchesi A Pini S Valgiusti M Bravaccini S Del Monte A Burgio MA Marisi G Amadori D Frassineti GL Paraneoplastic lipase and amylase production in a patient with small-cell lung cancer: case report BMC Cancer 2016 16 118 26887807 10.1186/s12885-016-2167-7 PMC4758001
19 Leone J Dehlinger V Mary V Malgrange D Schvartz H Pennaforte JL Etienne JC [Bone localization of Weber-Christian syndrome associated with chronic pancreatitis developing bone metastasis of pancreatic adenocarcinoma] Ann Med Interne (Paris) 1998 149 305 307 9791569
20 Tanvetyanon T Stiff PJ Recurrent steroid-responsive pancreatitis associated with myelodysplastic syndrome and transformations Leuk Lymphoma 2005 46 151 154 15621795 10.1080/10428190400011617
21 Lekakis L Tryfonopoulos D Fakinos G Panopoulos C Theochari M Koumakis G Demiri S Efremidis A A case of paraneoplastic autoimmune pancreatitis: mini-review of paraneoplastic syndromes in breast cancer Anticancer Res 2012 32 3311 3314 22843907
22 Miyazaki H Kuroda K Fujii M Shirasaka D Era Y Tsuda K Tanaka S Nagao K Kadowaki Y Okino T [Intraductal papillary neoplasm of bile duct developed in a patient with IgG4-related sclerosing cholangitis, autoimmune pancreatitis, and myasthenia gravis] Nihon Shokakibyo Gakkai Zasshi 2019 116 443 451 31080225 10.11405/nisshoshi.116.443
23 Mittra ES Davidzon G Case 207: Hodgkin lymphoma with paraneoplastic hypercalcemic pancreatitis Radiology 2014 272 296 300 24956051 10.1148/radiol.14120419
24 Colaut F Toniolo L Sperti C Pozzobon M Scapinello A Sartori CA Autoimmune-like pancreatitis in thymoma with myasthenia gravis Chir Ital 2002 54 91 94 11942018
25 Tomiyama M Arai A Kimura T Suzuki C Watanabe M Kawarabayashi T Shoji M Exacerbation of chronic pancreatitis induced by anticholinesterase medications in myasthenia gravis Eur J Neurol 2008 15 e40 e41 18325026 10.1111/j.1468-1331.2008.02098.x
26 Wynn D Everett GD Boothby RA Small cell carcinoma of the ovary with hypercalcemia causes severe pancreatitis and altered mental status Gynecol Oncol 2004 95 716 718 15581988 10.1016/j.ygyno.2004.08.038
27 Seifert G Seemann N [Paraneoplastic hypercalcemic syndrome in ovarian carcinoma] Dtsch Med Wochenschr 1967 92 1104 1107 6026349 10.1055/s-0028-1103748
28 Donovan PJ Achong N Griffin K Galligan J Pretorius CJ McLeod DS PTHrP-mediated hypercalcemia: causes and survival in 138 patients J Clin Endocrinol Metab 2015 100 2024 2029 25719931 10.1210/jc.2014-4250
29 Kearns AE Thompson GB Medical and surgical management of hyperparathyroidism Mayo Clin Proc 2002 77 87 91 11794462 10.4065/77.1.87
30 Solimando DA Overview of hypercalcemia of malignancy Am J Health Syst Pharm 2001 58 Suppl 3 S4 S7 10.1093/ajhp/58.suppl_3.S4 11757205
31 Bilezikian JP Potts JT Jr Fuleihan Gel-H Kleerekoper M Neer R Peacock M Rastad J Silverberg SJ Udelsman R Wells SA Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century J Clin Endocrinol Metab 2002 87 5353 5361 12466320 10.1210/jc.2002-021370
32 Phillips CD Shatzkes DR Imaging of the parathyroid glands Semin Ultrasound CT MR 2012 33 123 129 22410360 10.1053/j.sult.2011.12.003
33 Fang SH Lal G Parathyroid cancer Endocr Pract 2011 17 Suppl 1 36 43 21454239 10.4158/EP10310.RA
34 Rodrigo JP Hernandez-Prera JC Randolph GW Zafereo ME Hartl DM Silver CE Suárez C Owen RP Bradford CR Mäkitie AA Shaha AR Bishop JA Rinaldo A Ferlito A Parathyroid cancer: An update Cancer Treat Rev 2020 86 102012 32247225 10.1016/j.ctrv.2020.102012
35 Muggia FM Overview of cancer-related hypercalcemia: epidemiology and etiology Semin Oncol 1990 17 3 9 2185551
36 Motilal Nehru V Garcia G Ding J Kong F Dai Q Humoral Hypercalcemia in Uterine Cancers: A Case Report and Literature Review Am J Case Rep 2017 18 22 25 28057913 10.12659/AJCR.900088 PMC5234677
37 Gaur S Sarcoidosis manifested as hypercalcemic pancreatitis South Med J 2001 94 939 940 11592759