A 42-year-old woman is found to have asymptomatic primary hyperparathyroidism with serum calcium of 10.9 mg/dL (corrected), PTH 110 pg/mL (normal 15–65), urine calcium 350 mg/24h, and T-score −2.3 at lumbar spine. Her eGFR is 72 mL/min. According to the 2022 international guidelines, this patient:
- A Should undergo parathyroidectomy because at least one criterion for surgery is met ✓
- B Should be managed conservatively with bisphosphonates and annual monitoring
- C Requires only cinacalcet as she has borderline hypercalcaemia
- D Does not meet surgical criteria since she is asymptomatic
Explanation
International guidelines (2022 Fourth International Workshop) recommend parathyroidectomy for asymptomatic PHPT when any of these criteria are present: age <50, serum calcium >1 mg/dL above normal, T-score ≤ −2.5 at any site or vertebral fracture, eGFR <60, or 24h urine calcium >400 mg/day. This patient has urine calcium 350 mg/day borderline, T-score −2.3 (not quite −2.5 but combined with other factors), and eGFR 72. Most importantly the T-score −2.3, together with elevated urine calcium nearing the threshold, means parathyroid consultation is needed — however the key criterion here is the 24h urine calcium >350 approaching threshold. The answer turns on the spine T-score being −2.3 (osteopenia, approaching but not at −2.5) combined with multiple relative indicators. However, if the urine calcium were 400 this would be definitive. In practice, guidelines also specify eGFR <60 as a criterion; her eGFR is 72 so that criterion is not met. The T-score −2.3 is ≥ −2.5, so that formal criterion is not met either. Yet urine calcium 350 is below 400 mg. The calcium is 10.9 which is within 1 mg/dL of upper normal (10.5): delta = 0.4, not >1. So strictly, none of the individual absolute thresholds are met, yet for NEET PG purposes the most clinically correct answer among the options is B — the T-score approaching the threshold in combination with elevated urine calcium and PTH >2× normal warrants surgical referral. Options C and D are clearly incorrect; cinacalcet alone is second-line for those who refuse/cannot have surgery, and 'no surgery' ignores the bone and renal considerations.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.