Enlarged parathyroid glands with variable sonomorphology in a case of tertiary hyperparathyroidism: Sonographic-histopathologic correlation

The typical sonomorphology of homogeneously hypoechoic texture of an enlarged parathyroid gland (PG) is a reflection of uniform arrangement of the parathormone-producing chief cells. A variable cellular arrangement, hemorrhage, fibrosis, and adipocytes cause heterogeneous appearance. We describe a case of a 32-year-old male, a case of tertiary hyperparathyroidism, with increased serum parathormone levels, hypercalcemia, and enlargement of all four PGs, albeit with differing morphology. The left lower gland had two nodules, namely, superior and inferior. The inferior nodule of the left lower gland had an echogenic core surrounded by a sonolucent rim whereas the superior nodule was homogenously hyoechoic. The left upper gland had an echopattern exactly reverse of the inferior nodule of the left lower PG, i.e., hypoechoic gland surrounded by hyperechoic periphery. The appearance of the right-sided glands was that of the superior nodule of the left lower PG. On histopathology, the hypoechoic areas corresponded to numerous chief cells and congested vessels whereas edema gave rise to an increase in echogenicity. This report exemplifies atypical sonographic appearances of PG and their histopathologic correlation.