A 62-year-old man on long-term lithium therapy for bipolar disorder is found to have serum calcium 11.2 mg/dL and PTH 78 pg/mL. Sestamibi scan shows mild uptake in all four parathyroid glands. What is the most appropriate management?

• A Stop lithium and repeat calcium levels in 3 months
• B Perform focused parathyroidectomy on the single most enlarged gland
• C Start cinacalcet and continue lithium
• D Perform subtotal parathyroidectomy or total parathyroidectomy with autotransplantation ✓

Explanation

Lithium-associated hyperparathyroidism typically causes multigland hyperplasia rather than a single adenoma. When surgery is indicated, bilateral neck exploration with subtotal parathyroidectomy or total parathyroidectomy with autotransplantation is appropriate. Focused parathyroidectomy is suitable for single adenomas, not multigland disease. Stopping lithium does not reliably reverse the biochemical abnormalities and is often not feasible for psychiatric stability.

Reference: Schwartz's Principles of Surgery, 11th ed.

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