A patient undergoes parathyroid surgery for primary hyperparathyroidism. Intraoperatively, after removal of an apparent adenoma, intact PTH drops by 65% at 10 minutes (from 145 pg/mL to 50 pg/mL). The Miami criterion for cure is met. However, postoperatively, serum calcium drops to 6.8 mg/dL and PTH is 8 pg/mL at 24 hours. What is the most likely diagnosis?
- A Multigland parathyroid disease with missed adenoma
- B Hypomagnesaemia-induced PTH suppression
- C Hungry bone syndrome ✓
- D Permanent hypoparathyroidism due to inadvertent excision of all glands
Explanation
Hungry bone syndrome occurs after parathyroidectomy in patients with pre-existing significant hypercalcaemia and consequent elevated bone resorption. After sudden PTH withdrawal, skeletal calcium uptake accelerates (remineralization), causing profound hypocalcaemia with appropriately suppressed PTH. Distinguishing features include low calcium, low PTH, low phosphate, and normal magnesium. In permanent hypoparathyroidism all four glands would be affected (intraoperative identification of 4 glands), whereas in hungry bone syndrome the PTH suppression is transient. The Miami criterion (>50% PTH fall at 10 min) was met, supporting successful adenoma removal.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.