The diagnostic and therapeutic challenges in the management of a double giant parathyroid adenoma.

Primary hyperparathyroidism is a common endocrine disorder of the parathyroid gland. It is mostly seen as a single gland adenoma in up to 85% of the cases with the excess production of parathyroid hormone. Double adenomas although reported are very rare and double giant parathyroid adenomas are even rarer. We possibly report the second case in the literature of primary hyperparathyroidism caused by double giant parathyroid adenomas, presenting with severe symptomatic hypercalcemia and review the diagnostic and therapeutic challenges in its management. The presentation with severe hypercalcemia and the presence of atypia in one of the adenomas added to its uniqueness. A combination of the neck ultrasound and a parathyroid scintigraphy should be used for preoperative localization and selection of the right surgical approach for patients undergoing parathyroidectomy. The parathyroid scintigraphic protocols keep getting refined; it is hence vitally important and practical to adapt the diagnostic algorithms in accordance with local availability and expertise.