A 72 year old gentleman presented to the emergency department with symptoms of diffuse joint and muscular pain, fatigue and diminished memory. Serum calcium and parathyroid hormone levels were raised, consistent with primary hyperparathyroidism. No abnormality was found on an ultrasound scan of the neck. However, a sestamibi scan suggested a possible adenoma in the anterior mediastinum, which on computed tomography (CT) scan was 1.5 cm in size. A partial upper sternotomy was performed in order to excise the adenoma and his symptoms disappeared within several weeks. This case highlights the variable and commonly nonspecific symptoms of primary hyperparathyroidism and the less well known fact that parathyroid adenoma may occasionally be found intrathoracically.

Figure 1.        
A sestamibi scan showing a potential adenoma in the anterior mediastinum (arrow).

Figure 2.        
A chest CT scan (saggital view), showing a 1,5 cm sized tumor in the anterior mediastinum (arrow), just below the aortic arch.

Figure 3.        
A photograph from the operation. The tumor (arrow) is visible in the mediastinum, seen through a partial upper sternotomy. The neck incision is shown below.

Figure 4.
Cellular parathyroid tissue made of chief cells (right) and red staining oxyphil cells (left)

Table I.          
Recommendations for surgery for primary hyperparathyroidism. Based on National Institutes of Health Consensus Conference on Hyperparathyroidism Recommendations for Surgery in 1990 and 2002.²⁸

Typical bone, renal, gastrointestinal, or neuromuscular symptoms; life-threatening hypercalcemia

Calcium level > 0.25 mmol/L above normal for each laboratory

Urine calcium level > 10 mmol/dL or renal stones

BMD T score < -2.5 at any site (WHO definition of osteoporosis)

Creatinine clearance reduced by > 30%

Age < 50 years

Patient request; adequate follow-up unlikely

Abbreviations: BMD, bone mineral density; WHO, World Health Organization.