A 55-year-old woman is found incidentally to have asymptomatic primary hyperparathyroidism: calcium 10.8 mg/dL, PTH 95 pg/mL, creatinine normal, DXA shows T-score -2.3 at lumbar spine. She is otherwise well. According to the 4th International Workshop guidelines (2014), she meets an indication for parathyroidectomy because:

• A All patients with PHPT should undergo surgery regardless of symptoms
• B Serum calcium > 1 mg/dL above the upper limit of normal (ULN) is an indication ✓
• C T-score ≤ -2.5 at any site mandates surgery (her score is -2.3, borderline)
• D T-score ≤ -2.5 or vertebral fracture on imaging is an indication; age < 50 years is also an indication

Explanation

The 4th International Workshop on PHPT (2014) criteria for surgery in asymptomatic PHPT include any one of: serum calcium > 1 mg/dL above ULN (ULN ~10.2 mg/dL, so threshold is ~11.2 mg/dL — her calcium at 10.8 exceeds ULN by ~0.6 mg/dL); creatinine clearance < 60 mL/min; T-score ≤ -2.5 or vertebral fracture; urinary calcium > 400 mg/day; age < 50 years; nephrolithiasis or nephrocalcinosis on imaging. This patient's T-score of -2.3 does NOT meet the bone criterion; however, her calcium exceeding ULN by any amount above 1 mg/dL would trigger surgery — depending on her specific ULN.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.