Acute pancreatitis as an initial manifestation of parathyroid carcinoma

RATIONALE Parathyroid carcinoma is a rare endocrine malignancy. Acute pancreatitis as an initial manifestation of parathyroid carcinoma has been rarely reported. PATIENT CONCERNS A 22-year-old woman was admitted to emergency room with a sudden attack of severe epigastric pain. DIAGNOSES Acute pancreatitis was diagnosed as elevated levels of serum amylase. During the work-up for acute pancreatitis, patient's abnormally increased serum calcium and bones destruction revealed by abdominal computed tomography (CT) scan raised the suspicion of hyperparathyroidism or malignancy. Elevated serum parathyroid hormone (PTH) levels, parathyroid ultrasound and scintigraphy gave rise to the diagnosis of primary hyperparathyroidism (PHPT) due to a left parathyroid tumor. INTERVENTIONS The patient was given a complete tumor excision. After the surgery, parathyroid carcinoma with capsular and vascular invasion was confirmed histologically. A second surgery was then performed, including resection of the ipsilateral thyroid lobe and anterior cervical nodes. OUTCOMES Serum calcium and PTH levels returned to normal postoperatively. LESSONS Acute pancreatitis accompanied with hypercalcemia should always raise the suspicion of PHPT. The spicule sign, which always suggests the infiltrating pattern growth of tumor, was neglected at first and was observed during a second review of the ultrasound images postoperatively. This specific feature may be predictive for the preoperative diagnosis of parathyroid carcinoma or at least suspicion of malignancy.