A 48-year-old man is found to have primary hyperparathyroidism with serum calcium 2.9 mmol/L, PTH 120 pg/mL, and a DEXA T-score of -2.7 at the lumbar spine. 24-hour urine calcium is 580 mg. Preoperative sestamibi scan shows a solitary right inferior adenoma. What is the indication for surgery in this patient?
- A Age under 50 years alone
- B Osteoporosis (T-score ≤ -2.5) with hypercalciuria ✓
- C PTH elevation above 100 pg/mL alone
- D Serum calcium >0.25 mmol/L above upper limit of normal
Explanation
Per the 2022 Fourth International Workshop guidelines for asymptomatic primary hyperparathyroidism, surgery is recommended when any of the following are met: serum calcium >0.25 mmol/L above ULN, creatinine clearance <60 mL/min, bone density T-score ≤ -2.5 at any site, age <50, 24-hour urine calcium >400 mg on low-calcium diet, or presence of nephrolithiasis/nephrocalcinosis. This patient meets T-score ≤ -2.5 AND hypercalciuria >400 mg, fulfilling at least two criteria. PTH elevation alone is not a guideline criterion. Option D is a criterion but the question asks what specifically applies to this patient in combination.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.